Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morrow Memorial Home during CMS and state inspections, most recent first.
A resident with a history of multiple health issues experienced new symptoms of cardio-respiratory complications and significant weight gain. Despite these alarming signs, the nursing staff failed to notify the resident's physician promptly, resulting in the resident's hospitalization with heart failure and atrial fibrillation with RVR.
The facility failed to ensure dignified treatment of residents during dining. Staff were observed standing while feeding residents, using clothing protectors to wipe residents' faces, and conversing with each other instead of focusing on the residents. Interviews confirmed these practices, and the Nursing Home Administrator acknowledged the lack of dignified treatment.
A resident with multiple diagnoses developed an unavoidable stage 3 pressure injury at the facility. Despite having interventions in place, the resident's wound care was observed to have poor infection control practices, including not cleaning stool near the wound before care and not changing gloves appropriately. Interviews with staff confirmed the correct procedures were not followed.
The facility failed to adequately assess and treat pain for a resident during wound care. Despite the resident's verbal and non-verbal expressions of pain, staff continued with the treatment without performing an adequate pain assessment or waiting for the pain medication to take effect. Interviews revealed inconsistencies in how staff addressed the resident's pain, and an inappropriate pain scale was used for non-verbal residents.
A resident was prescribed an antibiotic for UTI prophylaxis without adequate indications for its use. The resident's chart lacked rationale, and there were no pharmacist recommendations for the long-term use of the medication. Interviews with nurses revealed that the antibiotic had been administered for an extended period without reevaluation, and the facility only contacted the pharmacists for a review on the day of the surveyor's inquiry.
The facility failed to maintain an effective infection control program as two CNAs did not perform hand hygiene between glove changes while providing care to two residents. One CNA admitted to not being trained on this protocol, and the DON confirmed that hand hygiene is a standard of care.
Failure to Notify Physician of Resident's Deteriorating Condition
Penalty
Summary
The facility failed to promptly notify and consult with a resident's physician when there was a deterioration in the resident's clinical condition. This deficiency was identified for a resident who presented with new symptoms of cardio-respiratory complications and significant weight gain. Despite these changes, the staff did not immediately notify the resident's provider, resulting in the resident being admitted to the hospital with a diagnosis of heart failure and atrial fibrillation with rapid ventricular rate (RVR) one week after the onset of symptoms. The resident, who had a history of Crohn's disease, major depressive disorder, hyperlipidemia, Alzheimer's, vascular dementia, cerebrovascular disease, and paroxysmal atrial fibrillation post-surgery, began showing symptoms on 4/23/23. These symptoms included restlessness, elevated blood pressure, increased pulse rate, shortness of breath, and significant weight gain. Despite these alarming signs, the nursing staff failed to notify the resident's physician or take appropriate action to address the resident's deteriorating condition. Interviews with the facility's staff, including LPNs, RNs, and the Director of Nursing, revealed inconsistencies in the understanding and execution of the facility's policy on notifying providers of significant changes in a resident's condition. The staff's failure to notify the provider promptly led to a delay in the resident receiving necessary medical intervention, culminating in the resident's hospitalization. The resident's physician expressed surprise and concern over the lack of notification and indicated that earlier intervention could have potentially mitigated the severity of the resident's condition.
Lack of Dignified Treatment During Dining
Penalty
Summary
The facility did not ensure residents were treated with dignity and respect during dining, affecting four residents. Observations revealed that a Registered Nurse wiped egg yolk from a resident's face using a clothing protector. Additionally, a Certified Nursing Assistant (CNA) was seen standing over a resident while feeding them and conversing with another CNA across the table. Similar behavior was observed during lunch, where two CNAs assisted residents with feeding but were engaged in conversation with each other rather than focusing on the residents they were assisting. Interviews with the CNAs confirmed these practices, with some CNAs admitting to standing while assisting residents and using clothing protectors to wipe residents' faces. The Nursing Home Administrator and Director of Nursing acknowledged that these actions were not dignified treatment of residents. The expectation is for staff to treat residents with dignity and respect, which includes not standing over them while assisting with meals and focusing on the residents rather than conversing with other staff members across the table.
