Elder Care Record

Wisconsin › Jefferson County › Fort Atkinson

Rock River Nursing & Rehab

430 Wilcox St, Fort Atkinson, WI 53538

CCN 525262 · For-profit, corporation · 87 certified beds · chain Bedrock Healthcare

Overall★★★★★
Health inspection★★★★★
Staffing★★★★★
Quality measures★★★★★

Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.

Certified for 87 beds, Rock River Nursing & Rehab serves Fort Atkinson in Jefferson County, Wisconsin and has taken Medicare and Medicaid residents since 1979.

CMS gives it 1 of 5 stars overall, below the Wisconsin median of 3; the health inspection rating is 1, staffing 2 and quality measures 2.

Inspectors recorded 115 health deficiencies across the three most recent survey cycles (8, 52, 55 by cycle, most recent first), 10 of them at the actual-harm or immediate-jeopardy level. That is 132.2 per 100 beds, more than the state median of 31.8.

CMS lists 5 penalties in the period covered: fines totalling $136K and 3 payment denials.

Reported nurse staffing is 4.4 hours per resident per day (0.8 RN), close to the Wisconsin median of 4.0; nursing staff turnover is 70.2%.

115health deficiencies, 3 survey cycles10 at actual harm or worse
$136Kfines listed by CMS5 penalties in period
4.4nurse hours per resident per daystate median 4.0
31%occupancy (residents ÷ beds)27 residents a day

Compared with county, state and nation

MeasureThis facilityJefferson Co. medianWisconsin medianUS average
Overall star rating1133.0
Health citations, 3 cycles115572128.7
Citations per 100 beds132.247.531.826.8
Total nurse hours per resident day4.43.64.03.9
RN hours per resident day0.80.90.90.7
Nursing staff turnover70.2%42.2%46.2%45.8%
Fines listed$136,384$136,384$0—

County and state figures are medians across facilities (3 in the county, 323 in the state); the US column is the CMS national average where CMS publishes one.

Citations by survey cycle

Cycle 1 (latest)8
Cycle 252
Cycle 355

Dark bar: this facility. Grey bar: Wisconsin average per facility for the same cycle, as published by CMS. Standard health survey dates: 6 May 2026, 4 Dec 2025.

Severity mix: J ×4 K ×1 G ×5 D ×73 E ×15 F ×15 C ×2

Health deficiencies

Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.

Scope and severity letters (A–L)
Isolated
Pattern
Widespread
Immediate jeopardy
J
K
L
Actual harm
G
H
I
Potential for more than minimal harm
D
E
F
Potential for minimal harm
A
B
C

