nursing home in Fort Atkinson, WI
Rock River Nursing & Rehab
430 Wilcox St, Fort Atkinson, WI 53538 · (920) 563-5533
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★1
- Staffing★★★★★2
- Quality measures★★★★★2
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Rock River Nursing & Rehab at a glance
Rock River Nursing & Rehab is a 87-bed for-profit nursing home in Fort Atkinson, Wisconsin (Jefferson County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the Wisconsin average of 3.
Residents receive about 4.4 hours of nursing care per day (0.8 of them from registered nurses), close to the state average of 4.2 hours.
Its most recent standard health inspection (May 6, 2026) found 8 health citations. The Wisconsin average is 9.5.
Federal regulators fined it 3 times in the past three years, totaling $228,344.
Nursing staff turnover is 70.2% per year (state average 46.9%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 87
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Bedrock Healthcare
- Medicare-certified since
- June 1, 1979
- Resident/family council
- Resident
- County
- Jefferson County
- CMS Certification Number
- 525262
Ratings
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 3 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 1 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 2 / 5 | 3.6 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 2 / 5 | 3 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 2 / 5 | 3.1 / 5 | 3.8 / 5 | Worse |
Staffing
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 4.36 hrs | 4.21 hrs | 3.86 hrs | Better |
| Registered nurse hours per resident per day (higher is better) | 0.83 hrs | 0.99 hrs | 0.69 hrs | Better |
| Nurse aide hours per resident per day (higher is better) | 2.45 hrs | 2.58 hrs | 2.32 hrs | Better |
| Weekend nurse staff hours per resident per day (higher is better) | 3.87 hrs | 3.77 hrs | 3.42 hrs | Better |
| Nursing staff turnover (yearly) (lower is better) | 70.2% | 46.9% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 77.8% | 39.7% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 3 | 1 | 1 | Worse |
Inspections
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 8 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 1 | 4 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 255.5 | 100.3 | 80.6 | Worse |
Penalties
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 3 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $228,344 | $48,150 | $30,972 | Worse |
| All federal penalties in the past 3 years (lower is better) | 6 | 1 | 1 | Worse |
Size
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 87 | 77 | 107 | |
| Average residents per day | 27 | 55 | 86 | |
| Occupancy | 31% | 74% | 80.9% |
Long-stay residents
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 2.1% | 3.3% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 6% | 5% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 31.4% | 15.8% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 7.5% | 2.7% | 1.6% | Worse |
| Long-stay residents with a catheter left in the bladder (lower is better) | 1.9% | 2.1% | 0.8% | Worse |
| Long-stay residents needing more help with daily activities (lower is better) | 22.1% | 16.1% | 13.9% | Worse |
| Long-stay residents whose walking worsened (lower is better) | 5.2% | 18.4% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 6.8% | 5.1% | 5.2% | Worse |
| Long-stay residents with depressive symptoms (lower is better) | 0% | 5.7% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 19.8% | 16.9% | 19.5% | Average |
| Long-stay residents with new or worse incontinence (lower is better) | 30.4% | 24.6% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 89.1% | 95% | 95.5% | Worse |
| Long-stay residents given a pneumonia vaccine (higher is better) | 99% | 95.7% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Wisconsin avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents given a pneumonia vaccine (higher is better) | 91.9% | 86.5% | 82% | Better |
Inspection citations
State inspectors cited this home for 115 health deficiencies and 46 fire safety deficiencies in the inspection records CMS currently publishes. 10 citations involved actual harm, including 5 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| May 6, 2026 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected June 4, 2026 |
| May 6, 2026 Standard | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Tag F0849 | D Potential harm, isolated | Corrected June 4, 2026 |
| May 6, 2026 Standard | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Tag F0804 | D Potential harm, isolated | Corrected June 4, 2026 |
| May 6, 2026 Standard | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Tag F0791 | D Potential harm, isolated | Corrected June 4, 2026 |
| May 6, 2026 Standard | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected June 4, 2026 |
| May 6, 2026 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected June 4, 2026 |
| May 6, 2026 Standard | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Tag F0688 | D Potential harm, isolated | Corrected June 4, 2026 |
| February 6, 2026 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected March 10, 2026 |
| December 4, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected January 4, 2026 |
| December 4, 2025 Fire safety | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Tag E0004 | F Potential harm, widespread | Corrected January 5, 2026 |
| December 4, 2025 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected January 9, 2026 |
| December 4, 2025 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected January 4, 2026 |
| December 4, 2025 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected January 4, 2026 |
| December 4, 2025 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | F Potential harm, widespread | Corrected January 4, 2026 |
| December 4, 2025 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | E Potential harm, pattern | Corrected January 5, 2026 |
| December 4, 2025 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | E Potential harm, pattern | Corrected February 6, 2026 |
