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.
| Cycle | Inspection date | This facility | Wisconsin avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-04-14 | 28 | 9.8 | 9.5 | +18.2 worse |
| 2 | 2024-02-22 | 12 | 9.2 | 9.8 | +2.8 worse |
| 3 | 2022-12-30 | 19 | 8.3 | 9.3 | +10.7 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 7 |
| Quality of life and care | 9 |
| Resident rights | 5 |
| Nutrition and dietary | 4 |
| Administration | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.49 | 37.1% |
| RN staffing (reported) | 0.85 | 21.4% |
| 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
- 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
- DF0692Provide enough food/fluids to maintain a resident's health.2026-01-22 · Health · corrected 2026-02-16
Potential for more than minimal harm
- 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
- 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
- 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
- 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
- EF0610Respond appropriately to all alleged violations.2025-09-16 · Health · corrected 2025-10-16
Potential for more than minimal harm
- 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
- 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
- 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
- DF0610Respond appropriately to all alleged violations.2025-04-14 · Health · corrected 2025-05-09
Potential for more than minimal harm
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- GF0692Provide enough food/fluids to maintain a resident's health.2025-04-14 · Health · corrected 2025-05-09
Actual harm
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- LF0880Provide and implement an infection prevention and control program.2025-04-14 · Health · corrected 2025-05-09
Immediate jeopardy
- 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
- 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
- DF0610Respond appropriately to all alleged violations.2024-07-24 · Health · corrected 2024-08-14
Potential for more than minimal harm
- 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
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2024-02-22 · Health · corrected 2024-03-21
Potential for more than minimal harm
- 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
- 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
- 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
- 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
- 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
- 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
- EF0880Provide and implement an infection prevention and control program.2024-02-22 · Health · corrected 2024-03-21
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2023-12-15 · Health · corrected 2024-01-17
Potential for more than minimal harm
- 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
- 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
- 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
- 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
- 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
- DF0610Respond appropriately to all alleged violations.2023-04-10 · Health · corrected 2023-05-12
Potential for more than minimal harm
- 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
- 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
- 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
- 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
- DF0572Give residents a notice of rights, rules, services and charges.2022-12-30 · Health · corrected 2023-01-27
Potential for more than minimal harm
- 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
- DF0610Respond appropriately to all alleged violations.2022-12-30 · Health · corrected 2023-01-27
Potential for more than minimal harm
- 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
- 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
- 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
- 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
- DF0880Provide and implement an infection prevention and control program.2022-12-30 · Health · corrected 2023-01-27
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| ORION OPERATING SERVICES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2019-12-09 |
| ATRIUM CENTERS, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-12-09 |
| BAILEY, ESSEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-12-09 |
| FINNEY, DONALD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-12-09 |
| ALBRIGHT ROSS, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-12-09 |
| ALBRIGHT ROSS, SUSAN | Individual | CORPORATE OFFICER | — | 2019-12-09 |
| BAILEY, ESSEL | Individual | CORPORATE OFFICER | — | 2019-12-09 |
| FINNEY, DONALD | Individual | CORPORATE OFFICER | — | 2019-12-09 |
| ALBRIGHT ROSS, SUSAN | Individual | W-2 MANAGING EMPLOYEE | — | 2019-12-09 |
Other facilities in WEST SALEM
| Name | Overall | Beds |
|---|---|---|
| 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.