Survey dateTagWhat the tag requiresSeverityTypeCorrected
6 May 2026F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard survey4 Jun 2026
6 May 2026F0688Provide 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.DStandard survey4 Jun 2026
6 May 2026F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DStandard survey4 Jun 2026
6 May 2026F0757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard survey4 Jun 2026
6 May 2026F0791Provide or obtain dental services for each resident.DStandard survey4 Jun 2026
6 May 2026F0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.DStandard survey4 Jun 2026
6 May 2026F0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard survey4 Jun 2026
6 Feb 2026F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint investigation10 Mar 2026
4 Dec 2025F0610Respond appropriately to all alleged violations.DComplaint investigation13 Jan 2026
4 Dec 2025F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard survey13 Jan 2026
4 Dec 2025F0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard survey13 Jan 2026
23 Jul 2025F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.KComplaint investigation28 Aug 2025
23 Jul 2025F0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.EComplaint investigation28 Aug 2025
23 Jul 2025F0745Provide medically-related social services to help each resident achieve the highest possible quality of life.DComplaint investigation28 Aug 2025
23 Jul 2025F0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.DComplaint investigation28 Aug 2025
23 Jul 2025F0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.DComplaint investigation28 Aug 2025
23 Jul 2025F0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.DComplaint investigation28 Aug 2025
23 Jul 2025F0732Post nurse staffing information every day.CComplaint investigation28 Aug 2025
17 Apr 2025F0610Respond appropriately to all alleged violations.DComplaint investigation23 May 2025
17 Apr 2025F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.JStandard survey23 May 2025
17 Apr 2025F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GStandard survey23 May 2025
17 Apr 2025F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GStandard survey23 May 2025
17 Apr 2025F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.FComplaint investigation23 May 2025
17 Apr 2025F0880Provide and implement an infection prevention and control program.FComplaint investigation23 May 2025
17 Apr 2025F0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.FComplaint investigation23 May 2025
17 Apr 2025F0926Have policies on smoking.EStandard survey23 May 2025
17 Apr 2025F0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.DStandard survey23 May 2025
17 Apr 2025F0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DComplaint investigation23 May 2025
17 Apr 2025F0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDStandard survey23 May 2025
17 Apr 2025F0757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard survey23 May 2025
17 Apr 2025F0758Implement 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.DStandard survey23 May 2025
17 Apr 2025F0883Develop and implement policies and procedures for flu and pneumonia vaccinations.DComplaint investigation23 May 2025
15 Jan 2025F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.JComplaint investigation23 May 2025
15 Jan 2025F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.JComplaint investigation13 Feb 2025
15 Jan 2025F0730Observe each nurse aide's job performance and give regular training.FComplaint investigation13 Feb 2025
15 Jan 2025F0837Establish 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.FComplaint investigation13 Feb 2025
15 Jan 2025F0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.FComplaint investigation13 Feb 2025
15 Jan 2025F0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.FComplaint investigation13 Feb 2025
15 Jan 2025F0946Provide training in compliance and ethics.FComplaint investigation13 Feb 2025
15 Jan 2025F0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.FComplaint investigation13 Feb 2025
15 Jan 2025F0584Honor 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.EComplaint investigation13 Feb 2025
15 Jan 2025F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint investigation13 Feb 2025
15 Jan 2025F0610Respond appropriately to all alleged violations.DComplaint investigation13 Feb 2025
15 Jan 2025F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint investigation13 Feb 2025
15 Jan 2025F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.DComplaint investigation13 Feb 2025
15 Jan 2025F0759Ensure medication error rates are not 5 percent or greater.DComplaint investigation13 Feb 2025
15 Jan 2025F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint investigation13 Feb 2025
15 Jan 2025F0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.DComplaint investigation13 Feb 2025
15 Jan 2025F0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.DComplaint investigation13 Feb 2025
15 Jan 2025F0945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.DComplaint investigation13 Feb 2025
11 Sep 2024F0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint investigation18 Oct 2024
11 Sep 2024F0584Honor 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.EComplaint investigation18 Oct 2024
11 Sep 2024F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EComplaint investigation18 Oct 2024
11 Sep 2024F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.EComplaint investigation18 Oct 2024
11 Sep 2024F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint investigation18 Oct 2024
11 Sep 2024F0552Ensure that residents are fully informed and understand their health status, care and treatments.DComplaint investigation18 Oct 2024
11 Sep 2024F0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.DComplaint investigation18 Oct 2024
11 Sep 2024F0558Reasonably accommodate the needs and preferences of each resident.DComplaint investigation18 Oct 2024
11 Sep 2024F0559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.DComplaint investigation18 Oct 2024
11 Sep 2024F0563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.DComplaint investigation18 Oct 2024
11 Sep 2024F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint investigation18 Oct 2024
11 Sep 2024F0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint investigation18 Oct 2024
11 Sep 2024F0660Plan the resident's discharge to meet the resident's goals and needs.DComplaint investigation18 Oct 2024
11 Sep 2024F0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.DComplaint investigation18 Oct 2024
11 Sep 2024F0677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint investigation18 Oct 2024
11 Sep 2024F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint investigation18 Oct 2024
11 Sep 2024F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint investigation18 Oct 2024
11 Sep 2024F0699Provide care or services that was trauma informed and/or culturally competent.DComplaint investigation18 Oct 2024
11 Sep 2024F0745Provide medically-related social services to help each resident achieve the highest possible quality of life.DComplaint investigation18 Oct 2024
11 Sep 2024F0758Implement 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.DComplaint investigation18 Oct 2024
11 Sep 2024F0759Ensure medication error rates are not 5 percent or greater.DComplaint investigation18 Oct 2024
11 Sep 2024F0880Provide and implement an infection prevention and control program.DComplaint investigation18 Oct 2024
11 Sep 2024F0814Dispose of garbage and refuse properly.CComplaint investigation18 Oct 2024
24 Jul 2024F0837Establish 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.FComplaint investigation15 Aug 2024
12 Jun 2024F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint investigation21 Oct 2024
12 Jun 2024F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint investigation16 Jul 2024
12 Jun 2024F0585Honor 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.DComplaint investigation16 Jul 2024
12 Jun 2024F0660Plan the resident's discharge to meet the resident's goals and needs.DComplaint investigation16 Jul 2024
12 Jun 2024F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint investigation16 Jul 2024
12 Jun 2024F0687Provide appropriate foot care.DComplaint investigation16 Jul 2024
12 Jun 2024F0880Provide and implement an infection prevention and control program.DComplaint investigation16 Jul 2024
25 Apr 2024F0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.JComplaint investigation9 Apr 2024
25 Apr 2024F0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint investigation21 Oct 2024
25 Apr 2024F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EComplaint investigation23 May 2024
25 Apr 2024F0610Respond appropriately to all alleged violations.DComplaint investigation23 May 2024
25 Apr 2024F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint investigation23 May 2024
25 Apr 2024F0807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.DComplaint investigation23 May 2024
25 Apr 2024F0880Provide and implement an infection prevention and control program.DComplaint investigation16 Jul 2024
7 Mar 2024F0677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint investigation19 Mar 2024
7 Mar 2024F0697Provide safe, appropriate pain management for a resident who requires such services.DComplaint investigation19 Mar 2024
21 Feb 2024F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint investigation12 Mar 2024
12 Dec 2023F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint investigation12 Jan 2024
12 Dec 2023F0572Give residents a notice of rights, rules, services and charges.EComplaint investigation12 Jan 2024
12 Dec 2023F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint investigation12 Jan 2024
12 Dec 2023F0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.DComplaint investigation12 Jan 2024
12 Dec 2023F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint investigation12 Mar 2024
12 Dec 2023F0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.DComplaint investigation12 Jan 2024
16 Oct 2023F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint investigation12 Mar 2024
16 Oct 2023F0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.FComplaint investigation10 Nov 2023
16 Oct 2023F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint investigation10 Nov 2023
16 Oct 2023F0814Dispose of garbage and refuse properly.FComplaint investigation10 Nov 2023
16 Oct 2023F0584Honor 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.EComplaint investigation10 Nov 2023
16 Oct 2023F0585Honor 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.EComplaint investigation10 Nov 2023
16 Oct 2023F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EComplaint investigation10 Nov 2023
16 Oct 2023F0759Ensure medication error rates are not 5 percent or greater.EComplaint investigation10 Nov 2023
16 Oct 2023F0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.EComplaint investigation10 Nov 2023
16 Oct 2023F0825Provide or get specialized rehabilitative services as required for a resident.EComplaint investigation10 Nov 2023
16 Oct 2023F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint investigation10 Nov 2023
16 Oct 2023F0554Allow residents to self-administer drugs if determined clinically appropriate.DComplaint investigation10 Nov 2023
16 Oct 2023F0583Keep residents' personal and medical records private and confidential.DComplaint investigation10 Nov 2023
16 Oct 2023F0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DComplaint investigation10 Nov 2023
16 Oct 2023F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint investigation10 Nov 2023
16 Oct 2023F0760Ensure that residents are free from significant medication errors.DComplaint investigation10 Nov 2023
16 Oct 2023F0810Provide special eating equipment and utensils for residents who need them and appropriate assistance.DComplaint investigation10 Nov 2023
16 Oct 2023F0880Provide and implement an infection prevention and control program.DComplaint investigation10 Nov 2023

