Cycle 1
Health 2025-06-04 · Fire 2025-06-04
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sparta, WI
Morrow Memorial Home
4-star overall rating with 4-star inspections with 3 recent health deficiencies
331 S Water St, Sparta, WI
(608) 269-3168
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
69
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.04
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,563
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.27% · Performance 22.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.58
Baseline 6.23% · Performance 6.47% · Measure score 4.58 · Achievement 4.58 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.16
Baseline 3.54 hours · Performance 4.55 hours · Measure score 5.16 · Achievement 5.16 · Improvement 3.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.76% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 6.48% · Lower 95% interval 6.23% |
| Discharge to community | 52.29% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 51.38% · Lower 95% interval 43% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 98 |
| Discharge self-care score | 37.84% |
53.69%
15.8 pts worse
|
Numerator 28 · Denominator 74 |
| Discharge mobility score | 41.89% |
50.94%
9 pts worse
|
Numerator 31 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 98 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 4% · Lower 95% interval 2.76% |
| Staff COVID-19 vaccination coverage | 17.46% |
8.2%
9.3 pts better
|
Numerator 22 · Denominator 126 |
| Staff flu vaccination coverage | 92.82% |
42%
50.8 pts better
|
Numerator 181 · Denominator 195 |
| Discharge function score | 47.3% |
56.45%
9.2 pts worse
|
Numerator 35 · Denominator 74 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 21 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 49 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 46.81% |
25.2%
21.6 pts better
|
Numerator 22 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
95.7%
3.2 pts worse
|
93.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 91.1% · Q3 92.5% · Q4 90.6% · 4Q avg 92.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
95.0%
3.9 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.2%
1.5 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.6% · Q3 7.5% · Q4 5.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.9% |
5.0%
7.9 pts worse
|
11.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 17.0% · Q3 17.3% · Q4 0.0% · 4Q avg 12.9% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.9%
1.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.0% · Q3 2.2% · Q4 4.3% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
16.6%
0.2 pts worse
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 13.2% · Q3 21.3% · Q4 22.4% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
16.7%
1.9 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 30.3% · Q3 13.9% · Q4 13.5% · 4Q avg 18.6% · 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 | 33.1% |
21.1%
12 pts worse
|
16.3%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 24.6% · 4Q avg 33.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.7% |
17.3%
8.4 pts worse
|
14.9%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 28.8% · Q3 17.8% · Q4 18.8% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
2.3%
1.6 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.6% · Q3 3.5% · Q4 4.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
3.0%
2 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
25.5%
0.6 pts better
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 30.1% · Q3 15.6% · Q4 27.3% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.5%
3.1 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 0.0% · Q4 5.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
86.8%
4.1 pts worse
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 84.0% · Q3 83.1% · Q4 88.0% · 4Q avg 82.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
15.0%
0.1 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 13.2% · Expected 9.8% · Used in QM five-star |
| 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.3% |
82.2%
10.9 pts worse
|
79.7%
8.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
22.7%
5.1 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 22.1% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-28
E · Potential for more than minimal harm
2024-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-28
F · Potential for more than minimal harm
2023-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-18
E · Potential for more than minimal harm
2023-02-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-04
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 2025-07-04
D · Potential for more than minimal harm
2025-06-04
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 2025-07-04
D · Potential for more than minimal harm
2025-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-04
G · Actual harm
2024-03-28
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 2024-04-28
D · Potential for more than minimal harm
2024-03-28
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 2024-04-28
D · Potential for more than minimal harm
2024-03-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-28
F · Potential for more than minimal harm
2023-02-16
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 2023-03-18
E · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-03-18
D · Potential for more than minimal harm
2023-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-18
Penalties and ownership
What sits behind the stars
Ownership
Brieske, Jennifer
Operational/Managerial Control · Individual
Faller, Annette
Operational/Managerial Control · Individual
Foss, Pete
Corporate Officer · Individual
Hoffman, Suzanne
Corporate Officer · Individual
Meyer, Daniel
Corporate Director · Individual
Rapos, Brent
Operational/Managerial Control · Individual
Simonson, Bryan
Corporate Officer · Individual
Smith, Debra
Corporate Officer · Individual
Sund, Nikki
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Rolling Hills Rehab Ctr
Sparta, WI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Lakeview Health Center
West Salem, WI
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Mulder Health Care Facility
West Salem, WI
1-star overall rating with 1-star inspections with $292,588 in total fines with 28 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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