Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 525262

Rock River Nursing & Rehab

120 federal citations on record , including 5 at the Immediate Jeopardy level, and 5 federal enforcement actions totaling $136,384.

Special Focus Status 5 Immediate Jeopardy

Record summary

Federal record · Q1 2026
120
Total citations
117
Last 3 years
10
Actual harm+
5
Federal penalties
$136,384
Total fines
—
Overall ★ rating

Most common violation categories here

Quality of Care31 Resident Rights25 Medication & Pharmacy13 Nutrition & Dietary10 Nursing & Physician Services8

Most common F-tags at this facility

F6898 F6846 F8805 F6104 F5804

Citation history

120 on record
SurveyF-TagViolationSeveritySource
Dec 4, 2025F610Respond appropriately to all alleged violations.DComplaint
Dec 4, 2025F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Dec 4, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Jul 23, 2025F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.EComplaint
Jul 23, 2025F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.DComplaint
Jul 23, 2025F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.DComplaint
Jul 23, 2025F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.DComplaint
Jul 23, 2025F745Provide medically-related social services to help each resident achieve the highest possible quality of life.DComplaint
Jul 23, 2025F732Post nurse staffing information every day.CComplaint
Jul 23, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.KComplaint
Apr 17, 2025F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DComplaint
Apr 17, 2025F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.FComplaint
Apr 17, 2025F880Provide and implement an infection prevention and control program.FComplaint
Apr 17, 2025F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.FComplaint
Apr 17, 2025F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DComplaint
Apr 17, 2025F926Have policies on smoking.EStandard
Apr 17, 2025F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.DStandard
Apr 17, 2025F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Apr 17, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GStandard
Apr 17, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GStandard
Apr 17, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.JStandard
Apr 17, 2025F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDStandard
Apr 17, 2025F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.DStandard
Apr 17, 2025F610Respond appropriately to all alleged violations.DComplaint
Jan 15, 2025F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.FComplaint
Jan 15, 2025F946Provide training in compliance and ethics.FComplaint
Jan 15, 2025F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.DComplaint
Jan 15, 2025F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.FComplaint
Jan 15, 2025F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.DComplaint
Jan 15, 2025F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.DComplaint
Jan 15, 2025F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.FComplaint
Jan 15, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Jan 15, 2025F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.FComplaint
Jan 15, 2025F759Ensure medication error rates are not 5 percent or greater.DComplaint
Jan 15, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.JComplaint
Jan 15, 2025F730Observe each nurse aide's job performance and give regular training.FComplaint
Jan 15, 2025F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.DComplaint
Jan 15, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Jan 15, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.JComplaint
Jan 15, 2025F610Respond appropriately to all alleged violations.DComplaint
Jan 15, 2025F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.EComplaint
Jan 15, 2025F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Sep 11, 2024F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint
Sep 11, 2024F880Provide and implement an infection prevention and control program.DComplaint
Sep 11, 2024F814Dispose of garbage and refuse properly.CComplaint
Sep 11, 2024F759Ensure medication error rates are not 5 percent or greater.DComplaint
Sep 11, 2024F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.DComplaint
Sep 11, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Sep 11, 2024F745Provide medically-related social services to help each resident achieve the highest possible quality of life.DComplaint
Sep 11, 2024F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.EComplaint
Sep 11, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EComplaint
Sep 11, 2024F699Provide care or services that was trauma informed and/or culturally competent.DComplaint
Sep 11, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Sep 11, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Sep 11, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Sep 11, 2024F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.DComplaint
Sep 11, 2024F660Plan the resident's discharge to meet the resident's goals and needs.DComplaint
Sep 11, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint
Sep 11, 2024F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.EComplaint
Sep 11, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Sep 11, 2024F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.DComplaint
Sep 11, 2024F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.DComplaint
Sep 11, 2024F558Reasonably accommodate the needs and preferences of each resident.DComplaint
Sep 11, 2024F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.DComplaint
Sep 11, 2024F552Ensure that residents are fully informed and understand their health status, care and treatments.DComplaint
Jul 24, 2024F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.FComplaint
Jun 12, 2024F880Provide and implement an infection prevention and control program.DComplaint
Jun 12, 2024F687Provide appropriate foot care.DComplaint
Jun 12, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Jun 12, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Jun 12, 2024F660Plan the resident's discharge to meet the resident's goals and needs.DComplaint
Jun 12, 2024F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.DComplaint
Jun 12, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Apr 25, 2024F880Provide and implement an infection prevention and control program.DComplaint
Apr 25, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EComplaint
Apr 25, 2024F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.DComplaint
Apr 25, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Apr 25, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Apr 25, 2024F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.JComplaint
Apr 25, 2024F610Respond appropriately to all alleged violations.DComplaint
Apr 25, 2024F761Ensure 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.DStandard
Apr 25, 2024F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.DStandard
Apr 25, 2024F742Provide 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.DStandard
Apr 25, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.FStandard
Apr 25, 2024F692Provide enough food/fluids to maintain a resident's health.DStandard
Apr 25, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EStandard
Apr 25, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Apr 25, 2024F625Notify 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.EStandard
Apr 25, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Apr 25, 2024F578Honor 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.DStandard
Mar 7, 2024F697Provide safe, appropriate pain management for a resident who requires such services.DComplaint
Mar 7, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Feb 21, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Dec 12, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint
Dec 12, 2023F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.DComplaint
Dec 12, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Dec 12, 2023F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.DComplaint
Dec 12, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Dec 12, 2023F572Give residents a notice of rights, rules, services and charges.EComplaint
Oct 16, 2023F880Provide and implement an infection prevention and control program.DComplaint

Federal enforcement history

Federal regulators have imposed 5 enforcement actions against this facility, including 2 civil money penalties totaling $136,384 and 3 payment-denial actions spanning 312 days.

DateTypeFinePayment denial
Jul 23, 2025Payment Denial—Jul 23, 2025 · 36 days
Apr 25, 2024Fine$119,141—
Apr 25, 2024Payment Denial—May 24, 2024 · 150 days
Oct 16, 2023Fine$17,243—
Oct 16, 2023Payment Denial—Nov 14, 2023 · 126 days
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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