| December 4, 2025 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | D Potential harm, isolated | Corrected January 5, 2026 |
| December 4, 2025 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | D Potential harm, isolated | Corrected January 4, 2026 |
| December 4, 2025 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | D Potential harm, isolated | Corrected December 19, 2025 |
| December 4, 2025 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected January 13, 2026 |
| December 4, 2025 Standard | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Tag F0756 | D Potential harm, isolated | Corrected January 13, 2026 |
| December 4, 2025 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected January 13, 2026 |
| July 23, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | K Immediate jeopardy, pattern | Corrected August 28, 2025 |
| July 23, 2025 Complaint | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Tag F0949 | E Potential harm, pattern | Corrected August 28, 2025 |
| July 23, 2025 Complaint | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Tag F0944 | D Potential harm, isolated | Corrected August 28, 2025 |
| July 23, 2025 Complaint | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Tag F0745 | D Potential harm, isolated | Corrected August 28, 2025 |
| July 23, 2025 Complaint | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 | D Potential harm, isolated | Corrected August 28, 2025 |
| July 23, 2025 Complaint | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Tag F0942 | D Potential harm, isolated | Corrected August 28, 2025 |
| July 23, 2025 Complaint | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Tag F0732 | C No harm, widespread | Corrected August 28, 2025 |
| April 17, 2025 Fire safety | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Tag E0004 | F Potential harm, widespread | Corrected May 16, 2025 |
| April 17, 2025 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected June 6, 2025 |
| April 17, 2025 Fire safety | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Tag E0007 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Tag E0036 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Tag E0025 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Tag E0031 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Tag E0013 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Tag K0354 | F Potential harm, widespread | Corrected June 1, 2025 |
| April 17, 2025 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected June 11, 2025 |
| April 17, 2025 Fire safety | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Tag K0347 | E Potential harm, pattern | Corrected June 13, 2025 |
| April 17, 2025 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | E Potential harm, pattern | Corrected June 9, 2025 |
| April 17, 2025 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | D Potential harm, isolated | Corrected July 10, 2025 |
| April 17, 2025 Fire safety | Ensure that sources of ignition are removed from patients receiving respiratory therapy. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0925 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Tag K0781 | D Potential harm, isolated | Corrected June 26, 2025 |
| April 17, 2025 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | D Potential harm, isolated | Corrected June 1, 2025 |
| April 17, 2025 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | D Potential harm, isolated | Corrected June 13, 2025 |
| April 17, 2025 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | J Immediate jeopardy, isolated | Corrected May 23, 2025 |
| April 17, 2025 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | G Actual harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Complaint | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Tag F0882 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Complaint | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Tag F0725 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | F Potential harm, widespread | Corrected May 23, 2025 |
| April 17, 2025 Standard | Have policies on smoking. Environmental Deficiencies · Tag F0926 | E Potential harm, pattern | Corrected May 23, 2025 |
| April 17, 2025 Standard | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Standard | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Tag F0655 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Complaint | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Standard | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Tag F0553 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Standard | 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. Pharmacy Service Deficiencies · Tag F0758 | D Potential harm, isolated | Corrected May 23, 2025 |
| April 17, 2025 Complaint | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | D Potential harm, isolated | Corrected May 23, 2025 |
| January 15, 2025 Fire safety | Meet other general requirements that are deficient. Services Deficiencies · Tag K0500 | E Potential harm, pattern | Corrected February 21, 2025 |
| January 15, 2025 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | J Immediate jeopardy, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | J Immediate jeopardy, isolated | Corrected May 23, 2025 |
| January 15, 2025 Complaint | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Tag F0730 | F Potential harm, widespread | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Tag F0941 | F Potential harm, widespread | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Tag F0944 | F Potential harm, widespread | Corrected February 13, 2025 |
| January 15, 2025 Complaint | 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. Administration Deficiencies · Tag F0837 | F Potential harm, widespread | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Tag F0949 | F Potential harm, widespread | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Provide training in compliance and ethics. Administration Deficiencies · Tag F0946 | F Potential harm, widespread | Corrected February 13, 2025 |
