Public Record
Rock River Nursing & Rehab
From CMS
Facility profile
- Certified beds
- 87
- Avg. residents per day
- 21.3
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 167
- Inspections on file
- 18
- Last inspection
- 2026-02-06
*CMS
*CMS
*CMS
Citations
167 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0944Generalpotential for harm
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- 0943Generalpotential for harm
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0942Generalpotential for harm
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0949Generalpotential for harm
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0882Generalpotential for harm
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0031Generalpotential for harm
Provide emergency officials' contact information.
- 0025Generalpotential for harm
Create arrangements with other facilities to receive patients.
- 0013Generalpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0007Generalpotential for harm
Address patient/client population and determine types of services needed.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0925Generalpotential for harm
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0347Generalpotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0553Generalpotential for harm
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0758Generalpotential for harm
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.
- 0926Generalpotential for harm
Have policies on smoking.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0949Generalpotential for harm
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- 0946Generalpotential for harm
Provide training in compliance and ethics.
- 0945Generalpotential for harm
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
- 0944Generalpotential for harm
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- 0943Generalpotential for harm
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0942Generalpotential for harm
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- 0941Generalpotential for harm
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0837Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0500Generalpotential for harm
Meet other general requirements that are deficient.
- 0755Seriousimmediate jeopardy
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0726Generalpotential for harm
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.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0553Generalpotential for harm
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0559Generalpotential for harm
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
- 0563Generalpotential for harm
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0726Generalpotential for harm
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.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0758Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0814Generalno actual harm
Dispose of garbage and refuse properly.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0837Generalpotential for harm
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.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0585Generalpotential for harm
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.
- 0687Generalpotential for harm
Provide appropriate foot care.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0742Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
- 0758Generalpotential for harm
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.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0678Seriousimmediate jeopardy
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0807Generalpotential for harm
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222Generalpotential for harm
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.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalno actual harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0911Generalpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0919Generalpotential for harm
Meet requirements for the use of electrical equipment.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0572Generalpotential for harm
Give residents a notice of rights, rules, services and charges.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0678Generalpotential for harm
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0810Generalpotential for harm
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0825Generalpotential for harm
Provide or get specialized rehabilitative services as required for a resident.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0585Generalpotential for harm
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.
- 0584Generalpotential for harm
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.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0559Generalpotential for harm
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection1 deficiency
- View inspection reportInspection14 deficiencies
- View inspection reportInspection14 deficiencies
- View inspection reportInspection7 deficiencies
- View inspection reportInspection33 deficiencies
- View inspection reportInspection33 deficiencies
- View inspection reportInspection19 deficiencies
- View inspection reportInspection19 deficiencies
- View inspection reportInspection23 deficiencies
- View inspection reportInspection1 deficiency
Showing the 10 most recent inspections. 8 earlier inspections are also on record.
FAQ
Questions and answers
- What is Rock River Nursing & Rehab?
- Rock River Nursing & Rehab is a Medicare- and Medicaid-certified nursing home in Fort Atkinson, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525262.
- How many beds does Rock River Nursing & Rehab have?
- Rock River Nursing & Rehab is certified for 87 beds. It serves an average of 21.3 residents per day.
- How many citations does Rock River Nursing & Rehab have?
- Rock River Nursing & Rehab has 167 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Rock River Nursing & Rehab last inspected?
- Rock River Nursing & Rehab was last inspected on February 6, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/525262-rock-river-nursing-rehab