Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock County Hospital Long Term Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple co-morbid conditions developed pressure ulcers on the left heel and coccyx after being readmitted to the facility. Despite the resident's risk for pressure sores, the facility failed to document or implement preventive measures, leading to the development of the ulcers. The facility's inaction in reassessing and planning for the resident's needs contributed to the skin breakdown.
Two residents at high risk for falls experienced multiple falls without new interventions being implemented. Despite the facility's policy requiring fall risk assessments and interventions, no new measures were taken following several incidents. The DON confirmed the lack of action to prevent future falls.
The facility pharmacist failed to identify medication irregularities, including prescribing antipsychotics without proper diagnosis and not reviewing antidepressant doses for reduction. A resident was given Risperidone without a psychosis diagnosis, and another's Mirtazapine dose was not reviewed for reduction. Additionally, as-needed antipsychotic orders for three residents exceeded the 14-day reassessment limit without provider evaluation.
A facility failed to ensure a resident's antibiotic order included a required duration or documented rationale for continued use, as per their antibiotic stewardship policy. The resident, with a history of UTIs and other health issues, was prescribed Nitrofurantoin Monohyd Macro daily without an end date. Despite staff monitoring and contacting the provider, no rationale was documented for the continued use of the antibiotic, even after breakthrough infections.
The facility failed to comply with regulations for psychotropic medications, including prescribing antipsychotics without a supporting diagnosis, not reviewing antidepressant doses for reduction, and exceeding the 14-day limit for PRN antipsychotic orders for several residents.
A resident with severe cognitive impairment and a history of falls experienced another fall while unattended. Despite the facility's policy requiring immediate investigation and reporting to the State Agency, the investigation results were not submitted. This oversight constitutes a deficiency in compliance with state regulations.
A resident with severe cognitive impairment and multiple health conditions was readmitted to a facility with an increased risk for pressure sores. The facility failed to update the care plan to reflect this risk, leading to the development of pressure injuries on the resident's heel and coccyx. Although some interventions were implemented, they were not documented in the care plan, and the plan was revised only after the injuries were identified.
A facility failed to follow infection control protocols during wound care and medication handling for two residents. Staff did not change gloves or perform hand hygiene at appropriate intervals, improperly disposed of soiled dressings, and failed to use barriers for medication tubes. The DON confirmed these lapses, which were inconsistent with the facility's infection control policies.
Failure to Prevent Pressure Ulcers in a Resident
Penalty
Summary
The facility failed to implement measures to prevent the development of pressure ulcers for a resident, identified as Resident 10, prior to the development of pressure ulcers. The facility's policy on Pressure Injury Prevention and Management, reviewed in July 2023, outlined a commitment to preventing avoidable pressure injuries and promoting healing of existing pressure ulcers. However, the facility did not adequately evaluate the resident's clinical condition and risk factors, nor did it implement interventions consistent with the resident's needs and professional standards of practice. This lack of action led to the development of pressure ulcers on the resident's left heel and coccyx. Resident 10, who had severe cognitive impairment and required substantial assistance with transfers, bed mobility, dressing, and toileting hygiene, was readmitted to the facility from the hospital following a fall. The resident had multiple co-morbid conditions, including anemia, diabetes, heart failure, kidney disease, a thyroid disorder, high blood pressure, and dementia. Upon readmission, the resident's Braden Scale score indicated a risk for pressure sores, yet the facility did not document or care plan additional pressure sore prevention measures. Four days after readmission, a large blister with dark purple coloring was observed on the resident's left heel, and a pressure ulcer was identified on the coccyx the following day. The facility's failure to reassess and document the resident's risk for pressure sores and implement preventive measures contributed to the development of the pressure ulcers. Despite the resident's compromised movement and history of skin breakdown, the facility did not take timely action to prevent further skin damage. The Director of Nursing confirmed that the facility identified the pressure sores after the resident's readmission but did not document or plan additional preventive measures before the skin breakdown was observed.