WEST SALEM, WI - A state inspection of Mulder Health Care Facility found serious violations involving inadequate supervision and care for residents with suicidal thoughts, including a resident who stabbed himself with scissors and another who demonstrated concerning behaviors with sharp objects. The April 2025 inspection also revealed problems with cold food service and improper dietary assessments affecting multiple residents.
Resident's Suicide Attempt Highlights Systemic Failures
The most severe violation centered on a 11-year resident who attempted suicide by stabbing himself in the chest with scissors on May 24, 2024, following months of expressing suicidal thoughts related to chronic phantom limb pain. The resident, identified as R11 in the report, had repeatedly told staff he wanted to die due to excruciating pain from his amputation.
Despite the suicide attempt that resulted in hospitalization and emergency psychiatric detention, the facility failed to implement adequate safety measures. Inspection records show R11 continued obtaining sharp objects after returning to the facility. During the April 2025 inspection, R11 told surveyors that scissors were still being left in his room and that he was "disappointed the scissors were so small, and it didn't cut me deep enough."
The inspection found that although physician orders required staff to check R11's room for sharp objects every shift following the incident, adequate supervision was not consistently provided when the resident expressed suicidal thoughts. Pain assessments were ordered every four hours with mandatory interventions if pain exceeded 6 out of 10, but documentation showed these protocols were not always followed effectively.
A second resident, R55, demonstrated similar concerning behaviors between August 2024 and April 2025. Staff discovered scissors hidden in socks under his bed, found a knife bungee-corded to his walker, and observed him wrapping silverware in napkins to hide in drawers. On one occasion after scissors were removed from his room, R55 held his hand to his throat and stated "if he had them, he would use them like this."
Inadequate Mental Health Services and Staff Training
The facility failed to provide appropriate mental health services for residents experiencing suicidal thoughts. Neither R11 nor R55 received trauma assessments despite clear indicators of need. R11 had a significant history of childhood abuse that went unaddressed in his care planning. Depression screening tools (PHQ-9 assessments) were not conducted following suicidal statements, contrary to standard protocols.
The social services director admitted to surveyors that she was unaware of R11's trauma history and had not conducted appropriate assessments. When asked about protocols for residents expressing suicidal thoughts, she indicated uncertainty about whether depression screenings should be performed, stating she would "try to ask them what's going on" rather than conduct formal assessments.
Staff training records revealed significant gaps in behavioral health education. Only 53% of registered nurses had completed all three required behavioral health trainings. Among licensed practical nurses, 75% completed the trainings, while just 63% of certified nursing assistants had done so. The social services director had only completed one of the three required trainings.
Medical Context: Understanding Phantom Limb Pain
Phantom limb pain, the condition affecting R11, involves perception of pain in a limb that is no longer present. This complex neurological condition results from trauma to nerves surrounding the amputation site and involves neurons in both the spinal cord and brain. The pain can manifest as tingling, throbbing, sharp sensations, or feelings of pins and needles in the absent limb.
Treatment options remain limited and focus primarily on symptomatic control. Standard approaches include acetaminophen, anti-inflammatory medications, antidepressants, anticonvulsants, and topical anesthetics. The condition's complexity and resistance to treatment make it particularly challenging, requiring coordinated care from mental health professionals, pharmacists, and pain management physicians.
The intersection of chronic pain and mental health creates heightened suicide risk. Risk factors present in this case included male gender, past suicide attempts, chronic illness diagnosis, and access to lethal means - all recognized indicators requiring enhanced monitoring and intervention protocols.
Cold Food Service Affects Multiple Residents
Beyond the behavioral health violations, inspectors documented widespread problems with food temperature and palatability. Multiple residents reported receiving cold meals regularly, with test trays confirming the issue. Scrambled eggs were served at 96.1°F, well below acceptable temperatures. Coffee was measured at 102.6°F to 103.6°F, rendering it unpalatable.
Resident council minutes from November 2024 through March 2025 repeatedly documented complaints about cold food. One resident stated the food was "often served cold and tasted awful," while another specifically mentioned cold coffee and breakfast items. The dietary manager acknowledged that foods should be served at appropriate temperatures and be palatable, but systematic problems persisted.
Additional Issues Identified
The inspection revealed numerous other violations affecting resident care. One resident with an oral abscess who could not wear her dentures went weeks without proper dietary assessment to ensure safe food texture, despite staff awareness of her condition. The resident specifically requested minced or small-cut food to facilitate eating but received no accommodation until surveyors intervened.
The facility's own assessment failed to address critical operational questions, including how many residents with suicidal ideation could be safely managed, staffing requirements for mental health needs, and specific training requirements for trauma-informed care. When questioned, the director of nursing could not specify the facility's capacity for managing residents with complex behavioral health needs.
Documentation failures compounded care deficiencies. Progress notes regarding suicidal statements were inconsistently written, rehabilitation staff failed to document dietary consultations, and competency observations for staff providing behavioral health services went unrecorded.
The facility's quality assurance program failed to identify or address these systemic issues before the state inspection, despite the severity of problems including a suicide attempt requiring hospitalization. The inspection team noted that the number and seriousness of citations demonstrated ineffective quality assessment and corrective action processes.
Industry Standards and Required Protocols
Nursing homes must maintain sufficient staff with appropriate competencies to meet residents' behavioral health needs. This includes conducting comprehensive assessments, implementing individualized interventions, providing adequate supervision during crisis periods, and ensuring proper staff training in trauma-informed care and suicide prevention.
Federal regulations require facilities to provide medically-related social services helping residents achieve their highest practicable well-being. This encompasses mental health assessments, care planning for psychological needs, coordination with psychiatric services, and implementation of both pharmacological and non-pharmacological interventions.
Food service standards mandate that meals be palatable, attractive, and served at safe, appetizing temperatures. Facilities must also ensure food texture modifications accommodate individual needs, particularly when medical conditions affect chewing or swallowing ability.
The violations at Mulder Health Care Facility resulted in an immediate jeopardy designation - the most serious level of deficiency indicating immediate risk to resident health and safety. While the immediate jeopardy was removed after the facility implemented an action plan, deficient practices continued at lower severity levels as corrective measures were being implemented.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.