Deficiency Index

Morrow Memorial Home

Sparta, Wisconsin · CCN 525662

19 surveys since 2011, 5 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
80
Surveys
19
Harm or worse
5
Immediate jeopardy
0
The record, 2011–2025
’11’15’20’25
No harm recordedHarm or worseNot surveyed
Harm or worse5

Findings where a surveyor recorded actual harm to a resident.

Beyond CMS’s monthly file16/19

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
78
Ownership
Non profit - Church related
Chain
Independent
County
Monroe · rural
Medicare-certified since
2001

CMS ratings

Overall
5
Health inspection
4
Staffing
5
Quality measures
2

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=15, floor 20).

Last survey on record

Jun 4, 2025

523 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day4.334.33
Registered-nurse hours per resident day0.91—
Annual nurse turnover40.6%49.2%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG17.7%H—I—
No harm, potential for more than minimalD969.2%E17.7%F215.4%
No harm, potential for minimalA—B—C—
CMS’s current file: 13 of the 80 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F8803×

    Provide and implement an infection prevention and control program.

  • F5502×

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

  • F8122×

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

  • F5801×

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

  • F6401×

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

In the surveyor’s words

From the most serious findings on record at Morrow Memorial Home, in the surveyor’s own words.

  • Actual harm, isolatedF580Mar 28, 2024

    Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. This occurred for 1 of 2 residents (R39) reviewed for physician notification and consultation. R39 presented with new symptoms of cardio-respiratory complications in addition to a significant weight gain. Staff did not immediately notify R39's provider of this occurrence resulting in R39 being admitted to the hospital 4/30 - 5/4/23, one week after the start of these symptoms, with a diagnosis of heart failure and atrial fibrillation with RVR (rapid ventricular rate). […]

  • No harm, potential for more than minimal, widespreadF812Jun 4, 2025

    Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness. This has the potential to affect all to 65 residents. The dry storage area and kitchen cooler contained multiple open food items not labeled with open or use-by dates. Personal beverage stored in kitchen cooler. Culinary Aide (CA) C was not wearing hair restraint on facial hair while assisting with meal service in kitchen. Findings include: Facility policy titled, Food Storage, dated 07/23, states in part: All food items will be stored, thawed and prepared in accordance with proper sanitary practices .Dry goods .5. All open products must be stored in clean air-tight containers. 6. […]

  • No harm, potential for more than minimal, widespreadF812Feb 16, 2023

    Based on observation, interview and record review, the facility did not ensure foods were stored at safe ranges to prevent spoilage by not consistently checking refrigerator and freezer temperatures in accordance with professional standards for food service safety. This has the potential to affect all 60 residents in the facility. Findings include: 02/13/23 09:43 AM Initial tour of the kitchen and kitchenettes with Registered Dietician (RD) H. Temperature logs for February missing temperatures: Cold storage in kitchen missing Feb. 11 and 12th. Freezer temperature in kitchen missing Feb. 11 and 12th Kitchenette Rehab refrigerator missing Feb. 10, 11, and 12. Kitchenette Day room refrigerator missing Feb. […]

  • No harm, potential for more than minimal, patternF880Feb 16, 2023

    Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure all staff sanitized mechanical lifts between use with multiple residents. This had the potential to effect 12 residents, who require transfers with a mechanical lift, out of 19 residents residing on the north wing of the second floor. The facility did not ensure all staff handled soiled linens properly. Four staff were observed holding soiled linens against uniforms when carrying to dirty linen bins in hallway. […]

  • No harm, potential for more than minimal, isolatedF550Jun 4, 2025

    Based on observations, interview and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner that promotes their quality of life. Resident (R) R44 was not provided privacy of the window shade being closed during cares when lying in bed not fully clothed. This occurred for 1 of 17 sampled residents (R44). This is evidenced by: R44 was admitted to the facility on [DATE]. R44's current diagnoses include chronic obstructive pulmonary disease, chronic kidney disease, Parkinsonism, reduced mobility, major depressive disorder, and anxiety. Minimum data set (MDS) assessment dated [DATE] documents R44 has a Brief Interview for Mental Status (BIMS) score of 2/15, meaning R44 has severe cognitive impairment. […]

Read 23 findings in full →The most serious and the most recent: 23 of 80 on record.

Every survey on record

FindingsAt actual harm or above

  • Jun 4, 2025Standard3 findings
  • Mar 28, 2024Standard6 findings · 1 harm
  • Feb 16, 2023Standard4 findings
  • Nov 4, 2021Standard2 findings
  • Aug 19, 2020Complaint1 finding · 1 harm
  • Oct 31, 2019Standard and complaint4 findings
  • Jan 3, 2019Complaint1 finding
  • Aug 30, 2018Standard5 findings · 1 harm
Show the 11 earlier surveys
  • Jan 3, 2018Complaint2 findings
  • Jan 18, 2017Complaint1 finding
  • Jul 14, 2016Standard10 findings
  • Oct 15, 2015Complaint2 findings
  • Jul 13, 2015Standard10 findings
  • May 28, 2015Complaint1 finding
  • Jul 10, 2014Standard6 findings · 1 harm
  • Jun 27, 2013—7 findings
  • Jul 25, 2012—9 findings · 1 harm
  • Apr 25, 2012—2 findings
  • Feb 10, 2011—4 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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