Wisconsin ›Fort Atkinson

Rock River Nursing & Rehab

Costs & paymentPlan a visit

430 Wilcox St, Fort Atkinson, WI 53538 (opens Google Maps) · Jefferson County · (920) 563-5533· 87 certified beds · avg 27 residents/day · certified since Jun 1, 1979 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

Part of chain: BEDROCK HEALTHCARE (9 facilities, chain avg rating 1.4★)

1/5
Health inspection rating (on-site)
inspected May 6, 2026
10
Serious findings on record
most recent Jul 23, 2025
$136,384
Fines, last 3 years
4.11
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, pattern · Jul 23, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (K): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Aug 28, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Apr 17, 2025 · F-0684

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 23, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Jan 15, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 23, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Jan 15, 2025 · F-0755 · triggered by a complaint

The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.

Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 13, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Apr 25, 2024 · F-0678 · triggered by a complaint

The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.

Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Apr 9, 2024 (Past Non-Compliance)

▲ Actual harm, isolated · Apr 17, 2025 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 23, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Apr 17, 2025 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 23, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jun 12, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Oct 21, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Apr 25, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Oct 21, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Oct 16, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Mar 12, 2024 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 115 inspection findings. Open the full record below to read every finding.

  1. D · Potential for more than minimal harm, isolated

    The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. F-0686

  2. D · Potential for more than minimal harm, isolated

    The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. F-0688

  3. D · Potential for more than minimal harm, isolated

    The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. F-0689

View all 115 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · F-0791
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804
May 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · F-0849
Feb 6, 2026D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Dec 4, 2025D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Dec 4, 2025D · Potential for more than minimal harm, isolatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656
Dec 4, 2025D · Potential for more than minimal harm, isolatedThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756
Jul 23, 2025▲ K · Immediate jeopardy, patternThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jul 23, 2025E · Potential for more than minimal harm, patternThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint · F-0949
Jul 23, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint · F-0745
Jul 23, 2025D · Potential for more than minimal harm, isolatedThe facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. · from a complaint · F-0942
Jul 23, 2025D · Potential for more than minimal harm, isolatedThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint · F-0943
Jul 23, 2025D · Potential for more than minimal harm, isolatedThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint · F-0944
Jul 23, 2025C · Potential for minimal harm, widespreadThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint · F-0732
Apr 17, 2025▲ J · Immediate jeopardy, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Apr 17, 2025▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
Apr 17, 2025▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Apr 17, 2025F · Potential for more than minimal harm, widespreadThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Apr 17, 2025F · Potential for more than minimal harm, widespreadThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
Apr 17, 2025F · Potential for more than minimal harm, widespreadThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint · F-0882
Apr 17, 2025E · Potential for more than minimal harm, patternThe facility did not have policies on smoking. · F-0926
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · F-0553
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint · F-0604
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · F-0655
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758
Apr 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint · F-0883
Jan 15, 2025▲ J · Immediate jeopardy, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Jan 15, 2025▲ J · Immediate jeopardy, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Jan 15, 2025F · Potential for more than minimal harm, widespreadThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730
Jan 15, 2025F · Potential for more than minimal harm, widespreadThe facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint · F-0837
Jan 15, 2025F · Potential for more than minimal harm, widespreadThe facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. · from a complaint · F-0941
Jan 15, 2025F · Potential for more than minimal harm, widespreadThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint · F-0944
Jan 15, 2025F · Potential for more than minimal harm, widespreadThe facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. · from a complaint · F-0946
Jan 15, 2025F · Potential for more than minimal harm, widespreadThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint · F-0949
Jan 15, 2025E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint · F-0726
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. · from a complaint · F-0942
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint · F-0943
Jan 15, 2025D · Potential for more than minimal harm, isolatedThe facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · from a complaint · F-0945
Sep 11, 2024F · Potential for more than minimal harm, widespreadThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint · F-0925
