Facility Watch Inspection records for every certified US nursing home

Rock River Nursing & Rehab

430 Wilcox ST
Fort Atkinson, WI 53538
(920) 563-5533

Special Focus Facility — SFF
CCN
525262
Certified beds
87
Ownership
For profit - Corporation
Chain
Bedrock Healthcare

Nurse staffing

4.76
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.99 hours per resident per day

Nursing staff turnover: 77% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected February 6, 2026

1 citation · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected March 10, 2026

Inspected December 4, 2025

3 citations · from a complaint investigation · Health
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected January 13, 2026
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected January 13, 2026
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected January 13, 2026

Inspected July 23, 2025

7 citations · from a complaint investigation · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected August 28, 2025
D
F0745 No actual harm with potential for more than minimal harm · Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected August 28, 2025
D
F0942 No actual harm with potential for more than minimal harm · Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected August 28, 2025
D
F0943 No actual harm with potential for more than minimal harm · Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected August 28, 2025
D
F0944 No actual harm with potential for more than minimal harm · Isolated

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected August 28, 2025
E
F0949 No actual harm with potential for more than minimal harm · Pattern

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected August 28, 2025
K
F0689 Immediate jeopardy to resident health or safety · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected August 28, 2025

Inspected April 17, 2025

14 citations · from a complaint investigation · Health
D
F0553 No actual harm with potential for more than minimal harm · Isolated

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Deficient, Provider has date of correction · corrected May 23, 2025
D
F0604 No actual harm with potential for more than minimal harm · Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Deficient, Provider has date of correction · corrected May 23, 2025
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected May 23, 2025
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected May 23, 2025
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected May 23, 2025
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 23, 2025
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected May 23, 2025
E
F0926 No actual harm with potential for more than minimal harm · Pattern

Have policies on smoking.

Deficient, Provider has date of correction · corrected May 23, 2025
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected May 23, 2025
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected May 23, 2025
F
F0882 No actual harm with potential for more than minimal harm · Widespread

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Deficient, Provider has date of correction · corrected May 23, 2025
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected May 23, 2025
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected May 23, 2025
J
F0684 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 23, 2025

Inspected January 15, 2025

18 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0726 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0942 No actual harm with potential for more than minimal harm · Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0943 No actual harm with potential for more than minimal harm · Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected February 13, 2025
D
F0945 No actual harm with potential for more than minimal harm · Isolated

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Deficient, Provider has date of correction · corrected February 13, 2025
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected February 13, 2025
F
F0730 No actual harm with potential for more than minimal harm · Widespread

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected February 13, 2025
F
F0837 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected February 13, 2025
F
F0941 No actual harm with potential for more than minimal harm · Widespread

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected February 13, 2025
F
F0944 No actual harm with potential for more than minimal harm · Widespread

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected February 13, 2025
F
F0946 No actual harm with potential for more than minimal harm · Widespread

Provide training in compliance and ethics.

Deficient, Provider has date of correction · corrected February 13, 2025
F
F0949 No actual harm with potential for more than minimal harm · Widespread

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected February 13, 2025
J
F0684 Immediate jeopardy to resident health or safety · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 23, 2025
J
F0755 Immediate jeopardy to resident health or safety · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected February 13, 2025

Inspected September 11, 2024

23 citations · from a complaint investigation · Health
C
F0814 No actual harm with potential for minimal harm · Widespread

Dispose of garbage and refuse properly.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0553 No actual harm with potential for more than minimal harm · Isolated

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0559 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0563 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0660 No actual harm with potential for more than minimal harm · Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0676 No actual harm with potential for more than minimal harm · Isolated

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0699 No actual harm with potential for more than minimal harm · Isolated

Provide care or services that was trauma informed and/or culturally competent.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0745 No actual harm with potential for more than minimal harm · Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected October 18, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected October 18, 2024
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected October 18, 2024
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected October 18, 2024
E
F0726 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected October 18, 2024
E
F0755 No actual harm with potential for more than minimal harm · Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected October 18, 2024
F
F0925 No actual harm with potential for more than minimal harm · Widespread

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Deficient, Provider has date of correction · corrected October 18, 2024

Inspected July 24, 2024

1 citation · from a complaint investigation · Health
F
F0837 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected August 15, 2024

Inspected June 12, 2024

7 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected July 16, 2024
D
F0585 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 16, 2024
D
F0660 No actual harm with potential for more than minimal harm · Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Deficient, Provider has date of correction · corrected July 16, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 16, 2024
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected July 16, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 16, 2024
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected October 21, 2024

Inspected April 25, 2024

17 citations · from a complaint investigation · Health
D
F0578 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0742 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0807 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Deficient, Provider has date of correction · corrected May 23, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 16, 2024
E
F0625 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected May 23, 2024
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected May 23, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected May 23, 2024
F
F0725 No actual harm with potential for more than minimal harm · Widespread

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected May 23, 2024
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected October 21, 2024
J
F0678 Immediate jeopardy to resident health or safety · Isolated

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Past Non-Compliance · corrected April 9, 2024

Inspected March 7, 2024

2 citations · from a complaint investigation · Health
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected March 19, 2024
D
F0697 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected March 19, 2024

Inspected February 21, 2024

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected March 12, 2024

Inspected December 12, 2023

6 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected January 12, 2024
D
F0678 No actual harm with potential for more than minimal harm · Isolated

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Deficient, Provider has date of correction · corrected January 12, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 12, 2024
D
F0804 No actual harm with potential for more than minimal harm · Isolated

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected January 12, 2024
E
F0572 No actual harm with potential for more than minimal harm · Pattern

Give residents a notice of rights, rules, services and charges.

Deficient, Provider has date of correction · corrected January 12, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected January 12, 2024

Inspected October 16, 2023

18 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0554 No actual harm with potential for more than minimal harm · Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0604 No actual harm with potential for more than minimal harm · Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0810 No actual harm with potential for more than minimal harm · Isolated

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Deficient, Provider has date of correction · corrected November 10, 2023
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected November 10, 2023
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected November 10, 2023
E
F0585 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected November 10, 2023
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected November 10, 2023
E
F0759 No actual harm with potential for more than minimal harm · Pattern

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected November 10, 2023
E
F0805 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Deficient, Provider has date of correction · corrected November 10, 2023
E
F0825 No actual harm with potential for more than minimal harm · Pattern

Provide or get specialized rehabilitative services as required for a resident.

Deficient, Provider has date of correction · corrected November 10, 2023
F
F0804 No actual harm with potential for more than minimal harm · Widespread

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected November 10, 2023
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected November 10, 2023
F
F0814 No actual harm with potential for more than minimal harm · Widespread

Dispose of garbage and refuse properly.

Deficient, Provider has date of correction · corrected November 10, 2023
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 12, 2024

Penalties

DateTypeAmount
July 23, 2025Payment Denial · 36 days
April 25, 2024Fine$119,141
April 25, 2024Payment Denial · 150 days
October 16, 2023Fine$17,243
October 16, 2023Payment Denial · 126 days

Ownership transfers

EffectiveSellerBuyer
10/01/2019Dycora Transitional Health-fort Atkinson LLCBedrock HCS at Atkinson LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.