Penalties

DateTypeAmountDetail
23 Jul 2025Payment denial—36 days
25 Apr 2024Payment denial—150 days
25 Apr 2024Fine$119,141
16 Oct 2023Payment denial—126 days
16 Oct 2023Fine$17,243

Staffing

Total nursing4.36 h
Nurse aides2.45 h
LPN1.08 h
RN0.83 h
Weekend total3.87 h

Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Wisconsin average. Turnover: nursing staff 70.2%, RNs 77.8%; 3 administrators left in the reporting year.

Quality measures

MeasureResidentsThis facilityWisconsin medianUS median
Percentage of long-stay residents whose need for help with daily activities has increasedLong Stay22.1%15.4%12.6%
Percentage of long-stay residents with a catheter inserted and left in their bladderLong Stay1.9%1.5%0.3%
Percentage of long-stay residents with a urinary tract infectionLong Stay7.5%2.3%0.9%
Percentage of long-stay residents experiencing one or more falls with major injuryLong Stay2.1%3.0%2.8%
Percentage of long-stay residents whose ability to walk independently worsenedLong Stay5.2%16.8%12.5%
Percentage of long-stay residents with pressure ulcersLong Stay6.0%4.4%4.2%
Percentage of long-stay residents who received an antipsychotic medicationLong Stay31.4%14.4%13.4%

Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.

Ownership

Ownership type: for-profit, corporation. Legal business name: Bedrock Hcs At Atkinson Llc. Chain: Bedrock Healthcare (9 facilities).

OrganisationRole in the CMS recordInterestSince
Opal Healthcare Wi LLCOperational/managerial controlNOT APPLICABLE10/01/2019
Opal Healthcare Wi LLCAdp of the snfNOT APPLICABLE03/31/2025

Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.

Other nursing homes in Jefferson County

FacilityCityBedsOverallHealthStaffingCitationsPer 100 bedsFinesLast survey
Lake Mills Health ServicesLake Mills504441836.0$121K3 Jul 2025
Alden Estates of Countryside, IncJefferson1201125747.5$397K5 Jun 2026

All 3 facilities in Jefferson County

Questions and answers

How many deficiencies has Rock River Nursing & Rehab been cited for?

115 health deficiencies across the three most recent survey cycles, 10 at the actual-harm or immediate-jeopardy level. The Wisconsin median is 21 per facility.

Has Rock River Nursing & Rehab been fined?

Yes. CMS lists fines totalling $136K in the period covered, plus 3 payment denials.

How does staffing at Rock River Nursing & Rehab compare?

Reported total nurse staffing is 4.4 hours per resident per day against a Wisconsin median of 4.0 and a national average of 3.9.

Who operates Rock River Nursing & Rehab?

It is part of the Bedrock Healthcare chain. Ownership type is for-profit, corporation. Organisations in the CMS ownership record include Opal Healthcare Wi LLC. Individual owners and managers are not listed on this site.

When was Rock River Nursing & Rehab last inspected?

The most recent survey or investigation in the CMS record is dated 6 May 2026; the most recent standard health survey was 6 May 2026.

Where does this data come from?

All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.

Provenance

Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.