Mulder Health Care: Infection Control Failures - WI
Federal inspectors who visited the facility on April 14 found no evidence that Mulder had used its quality improvement process during or after the outbreak to examine what happened. The facility had a standing process for exactly this kind of review, one designed to collect feedback, analyze data, and drive improvements in infection prevention. Inspectors found no sign it had been used.
GI outbreaks in nursing homes are not routine inconveniences. Residents in long-term care are older, often medically fragile, and far more vulnerable to dehydration and complications from vomiting and diarrhea than the general population. An outbreak that passes without review is an outbreak that is free to return under the same conditions.
What inspectors documented was an absence. No data collection during the outbreak. No analysis afterward. No corrective steps identified. No process improvement implemented. The facility's own quality assurance infrastructure existed and was not used.
Inspectors also cited Mulder for a second violation, this one involving whether the facility had sufficient staff with the competency to meet residents' behavioral health needs. The inspection report does not detail the specific incidents that drove that finding, but the citation indicates inspectors found the facility fell short.
The two citations together describe a facility where systems that exist on paper were not functioning in practice. The quality improvement process was available and unused. Staffing for behavioral health was required and insufficient.
Mulder Health Care Facility is a long-term care nursing home operating in West Salem, a small city in La Crosse County in western Wisconsin. The April inspection was a standard health survey conducted by state surveyors working on behalf of the federal Centers for Medicare and Medicaid Services.
The infection control citation was filed under F880, a federal tag that covers a facility's overall infection prevention and control program. Deficiencies under F880 range from failures in hand hygiene and sanitation to, as in this case, failures to learn from outbreaks after they occur. The distinction matters because a facility that does not review an outbreak has no basis for knowing whether its response was adequate, whether the outbreak was contained as quickly as it could have been, or whether the same conditions still exist.
The residents who were sick during the outbreak are not named in the inspection report. Their experience is recorded only in the absence of any institutional response to it.
Facilities that skip post-outbreak review are not just failing a regulatory checkbox. They are declining to ask the question that protects the next group of residents who will live there. Gastrointestinal illness spreads quickly in congregate settings. The residents most likely to be harmed are the same residents who are always most likely to be harmed: those who are oldest, frailest, and least able to communicate that something is wrong.
What Mulder had after the outbreak was the same infection control program it had before it. No documented changes. No evidence that anyone in a leadership role sat down with the data and asked what it meant.
The behavioral health staffing citation adds a separate layer. Residents with behavioral health needs require staff who are trained and present in sufficient numbers to respond to them. When that staffing falls short, the consequences are not abstract. They are experienced by individual residents, in individual moments, without adequate support.
The inspection report does not describe those moments. It records only that inspectors found the facility lacking.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mulder Health Care Facility from 2025-04-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
MULDER HEALTH CARE FACILITY in WEST SALEM, WI was cited for violations during a health inspection on April 14, 2025.
Inspectors found no sign it had been used.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.