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement or revise interventions to prevent ongoing falls for two residents, despite their high risk for falls. The facility's policy on Fall Prevention and Treatment, last approved in January 2024, outlines that upon admission, a fall assessment should be completed to determine the resident's fall risk level, and appropriate interventions should be implemented. However, for both residents, the facility did not adhere to this policy, as no new interventions were put in place following multiple falls. Resident 8, diagnosed with high blood pressure, Alzheimer's Disease, and depression, was severely cognitively impaired and required assistance with daily activities. The resident had experienced several falls from February to April 2024, including rolling out of bed and being found on the floor multiple times. Despite these incidents, no new interventions were implemented to address the ongoing risk of falls, as confirmed by the Director of Nursing (DON). Similarly, Resident 24, who had hypertension and dementia, also experienced multiple falls from February to August 2024. The resident was found on the floor on several occasions, including sliding off the bed and falling in the hallway. Despite being at high risk for falls, as indicated by the facility's fall scale, no new interventions were implemented to prevent future falls. The DON confirmed that the facility did not take additional measures to prevent these incidents.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility pharmacist failed to identify medication irregularities for several residents, leading to deficiencies in medication management. Resident 15 was prescribed the antipsychotic medication Risperidone for anxiety and depression without a supporting diagnosis of psychosis, as confirmed by the Director of Nursing (DON). This oversight indicates a lack of adherence to the facility's policy, which requires psychotropic drugs to be prescribed only for specific diagnosed conditions documented in the clinical record. Resident 11's antidepressant medication, Mirtazapine, was not reviewed for a gradual dose reduction, nor was there documentation of a clinical rationale for maintaining the current dose. The medication had been prescribed since December 2022, and the facility pharmacist did not identify the need for a dose review, as confirmed by the DON. This failure to ensure a gradual dose reduction or provide a clinical rationale for continued use is a significant oversight in medication management. Additionally, Residents 8, 24, and 25 were prescribed as-needed antipsychotic medications without adhering to the 14-day reassessment requirement. The DON confirmed that the orders for these medications exceeded the 14-day limit without a provider's reassessment of the residents' conditions. This lack of compliance with the facility's policy on the use of psychotropic drugs highlights a systemic issue in the facility's medication management practices.
Failure to Document Antibiotic Duration and Rationale
Penalty
Summary
The facility failed to ensure that antibiotic medication orders for a resident included the required duration of use or a documented rationale for continued daily use, as per facility policies and clinical standards. The facility's antibiotic stewardship policy, revised in March 2024, mandates that all antibiotics require a diagnosis and duration of therapy, and are reviewed by the stewardship team to provide recommendations. However, the review of the resident's care plan and physician's order revealed that the resident was prescribed Nitrofurantoin Monohyd Macro daily without an end date, despite the facility's policy requirements. The resident, who has a history of urinary tract infections, bladder incontinence, self-care deficits, activity intolerance, and dementia, was given antibiotics as ordered. Despite the staff's efforts to monitor for signs and symptoms of infection and teach good hygiene practices, the provider did not document a rationale for the continued use of the antibiotic, even after being contacted by the Director of Nursing. This lack of documentation occurred despite breakthrough infections and no evidence that the prophylactic antibiotic was preventing further infections.
Non-compliance with Psychotropic Medication Regulations
Penalty
Summary
The facility failed to adhere to regulations regarding the use of psychotropic medications for several residents. Resident 15 was prescribed the antipsychotic medication Risperidone without a supporting diagnosis of psychosis, as confirmed by the Director of Nursing (DON). The resident's care plan indicated the use of psychotropic medications for anxiety and depression, but there was no documented evidence of psychosis, which is necessary to justify the use of such medication. Resident 11 was on the antidepressant medication Mirtazapine, which had not been reviewed for a gradual dose reduction since it was prescribed for mood in December 2022. The facility's Pharmacy Consultant did not identify the need for a dose reduction, nor was there any documented clinical contraindication for maintaining the current dose. This oversight was confirmed by the DON, indicating a failure to ensure the lowest effective dose was used. Additionally, the facility did not comply with the 14-day limit for PRN orders of antipsychotic medications for Residents 8, 24, and 25. Resident 8 received ABH Cream containing antipsychotic medication beyond the 14-day limit, as did Resident 24, who received the cream for agitation. Resident 25 was prescribed Haloperidol with a stop date exceeding the 14-day limit. These instances were confirmed by the DON, highlighting a systemic issue in managing PRN orders for psychotropic medications.
