Cycle 1
Health 2025-12-04 · Fire 2025-12-04
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fort Atkinson, WI
Rock River Nursing & Rehab
0-star overall rating with 0-star inspections with Special Focus status with $136,384 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
430 Wilcox St, Fort Atkinson, WI
(920) 563-5533
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
23
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Healthcare
Operator or chain grouping
Approved since
1979-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 1 overall / 1 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
93%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,082
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.09% · Performance 23.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.56
Baseline 8.34% · Performance 6.31% · Measure score 5.56 · Achievement 5.09 · Improvement 5.56
Total nurse turnover
0
Baseline 73.77% · Performance 73.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.04
Baseline 2.40 hours · Performance 3.60 hours · Measure score 3.04 · Achievement 1.83 · Improvement 3.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 14.93% · Lower 95% interval 7.66% |
| Discharge to community | 36.48% |
50.57%
14.1 pts worse
|
Worse than the National Rate · Eligible stays 57 · Observed rate 24.56% · Lower 95% interval 27.01% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 10 · Denominator 24 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 8 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 3.44% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 45.83% |
56.45%
10.6 pts worse
|
Numerator 11 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
95.7%
6.6 pts worse
|
93.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 81.1% · Q3 100.0% · Q4 95.7% · 4Q avg 89.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.1% |
95.0%
5.9 pts worse
|
95.5%
6.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
4.9%
0.7 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.7% · Q3 7.1% · Q4 4.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
16.6%
10.7 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 28.6% · Q3 24.1% · Q4 13.6% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.0% |
16.7%
10.3 pts worse
|
16.7%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.0% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
21.1%
16.7 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
17.3%
0.7 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 14.7% · Q3 29.6% · Q4 23.8% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
2.3%
1.3 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.4% · Q3 3.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
3.0%
0.7 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.7% · Q3 6.7% · Q4 4.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
25.5%
0.1 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 17.4% · Q3 31.2% · Q4 23.8% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
5.5%
3.9 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 8.6% · Q3 8.1% · Q4 6.2% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.8% |
86.8%
15 pts worse
|
81.7%
9.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.4% · 4Q avg 71.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-04-17 · Fire 2025-04-17
64 health deficiencies
Top issue: Quality of Life and Care (16 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2024-04-25 · Fire 2024-04-25
45 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
15 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-05
F · Potential for more than minimal harm
2025-12-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-09
F · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-04
F · Potential for more than minimal harm
2025-12-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-04
F · Potential for more than minimal harm
2025-12-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-04
F · Potential for more than minimal harm
2025-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-04
E · Potential for more than minimal harm
2025-12-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-05
E · Potential for more than minimal harm
2025-12-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-04
F · Potential for more than minimal harm
2025-04-17
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-04-17
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-04-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-01
F · Potential for more than minimal harm
2025-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-17
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-04-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-04-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-04-17
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-01-15
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-04-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-05-23
C · Minimal harm
2024-04-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-13
K · Immediate jeopardy
2025-07-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-28
E · Potential for more than minimal harm
2025-07-23
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-23
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-23
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-23
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-23
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-08-28
C · Minimal harm
2025-07-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-28
J · Immediate jeopardy
2025-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-23
G · Actual harm
2025-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-23
G · Actual harm
2025-04-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-17
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-17
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F758 · Pharmacy Service Deficiencies
Health
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 2025-05-23
D · Potential for more than minimal harm
2025-04-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-23
J · Immediate jeopardy
2025-01-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-23
J · Immediate jeopardy
2025-01-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-15
F837 · Administration Deficiencies
Health
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.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-15
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-15
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-15
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-15
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-01-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-15
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-02-13
F · Potential for more than minimal harm
2024-09-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-09-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F758 · Pharmacy Service Deficiencies
Health
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 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
C · Minimal harm
2024-09-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-24
F837 · Administration Deficiencies
Health
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.
Corrected 2024-08-15
G · Actual harm
2024-06-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-06-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-16
J · Immediate jeopardy
2024-04-25
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-04-09
G · Actual harm
2024-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-04-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F758 · Pharmacy Service Deficiencies
Health
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 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-03-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-12
F · Potential for more than minimal harm
2023-12-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-12
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-12
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-12
D · Potential for more than minimal harm
2023-12-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-12
G · Actual harm
2023-10-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-12
F · Potential for more than minimal harm
2023-10-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-16
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-16
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-03-21
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-15
Penalties and ownership
What sits behind the stars
$0
2025-07-23
Payment Denial
Payment Denial · denial start 2025-07-23 · 36 days
36 day denial
$119,141
2024-04-25
Fine
Fine · fine $119,141
Fine
$0
2024-04-25
Payment Denial
Payment Denial · denial start 2024-05-24 · 150 days
150 day denial
$17,243
2023-10-16
Fine
Fine · fine $17,243
Fine
$0
2023-10-16
Payment Denial
Payment Denial · denial start 2023-11-14 · 126 days
126 day denial
Ownership
Bedrock Hc Wi LLC
5% Or Greater Direct Ownership Interest · Organization
Chopp, Pnina
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Martin
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Brewer, Anthony
Operational/Managerial Control · Individual
Chopp, Martin
Operational/Managerial Control · Individual
Chopp, Pnina
Operational/Managerial Control · Individual
Chopp, Solomon
Operational/Managerial Control · Individual
Opal Healthcare Wi LLC
Operational/Managerial Control · Organization
Ramanujam, Sandeep
Operational/Managerial Control · Individual
Nearby options
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2-star overall rating with 2-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Edgerton Care Center, Inc
Edgerton, WI
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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