| January 15, 2025 Complaint | 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. Resident Rights Deficiencies · Tag F0584 | E Potential harm, pattern | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Tag F0945 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0943 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Tag F0942 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | 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. Nursing and Physician Services Deficiencies · Tag F0726 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected February 13, 2025 |
| January 15, 2025 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected February 13, 2025 |
| September 11, 2024 Complaint | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Tag F0925 | F Potential harm, widespread | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected October 18, 2024 |
| September 11, 2024 Complaint | 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. Nursing and Physician Services Deficiencies · Tag F0726 | E Potential harm, pattern | Corrected October 18, 2024 |
| September 11, 2024 Complaint | 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. Resident Rights Deficiencies · Tag F0584 | E Potential harm, pattern | Corrected October 18, 2024 |
| September 11, 2024 Complaint | 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. Pharmacy Service Deficiencies · Tag F0758 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Tag F0552 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Tag F0553 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies · Tag F0559 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Tag F0563 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Tag F0660 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Tag F0699 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Tag F0745 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected October 18, 2024 |
| September 11, 2024 Complaint | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Tag F0814 | C No harm, widespread | Corrected October 18, 2024 |
| July 24, 2024 Complaint | 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. Administration Deficiencies · Tag F0837 | F Potential harm, widespread | Corrected August 15, 2024 |
| June 12, 2024 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | G Actual harm, isolated | Corrected October 21, 2024 |
| June 12, 2024 Complaint | Provide appropriate foot care. Quality of Life and Care Deficiencies · Tag F0687 | D Potential harm, isolated | Corrected July 16, 2024 |
| June 12, 2024 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected July 16, 2024 |
| June 12, 2024 Complaint | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Tag F0660 | D Potential harm, isolated | Corrected July 16, 2024 |
| June 12, 2024 Complaint | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Tag F0585 | D Potential harm, isolated | Corrected July 16, 2024 |
| June 12, 2024 Complaint | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected July 16, 2024 |
| June 12, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected July 16, 2024 |
| April 25, 2024 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Tag E0006 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0911 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Tag K0222 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | C No harm, widespread | Corrected May 23, 2024 |
| April 25, 2024 Complaint | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Tag F0678 | J Immediate jeopardy, isolated | Corrected April 9, 2024 |
| April 25, 2024 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | G Actual harm, isolated | Corrected October 21, 2024 |
| April 25, 2024 Complaint | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected May 23, 2024 |
| April 25, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected May 23, 2024 |
| April 25, 2024 Complaint | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Nutrition and Dietary Deficiencies · Tag F0807 | D Potential harm, isolated | Corrected May 23, 2024 |
| April 25, 2024 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected May 23, 2024 |
| April 25, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected July 16, 2024 |
| March 7, 2024 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected March 19, 2024 |
| March 7, 2024 Complaint | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | D Potential harm, isolated | Corrected March 19, 2024 |
| February 21, 2024 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected March 12, 2024 |
| December 12, 2023 Complaint | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected January 12, 2024 |
| December 12, 2023 Complaint | Give residents a notice of rights, rules, services and charges. Resident Rights Deficiencies · Tag F0572 | E Potential harm, pattern | Corrected January 12, 2024 |
| December 12, 2023 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected March 12, 2024 |
| December 12, 2023 Complaint | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected January 12, 2024 |
| December 12, 2023 Complaint | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Tag F0678 | D Potential harm, isolated | Corrected January 12, 2024 |
| December 12, 2023 Complaint | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Tag F0804 | D Potential harm, isolated | Corrected January 12, 2024 |
| October 16, 2023 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected March 12, 2024 |
| October 16, 2023 Complaint | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Tag F0814 | F Potential harm, widespread | Corrected November 10, 2023 |
| October 16, 2023 Complaint | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected November 10, 2023 |
| October 16, 2023 Complaint | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Tag F0804 | F Potential harm, widespread | Corrected November 10, 2023 |
| October 16, 2023 Complaint | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Tag F0585 | E Potential harm, pattern | Corrected November 10, 2023 |
| October 16, 2023 Complaint | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected November 10, 2023 |
| October 16, 2023 Complaint | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Tag F0825 | E Potential harm, pattern | Corrected November 10, 2023 |
Showing the 150 most recent of 161 citations.