Failure to Report Investigation of Resident Fall
Penalty
Summary
The facility failed to submit a completed investigation report to the State Agency regarding a fall incident involving a resident. The facility's policy on Abuse, Neglect, and Exploitation, last approved in September 2023, mandates that any suspicion or report of abuse, neglect, or exploitation should trigger an immediate investigation. The policy requires that the nurse respond to the resident's needs, protect them from further incidents, notify the Director of Nursing (DON) and the Administrator, and report the alleged abuse to the State Agency within specified timeframes. However, in this case, the facility did not adhere to these procedures. Resident 8, who had severe cognitive impairment and required substantial assistance with daily activities, experienced a fall in their room. The resident's Minimum Data Set (MDS) indicated a history of falls without injuries. On the day of the incident, the resident was found walking unattended and fell. Although a call was placed to report the fall to the State Agency, an interview with the DON confirmed that no report was sent. This failure to report the investigation results within the required timeframe constitutes a deficiency in the facility's compliance with state regulations.
Failure to Revise Care Plan Leads to Pressure Injuries
Penalty
Summary
The facility failed to review and revise a resident's care plan addressing pressure ulcer risk, which led to the development of pressure injuries. The resident, who had severe cognitive impairment and multiple health conditions including anemia, diabetes, heart failure, kidney disease, a thyroid disorder, high blood pressure, and dementia, was readmitted to the facility from the hospital. Upon readmission, the resident's Braden Scale score indicated an increased risk for pressure sores, but the care plan was not updated to reflect this increased risk. The resident developed a large blister on the left heel and an open wound on the coccyx, which were not initially documented in the care plan. Although interventions such as a heel boot and a gel overlay mattress were implemented, these were not included in the care plan. The care plan was only revised eight days after the heel blister was identified and seven days after the coccyx wound was identified, failing to include all necessary pressure reduction interventions. The Director of Nursing confirmed that the facility assessed the resident's pressure ulcer risk upon readmission, but there was no evidence that the care plan was updated to reflect the increased risk. Additionally, there was no evidence that the facility implemented additional preventive measures until after the pressure injuries were identified, indicating a lapse in the facility's pressure injury prevention and management protocol.
Infection Control Deficiencies in Wound Care and Medication Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during wound care for two residents. For Resident 10, the staff did not change gloves or perform hand hygiene after cleaning a bowel movement before applying a clean dressing to a pressure ulcer. Additionally, the staff placed a soiled dressing directly on the floor and did not perform hand hygiene before applying a new dressing to another wound. These actions were contrary to the facility's infection control policy, which emphasizes the importance of hand hygiene and proper disposal of contaminated materials. Resident 20 also experienced deficiencies in care related to infection control. During a dressing change, the staff did not perform hand hygiene after changing gloves and before handling clean dressings. Furthermore, the staff failed to use a barrier when placing a medication tube on the resident's bedside table and did not clean the tube or the medication cart after use. These actions were inconsistent with the facility's policy on hand hygiene and the handling of potentially contaminated items. The Director of Nursing confirmed the lapses in infection control practices, acknowledging that the staff did not follow proper procedures for hand hygiene and the handling of potentially contaminated materials. These deficiencies highlight a failure to implement the facility's infection control policies effectively, which are designed to prevent the transmission of infectious agents and protect both residents and staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sandhills Care Center | 15.9 mi | — | 0 | 0 |
| Parkside Manor | 20.2 mi | — | 2 | 0 |
| Good Samaritan Society - Atkinson | 28.9 mi | — | 16 | 0 |
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