Sep 11, 2024E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Sep 11, 2024E · Potential for more than minimal harm, patternThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Sep 11, 2024E · Potential for more than minimal harm, patternThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint · F-0726
Sep 11, 2024E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint · F-0552
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint · F-0553
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint · F-0558
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint · F-0559
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint · F-0563
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint · F-0657
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint · F-0660
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint · F-0676
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint · F-0699
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint · F-0745
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint · F-0758
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Sep 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
Sep 11, 2024C · Potential for minimal harm, widespreadThe facility did not dispose of garbage and refuse properly. · from a complaint · F-0814
Jul 24, 2024F · Potential for more than minimal harm, widespreadThe facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · from a complaint · F-0837
Jun 12, 2024▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Jun 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Jun 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint · F-0585
Jun 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint · F-0660
Jun 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Jun 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint · F-0687
Jun 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
Apr 25, 2024▲ J · Immediate jeopardy, isolatedThe facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint · F-0678
Apr 25, 2024▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Apr 25, 2024E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint · F-0812
Apr 25, 2024D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Apr 25, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Apr 25, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. · from a complaint · F-0807
Apr 25, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
Mar 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677
Mar 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697
Feb 21, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Dec 12, 2023F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint · F-0812
Dec 12, 2023E · Potential for more than minimal harm, patternThe facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. · from a complaint · F-0572
Dec 12, 2023D · Potential for more than minimal harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Dec 12, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint · F-0678
Dec 12, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Dec 12, 2023D · Potential for more than minimal harm, isolatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint · F-0804
Oct 16, 2023▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Oct 16, 2023F · Potential for more than minimal harm, widespreadThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint · F-0804
Oct 16, 2023F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint · F-0812
Oct 16, 2023F · Potential for more than minimal harm, widespreadThe facility did not dispose of garbage and refuse properly. · from a complaint · F-0814
Oct 16, 2023E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Oct 16, 2023E · Potential for more than minimal harm, patternThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint · F-0585
Oct 16, 2023E · Potential for more than minimal harm, patternThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Oct 16, 2023E · Potential for more than minimal harm, patternThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Oct 16, 2023E · Potential for more than minimal harm, patternThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint · F-0805
Oct 16, 2023E · Potential for more than minimal harm, patternThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint · F-0825
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint · F-0554
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep residents' personal and medical information private and confidential. · from a complaint · F-0583
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint · F-0604
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. · from a complaint · F-0810
Oct 16, 2023D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 7).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 24
Serious citations (G–L): 1
2024
All citations: 41
Serious citations (G–L): 3
2025
All citations: 42
Serious citations (G–L): 6
2026
All citations: 8
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
2023241G ▲
2024413J ▲
2025426K ▲
202680D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

How to file a complaint about care →

2 fines totaling $136,384, plus 3 Medicare payment denial periods.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
Jul 23, 2025Payment Denial36 days from Jul 23, 2025
Apr 25, 2024Fine$119,141
Apr 25, 2024Payment Denial150 days from May 24, 2024
Oct 16, 2023Fine$17,243
Oct 16, 2023Payment Denial126 days from Nov 14, 2023

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityWisconsin averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 4.11
Wisconsin average: 4.29
U.S. average: 3.95
Registered Nurse hours
This facility: 0.78
Wisconsin average: 1.01
U.S. average: 0.69
Weekend total nurse staffing
This facility: 3.66
Wisconsin average: 3.84
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityWisconsin avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.114.293.95top 50% in Wisconsin; top 35% in the U.S.
Registered Nurse hours0.781.010.69bottom 30% in Wisconsin; top 29% in the U.S.
Weekend total nurse staffing3.663.843.50bottom 49% in Wisconsin; top 35% in the U.S.
Weekend RN hours (not acuity-adjusted)0.620.680.48bottom 50% in Wisconsin; top 21% in the U.S.
Total nursing staff turnover (%)70.246.945.8bottom 7% in Wisconsin; bottom 6% in the U.S.
RN turnover (%)77.839.742.9bottom 3% in Wisconsin; bottom 7% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.36, RN 0.83, weekend 3.87.Comparing with Medicare Care Compare? Care Compare shows the raw figure (4.36 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Rock River Nursing & Rehab. CMS inspection and staffing records do not tell us what this home will charge you.

