Rock River Nursing & Rehab
430 Wilcox St · Fort Atkinson, WI · 53538 · 9205635533
87 certified beds For profit - Corporation Chain: Bedrock Healthcare
Why this verdict
- On the federal Special Focus list of the most persistently poor performers.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- 5 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility
CMS has designated this facility one of the most persistently poor performers in the country — it is under increased inspection and enforcement.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
77% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: not rated Inspections: not rated Staffing: not rated Quality measures: not rated
| Total nurse hours / resident-day | 4.69 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.98 | 0.55–0.75 |
| Weekend hours / resident-day | 4.06 | ≈ weekday level |
| Nursing turnover / year | 77% | median 45% |
| Fines (3-yr window) | 2 · $136,384 |
Inspection citations (118 in the current record)
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Potential for harm · D February 6, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 10, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 4, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 13, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 4, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 13, 2026 · Pharmacy Service
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Potential for harm · D December 4, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected January 13, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K July 23, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 28, 2025 · Quality of Life and Care
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Potential for harm · D July 23, 2025 · found via complaint
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected August 28, 2025 · Quality of Life and Care
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Potential for harm · D July 23, 2025 · found via complaint
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected August 28, 2025 · Resident Rights
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Potential for harm · D July 23, 2025 · found via complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected August 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 23, 2025 · found via complaint
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected August 28, 2025 · Administration
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Potential for harm · E July 23, 2025 · found via complaint
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected August 28, 2025 · Administration
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No harm found · C July 23, 2025 · found via complaint
Post nurse staffing information every day.
Corrected August 28, 2025 · Nursing and Physician Services
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Immediate jeopardy · J April 17, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 23, 2025 · Quality of Life and Care
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Actual harm · G April 17, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 23, 2025 · Quality of Life and Care
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Actual harm · G April 17, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 23, 2025 · Quality of Life and Care
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Potential for harm · D April 17, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected May 23, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 17, 2025
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected May 23, 2025 · Resident Rights
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Potential for harm · D April 17, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 17, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 23, 2025 · Pharmacy Service
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Potential for harm · D April 17, 2025
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.
Corrected May 23, 2025 · Pharmacy Service
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Potential for harm · E April 17, 2025
Have policies on smoking.
Corrected May 23, 2025 · Environmental
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Potential for harm · D April 17, 2025 · found via complaint
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected May 23, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F April 17, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected May 23, 2025 · Nursing and Physician Services
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Potential for harm · F April 17, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 23, 2025 · Infection Control
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Potential for harm · F April 17, 2025 · found via complaint
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected May 23, 2025 · Infection Control
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Potential for harm · D April 17, 2025 · found via complaint
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected May 23, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 23, 2025 | Payment Denial | 36 days |
| April 25, 2024 | Fine | $119,141 |
| April 25, 2024 | Payment Denial | 150 days |
| October 16, 2023 | Fine | $17,243 |
| October 16, 2023 | Payment Denial | 126 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525262 · certified since June 1, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.