The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited July 2025 — limited pattern, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: K
Nursing home report
Rock River Nursing & Rehab
FORT ATKINSON, WI · Medicare-certified · 87 beds
Needs attention
Special Focus FacilityFor-profitChain member
Not yet rated
Overall rating: not rated. Rock River Nursing & Rehab is a Special Focus Facility (SFF) with reported nurse staffing above the federal benchmark (4.69 vs 4.1 hours per resident per day), $0 in fines over the last 24 months, and recent inspection citations related to accident hazards/supervision, treatment and care per orders and preferences, and pharmaceutical services.
Facility ratings
Health inspections
Staffing
4.6891 hrs/resident/day
Quality measures
Last inspection: February 6, 2026Penalties, last 24 months: $0special focus facility
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.6891.
Staffing detail
- Registered nurses
- 0.98
- Licensed practical nurses
- 1.17
- Nurse aides
- 2.54
- Weekend nursing
- 4.06
Hours per resident per day.
Total staff turnover: 77%
Registered nurse turnover: 83%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
—19%—
Residents with a fall causing major injury
0%4.5%Worsening
Residents with pressure ulcers (bedsores)
8.6%3.1%Improving
Residents with a urinary tract infection
2.7%10%Worsening
Residents who lost too much weight
5.7%4.5%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
14.7%10%Improving
Residents whose ability to walk got worse
—9%—
Long-stay residents on antianxiety or sleep medication
28.6%19%Improving
Residents with a long-term catheter
3.4%0%Improving
Residents with new or worsening incontinence
17.4%23.8%Worsening
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—89.1%—
Long-stay residents given the pneumonia vaccine
81.1%100%Improving
What the inspectors found
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited April 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: J
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited January 2025 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: J
The home failed to ensure staff provided basic life support, including CPR, before emergency medical personnel arrived. Cited April 2024 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 678 — 42 CFR §483.24(a)(3) — S/S: J
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- INSPECTION
Health inspection found 7 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 2 fines · $136,384 in total fines · 3 payment denials.
- 36 days
Medicare/Medicaid payment denial
Jul 23, 2025
- 150 days
Medicare/Medicaid payment denial
Apr 25, 2024
- $119,141
Federal fine
Apr 25, 2024
- 126 days
Medicare/Medicaid payment denial
Oct 16, 2023
- $17,243
Federal fine
Oct 16, 2023
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of BEDROCK HEALTHCARE · 9 homes · 1.4 stars avg
- Occupancy
- 21.3 residents on an average day (24% of 87 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 47 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.