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 6 federal penalties in the past three years, including $228,344 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| July 23, 2025 | Payment Denial | 6 days from August 22, 2025 |
| July 23, 2025 | Fine | $91,960 |
| April 25, 2024 | Payment Denial | 150 days from May 24, 2024 |
| April 25, 2024 | Fine | $119,141 |
| October 16, 2023 | Payment Denial | 126 days from November 14, 2023 |
| October 16, 2023 | Fine | $17,243 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| CHOPP, MARTIN Individual | 5% or greater indirect ownership interest | 20% | 10/01/2019 |
| CHOPP, PNINA Individual | 5% or greater indirect ownership interest | 60% | 10/01/2019 |
| CHOPP, SOLOMON Individual | 5% or greater indirect ownership interest | 20% | 10/01/2019 |
| BREWER, ANTHONY Individual | adp of the snf | NOT APPLICABLE | 07/08/2025 |
| CHOPP, MARTIN Individual | adp of the snf | NOT APPLICABLE | 10/01/2019 |
| CHOPP, PNINA Individual | adp of the snf | NOT APPLICABLE | 10/01/2019 |
| CHOPP, SOLOMON Individual | adp of the snf | NOT APPLICABLE | 10/01/2019 |
| OPAL HEALTHCARE WI LLC Organization | adp of the snf | NOT APPLICABLE | 03/31/2025 |
| BREWER, ANTHONY Individual | operational/managerial control | NOT APPLICABLE | 07/08/2025 |
| CHOPP, MARTIN Individual | operational/managerial control | NOT APPLICABLE | 10/01/2019 |
| CHOPP, PNINA Individual | operational/managerial control | NOT APPLICABLE | 10/01/2019 |
| CHOPP, SOLOMON Individual | operational/managerial control | NOT APPLICABLE | 10/01/2019 |
| OPAL HEALTHCARE WI LLC Organization | operational/managerial control | NOT APPLICABLE | 10/01/2019 |
| RAMANUJAM, SANDEEP Individual | operational/managerial control | NOT APPLICABLE | 02/01/2024 |
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Frequently asked questions
What is Rock River Nursing & Rehab's rating?
Rock River Nursing & Rehab has 1 out of 5 stars on the CMS overall star rating. The average for Wisconsin nursing homes is 3 stars.
How many inspection citations did Rock River Nursing & Rehab receive?
Its most recent standard health inspection found 8 citations, compared with a Wisconsin average of 9.5. Every citation is listed on this page with its severity.
Does Rock River Nursing & Rehab accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Rock River Nursing & Rehab?
It is for profit - corporation and part of Bedrock Healthcare. The ownership section on this page lists the owners and managers reported to CMS.
Where is Rock River Nursing & Rehab and how do I contact it?
Rock River Nursing & Rehab is at 430 Wilcox St, Fort Atkinson, WI 53538. Phone: (920) 563-5533.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.