Calculate a stay from a quote you receive

Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.

Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.

Before you compare prices

  • Request the room type, effective date and itemized daily rate in writing.
  • Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
  • Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.

Understand who pays for care · How we handle price evidence · Report an incorrect price

Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Corporation

Owner / managerTypeRoleStakeSince
Chopp, MartinIndividual5% or Greater Indirect Ownership Interest20%10/01/2019
Chopp, PninaIndividual5% or Greater Indirect Ownership Interest60%10/01/2019
Chopp, SolomonIndividual5% or Greater Indirect Ownership Interest20%10/01/2019
Brewer, AnthonyIndividualOperational/Managerial ControlNOT APPLICABLE07/08/2025
Brewer, AnthonyIndividualADP of the SNFNOT APPLICABLE07/08/2025
Chopp, MartinIndividualOperational/Managerial ControlNOT APPLICABLE10/01/2019
Chopp, MartinIndividualADP of the SNFNOT APPLICABLE10/01/2019
Chopp, PninaIndividualOperational/Managerial ControlNOT APPLICABLE10/01/2019
Chopp, PninaIndividualADP of the SNFNOT APPLICABLE10/01/2019
Chopp, SolomonIndividualOperational/Managerial ControlNOT APPLICABLE10/01/2019
Chopp, SolomonIndividualADP of the SNFNOT APPLICABLE10/01/2019
Opal Healthcare Wi LLCOrganizationOperational/Managerial ControlNOT APPLICABLE10/01/2019
Opal Healthcare Wi LLCOrganizationADP of the SNFNOT APPLICABLE03/31/2025
Ramanujam, SandeepIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024

All 14 owning or managing parties CMS has on file are shown — none excluded.

Other facilities in the same chain

CMS lists this facility under the chain Bedrock Healthcare — 9 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.

Listed by state, then facility name — not a ranking.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
  • "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
  • "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
  • "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
  • "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
  • "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
  • "How do residents get dental care here — is there a dentist who visits, and how are appointments arranged?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the Wisconsin midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 70% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 14 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Alden Estates of Countryside, INC4.1 miJefferson, WI★☆☆☆☆1/5
Lake Mills Health Services11.1 miLake Mills, WI★★★★☆4/5
Edgerton Care Center, INC14.2 miEdgerton, WI★☆☆☆☆1/5abuse
Rock Haven18.1 miJanesville, WI★★★★☆3/5
Masonic Center for Health & Rehab INC.19.1 miDousman, WI★★★★★5/5
Skaalen Nursing and Rehabilitation Center19.1 miStoughton, WI★★★★★5/5
Watertown Health Care Center19.5 miWatertown, WI★☆☆☆☆1/5SFF
Marquardt Memorial Manor19.6 miWatertown, WI★★☆☆☆2/5
St Elizabeth Nursing Home19.7 miJanesville, WI★★☆☆☆2/5
Mercy Manor Transition Center19.9 miJanesville, WI★★★★★4/5
Oak Park Place of Janesville19.9 miJanesville, WI★★☆☆☆2/5

Compare this facility with the 3 closest →

All facilities in Fort Atkinson →

Facility data as of CMS processing date 2026-08-01. CCN 525262.

This page is the printable visit checklist. If your browser did not open the print dialog automatically, use File → Print (Ctrl/⌘-P).

Your research

Viewed & saved homes

Kept in this browser tab for this session. Choose to remember them only on a device you trust. Opening a record or comparison sends its usual page request.

Selected for comparison

Recently viewed

Prices entered in a cost worksheet stay on that page and are not saved. Privacy details