Starfile

Starfile / Wisconsin

MULDER HEALTH CARE FACILITY

713 LEONARD ST N, WEST SALEM, WI 54669 · CCN 525209

Ratings

Overall
★☆☆☆☆ 1
Health inspection
★☆☆☆☆ 1
Quality measures
★★★★☆ 4
Staffing
★★★★☆ 4

Facility

Ownership type
For profit - Corporation
Certified beds
87
Avg residents/day
76.8
Phone
6087861600

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

CycleInspection dateThis facilityWisconsin avgNational avgvs state
12025-04-14289.89.5+18.2 worse
22024-02-22129.29.8+2.8 worse
32022-12-30198.39.3+10.7 worse

Cycle 1 deficiencies by category

CategoryDeficiencies
Abuse, neglect, exploitation7
Quality of life and care9
Resident rights5
Nutrition and dietary4
Administration2
Infection control1

Staffing (hours per resident per day)

MetricThis facilityTurnover
Total nurse staffing (reported)3.4937.1%
RN staffing (reported)0.8521.4%
Total nurse staffing (adjusted)3.96

Fines & penalties

Total fines
$292,588
Number of fines
2
Number of penalties
2
Payment denials
0

Chain

Chain
ATRIUM CENTERS
Facilities in chain
26
Chain avg overall
3.20 / 5

Inspection citations (59)3 immediate jeopardy2 actual harm

  1. EF0602Protect each resident from the wrongful use of the resident's belongings or money.2026-01-22 · Health · corrected 2026-02-16

    Potential for more than minimal harm

  2. DF0692Provide enough food/fluids to maintain a resident's health.2026-01-22 · Health · corrected 2026-02-16

    Potential for more than minimal harm

  3. EF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2026-01-22 · Health · corrected 2026-02-16

    Potential for more than minimal harm

  4. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2026-01-22 · Health · corrected 2026-02-16

    Potential for more than minimal harm

  5. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-09-16 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  6. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-09-16 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  7. EF0610Respond appropriately to all alleged violations.2025-09-16 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  8. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-09-16 · Health · corrected 2025-10-16

    Potential for more than minimal harm

  9. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  10. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  11. DF0610Respond appropriately to all alleged violations.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  12. DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  13. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  14. DF0624Prepare residents for a safe transfer or discharge from the nursing home.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  15. DF0625Notify 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.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  16. DF0626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  17. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  18. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  19. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  20. GF0692Provide enough food/fluids to maintain a resident's health.2025-04-14 · Health · corrected 2025-05-09

    Actual harm

  21. EF0700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  22. JF0741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.2025-04-14 · Health · corrected 2025-05-09

    Immediate jeopardy

  23. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  24. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  25. DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  26. FF0838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  27. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2025-04-14 · Health · corrected 2025-05-09

    Potential for more than minimal harm

  28. LF0880Provide and implement an infection prevention and control program.2025-04-14 · Health · corrected 2025-05-09

    Immediate jeopardy

  29. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-12-16 · Health · corrected 2024-12-31

    Potential for more than minimal harm

  30. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-11-04 · Health · corrected 2024-11-20

    Immediate jeopardy

  31. DF0610Respond appropriately to all alleged violations.2024-07-24 · Health · corrected 2024-08-14

    Potential for more than minimal harm

  32. EF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  33. DF0645PASARR screening for Mental disorders or Intellectual Disabilities2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  34. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  35. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  36. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  37. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  38. FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  39. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  40. EF0880Provide and implement an infection prevention and control program.2024-02-22 · Health · corrected 2024-03-21

    Potential for more than minimal harm

  41. FF0880Provide and implement an infection prevention and control program.2023-12-15 · Health · corrected 2024-01-17

    Potential for more than minimal harm

  42. FF0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.2023-12-15 · Health · corrected 2024-01-17

    Potential for more than minimal harm

  43. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-10-18 · Health · corrected 2023-11-09

    Potential for more than minimal harm

  44. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-10-18 · Health · corrected 2023-11-09

    Potential for more than minimal harm

  45. EF0584Honor 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.2023-04-10 · Health · corrected 2023-05-12

    Potential for more than minimal harm

  46. DF0585Honor 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.2023-04-10 · Health · corrected 2023-05-12

    Potential for more than minimal harm

  47. DF0610Respond appropriately to all alleged violations.2023-04-10 · Health · corrected 2023-05-12

    Potential for more than minimal harm

  48. DF0584Honor 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.2023-03-14 · Health · corrected 2023-05-12

    Potential for more than minimal harm

  49. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-03-14 · Health · corrected 2023-04-11

    Potential for more than minimal harm

  50. DF0660Plan the resident's discharge to meet the resident's goals and needs.2023-03-14 · Health · corrected 2023-04-11

    Potential for more than minimal harm

  51. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-03-14 · Health · corrected 2023-04-12

    Potential for more than minimal harm

  52. DF0572Give residents a notice of rights, rules, services and charges.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

  53. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

  54. DF0610Respond appropriately to all alleged violations.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

  55. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-12-30 · Health · corrected 2023-01-27

    Actual harm

  56. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

  57. DF0758Implement 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.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

  58. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

  59. DF0880Provide and implement an infection prevention and control program.2022-12-30 · Health · corrected 2023-01-27

    Potential for more than minimal harm

Ownership

OwnerTypeRolePercentSince
ORION OPERATING SERVICES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%2019-12-09
ATRIUM CENTERS, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST2019-12-09
BAILEY, ESSELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST2019-12-09
FINNEY, DONALDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST2019-12-09
ALBRIGHT ROSS, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL2019-12-09
ALBRIGHT ROSS, SUSANIndividualCORPORATE OFFICER2019-12-09
BAILEY, ESSELIndividualCORPORATE OFFICER2019-12-09
FINNEY, DONALDIndividualCORPORATE OFFICER2019-12-09
ALBRIGHT ROSS, SUSANIndividualW-2 MANAGING EMPLOYEE2019-12-09

Other facilities in WEST SALEM

NameOverallBeds
LAKEVIEW HEALTH CENTER★★★★★49

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.