Inadequate Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility did not provide care consistent with professional standards to prevent the development of a pressure injury for a resident (R40). R40, who had multiple diagnoses including dementia, diabetes, and chronic kidney disease, developed an unavoidable stage 3 pressure injury while at the facility. Despite having interventions in place such as an air mattress, pressure redistribution cushions, and a turning/repositioning program, R40 developed a coccyx wound due to a norovirus outbreak that caused continuous loose stools and the need to sit up to prevent aspiration while vomiting. The wound care provided to R40 was observed to have poor infection control practices, including not cleaning stool present near the wound before performing wound care and not changing gloves appropriately during the procedure. During wound care, RN D and LPN K were observed performing wound care on R40's coccyx and right heel pressure injuries. Both nurses used hand hygiene before donning gowns and gloves, but RN D did not provide a clean barrier under the wound and did not clean the stool present near the coccyx wound before starting the wound care. RN D also did not change gloves after cleaning the wound and before applying new dressings, which is against infection control protocols. Additionally, RN D used the same contaminated gloves to handle clean supplies and perform further wound care on R40's right heel. Interviews with facility staff, including CNAs and RNs, confirmed that the stool should have been cleaned before performing wound care and that gloves should have been changed between different steps of the wound care process. The Director of Nursing (DON) and the Infection Preventionist acknowledged the observations and stated that the glove changes should have been completed after cleaning the dirty area and before applying the clean dressing. The facility's failure to follow proper infection control practices during wound care contributed to the deficiency in providing appropriate pressure ulcer care for R40.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to adequately assess and treat pain for a resident (R40) during wound care. Despite R40's verbal and non-verbal expressions of pain, the staff continued with the wound care treatment without performing an adequate pain assessment or waiting for the pain medication to take effect. The facility's policy on pain management was not followed, as the staff did not ensure that the pain medication was effective before proceeding with the wound care. R40, who had severe cognitive impairment and multiple medical conditions including dementia, chronic kidney disease, and pressure ulcers, was observed to be in significant pain during wound care. The resident's care plan indicated that she showed non-verbal signs of pain and required pain management to maintain comfort. However, during the wound care procedure, the staff did not adequately address her pain, even after being advised by the surveyor and another staff member to allow the pain medication time to work. Interviews with various staff members revealed that some nurses did not stop to address R40's pain during wound care, while others did. The Director of Nursing acknowledged that the resident's pain should have been addressed and that the wound care should not have been completed just for the surveyor's observation. The facility used an inappropriate pain scale for non-verbal residents, and a more suitable tool, such as the PAINAD scale, was not utilized to assess R40's pain accurately.
Unnecessary Medication Use for Prophylaxis
Penalty
Summary
The facility did not ensure that a resident's drug regimen was free from unnecessary medication use. Specifically, Resident R5 was prescribed Nitrofuration Monohyd Macro, an antibiotic, for urinary tract infection (UTI) prophylaxis without adequate indications for its use. The resident's chart lacked a rationale for the continued use of the prophylactic antibiotic, and there were no recommendations from the pharmacists regarding the long-term use of the medication. The physician's progress notes also did not include a detailed evaluation of the resident's mental, physical, functional, or psychosocial benefits, nor did they describe any comorbid conditions that would justify the continued use of the antibiotic. Interviews with the facility's registered nurses revealed that the antibiotic had been administered for an extended period without reevaluation. One nurse indicated that the resident did not like changes to their medication regimen, while another nurse mentioned that the resident had a history of hysterectomy, ovarian cystectomy, and urogenital implants but confirmed that the facility had not considered discontinuing the antibiotic. The facility only contacted the pharmacists for a review of the antibiotic on the day of the surveyor's inquiry, indicating a lack of proactive management in ensuring the medication's necessity.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility did not maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the care of two residents. In the first instance, a CNA provided incontinence care for a resident and proceeded to perform multiple tasks, including applying barrier cream, positioning a mechanical sling, and using a lift, without changing gloves or performing hand hygiene between tasks. The CNA admitted that their training did not include instructions on hand hygiene between glove changes. This lapse in protocol was observed and documented by the surveyor. In the second instance, two CNAs were observed performing morning care for a resident with a catheter who was on transmission-based precautions. Although proper hand hygiene and PPE use were initially observed, one CNA failed to perform hand hygiene between glove changes multiple times during the care process. The Director of Nursing confirmed that hand hygiene should be performed between glove changes and that the staff should be aware of this standard of care. Another CNA interviewed confirmed that hand hygiene should be performed before putting on gloves and after removing them.
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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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Nursing homes near Sparta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolling Hills Rehab Ctr | 0.4 mi | ★★★★★ | 8 | 0 |
| Lakeview Health Center | 13.2 mi | ★★★★★ | 2 | 0 |
| Mulder Health Care Facility | 13.7 mi | ★★★★★ | 8 | 0 |
| Tomah Nursing And Rehab | 14.9 mi | ★★★★★ | 20 | 1 |
| Norseland Nursing Home | 19.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.