CareSentinel

Federal Nursing-Home Survey Record

Rock River Nursing & Rehab

CCN 525262 · 430 WILCOX ST, FORT ATKINSON, WI, 53538 · Operated within the BEDROCK HEALTHCARE chain

Does Rock River Nursing & Rehab have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Rock River Nursing & Rehab (CCN 525262), in FORT ATKINSON, WI, has federal inspection findings on its record. CMS also lists the facility in its Special Focus Facility program, the federal watch list CMS reserves for nursing homes with a persistent record of serious deficiencies. In its current inspection cycle, CMS cited the facility for 11 deficiencies; the most serious carries scope/severity K on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. The most recent federal survey on file is dated 2025-12-04. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $136,384 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

The Federal Record

CMS lists this facility on its federal Special Focus Facility watch list.

Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

SFF Watch List

On the federal Special Focus Facility watch list

CMS lists this facility in its Special Focus Facility program — the federal program CMS reserves for nursing homes with a persistent record of serious deficiencies.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations, as on file with federal regulators (CMS).

Civil money penalties on file

$136,384

CMS has $136,384 in civil money penalties on file against this facility. CMS also records 312 day(s) of payment denial.

Overall CMS star rating: this facility vs the CMS-published state average

This facility:  ·  CMS state average: 3.0

Side-by-side with the CMS-published Overall CMS star rating for this state. This is the government's own published state average — not a CareSentinel-computed figure or delta.

Deficiency timeline — full federal history

2026-02-06
CURRENT CYCLE
F609S/S D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2025-12-04
CURRENT CYCLE
F756S/S D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

2025-12-04
CURRENT CYCLE
F610S/S D

Respond appropriately to all alleged violations.

2025-12-04
CURRENT CYCLE
F656S/S D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2025-07-23
CURRENT CYCLE
F689S/S K

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2025-07-23
CURRENT CYCLE
F949S/S E

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

2025-07-23
CURRENT CYCLE
F944S/S D

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

2025-07-23
CURRENT CYCLE
F943S/S D

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

2025-07-23
CURRENT CYCLE
F745S/S D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

2025-07-23
CURRENT CYCLE
F942S/S D

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

2025-07-23
CURRENT CYCLE
F732S/S C

Post nurse staffing information every day.

2025-04-17
HISTORICAL
F684S/S J

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2025-04-17
HISTORICAL
F686S/S G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2025-04-17
HISTORICAL
F689S/S G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2025-04-17
HISTORICAL
F725S/S F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

2025-04-17
HISTORICAL
F880S/S F

Provide and implement an infection prevention and control program.

2025-04-17
HISTORICAL
F882S/S F

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

2025-04-17
HISTORICAL
F926S/S E

Have policies on smoking.

2025-04-17
HISTORICAL
F883S/S D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

2025-04-17
HISTORICAL
F758S/S D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

2025-04-17
HISTORICAL
F604S/S D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

2025-04-17
HISTORICAL
F757S/S D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

2025-04-17
HISTORICAL
F655S/S D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

2025-04-17
HISTORICAL
F553S/S D

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

2025-04-17
HISTORICAL
F610S/S D

Respond appropriately to all alleged violations.

2025-01-15
HISTORICAL
F684S/S J

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2025-01-15
HISTORICAL
F755S/S J

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2025-01-15
HISTORICAL
F949S/S F

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

2025-01-15
HISTORICAL
F946S/S F

Provide training in compliance and ethics.

2025-01-15
HISTORICAL
F944S/S F

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

2025-01-15
HISTORICAL
F837S/S F

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

2025-01-15
HISTORICAL
F941S/S F

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

2025-01-15
HISTORICAL
F730S/S F

Observe each nurse aide's job performance and give regular training.

2025-01-15
HISTORICAL
F584S/S E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

2025-01-15
HISTORICAL
F689S/S D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2025-01-15
HISTORICAL
F610S/S D

Respond appropriately to all alleged violations.

2025-01-15
HISTORICAL
F942S/S D

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

2025-01-15
HISTORICAL
F943S/S D

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

2025-01-15
HISTORICAL
F842S/S D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

2025-01-15
HISTORICAL
F759S/S D

Ensure medication error rates are not 5 percent or greater.

2025-01-15
HISTORICAL
F945S/S D

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

2025-01-15
HISTORICAL
F726S/S D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

2025-01-15
HISTORICAL
F580S/S D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

2024-09-11
HISTORICAL
F925S/S F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

2024-09-11
HISTORICAL
F726S/S E

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

2024-09-11
HISTORICAL
F725S/S E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

2024-09-11
HISTORICAL
F755S/S E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2024-09-11
HISTORICAL
F584S/S E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

2024-09-11
HISTORICAL
F699S/S D

Provide care or services that was trauma informed and/or culturally competent.

2024-09-11
HISTORICAL
F552S/S D

Ensure that residents are fully informed and understand their health status, care and treatments.

2024-09-11
HISTORICAL
F553S/S D

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

2024-09-11
HISTORICAL
F558S/S D

Reasonably accommodate the needs and preferences of each resident.

2024-09-11
HISTORICAL
F559S/S D

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

2024-09-11
HISTORICAL
F563S/S D

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

2024-09-11
HISTORICAL
F580S/S D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

2024-09-11
HISTORICAL
F657S/S D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

2024-09-11
HISTORICAL
F660S/S D

Plan the resident's discharge to meet the resident's goals and needs.

2024-09-11
HISTORICAL
F676S/S D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

2024-09-11
HISTORICAL
F677S/S D

Provide care and assistance to perform activities of daily living for any resident who is unable.

2024-09-11
HISTORICAL
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Each citation below is a federal survey finding, dated and labeled with its CMS deficiency tag, as on file with federal regulators (CMS). Older inspection cycles are de-emphasized; only the most recent cycle is current.

Document what happened

Were you or a loved one harmed at Rock River Nursing & Rehab?

Share a few details to put your inquiry on file. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. As qualified attorneys join our network in your area, one may reach out — we can’t guarantee contact yet, so we encourage you to consult a qualified attorney promptly on your own as well. There is no cost, and your information is handled with care.

Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Step 1 of 3 · What happened

Your relationship to the resident
What happened? Select all that apply.

Physical injury

Skin & wounds

Medical & clinical

Safety & abuse

Loss

Something else

The resident is…