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Mulder Health Care: Resident Abuse After CNA Grab - WI

Healthcare Facility
Mulder Health Care Facility
West Salem, WI  ·  1/5 stars

The incident happened on September 9, 2025, at Mulder Health Care Facility, a nursing home on Leonard Street in West Salem. The resident, identified in inspection records only as R4, had agreed to let staff help her onto a bedpan. What followed, according to witness statements and a nurse's account, was something different.

CNA G pulled back the resident's covers and grabbed her arm or wrist to turn her onto her left side. R4 tried to pull her arm away. She told the aide, "You don't have to grab my arm." CNA G responded, "I'm trying to put you on the bed pan. Do you want my help or not?" and kept holding on. R4 kept resisting. A second aide, CNA D, left to get the nurse because, as she put it, the situation was not deescalating.

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When Licensed Practical Nurse F arrived, R4's eyes were watering and she was visibly trembling.

LPN F told inspectors she asked CNA G to leave the room multiple times before the aide complied. In her written witness statement, dated the same day as the incident, LPN F described walking in to find CNA G "demanding resident roll," with R4 showing "a look of fear and distress." When LPN F said she would take over the resident's care, CNA G refused: "No, I got it." LPN F said it again. Then a third time, in a stern voice. CNA G finally turned toward R4, leaned in close to her face, and kept repeating, "Do you want me to leave?" using the resident's name. She said it more than once, with the nurse and the resident both telling her to go. When she finally walked out, she continued speaking aggressively to R4 on her way through the door.

LPN F noticed redness on R4's arm near the wrist. She told inspectors that R4 calmed down as soon as CNA G left the room. When a surveyor asked LPN F directly whether she believed CNA G had been abusive to R4, she said yes.

LPN F called the Director of Nursing within 30 minutes and began collecting statements for an investigation. She also told inspectors she was surprised by what happened next. CNA G was not removed from the building. She worked the remainder of the night shift, on the 100 hall, until 6:30 that morning. Sixteen residents lived on that hall.

It did not end there. The nursing home administrator confirmed to inspectors that CNA G returned to work on September 11, from 6 a.m. to 2:30 p.m., and again on September 12, same hours. The administrator acknowledged that while CNA G was primarily assigned to one hall, she had the potential to assist residents on any of the facility's four halls.

Federal inspectors who arrived September 16 cited the facility for failing to protect residents from abuse, a deficiency tagged at a level indicating minimal harm or potential for actual harm.

The inspection was complaint-driven, meaning someone had reported concerns before surveyors arrived.

LPN F's account does not read like someone uncertain about what she witnessed. She documented it the same day. She reported it within the half hour. She gathered statements. She told inspectors she was surprised the aide kept working. What she described, in her own words, was a woman with fear on her face and tears in her eyes, trembling, while someone leaned close and demanded to know if she wanted help.

R4 calmed down, the nurse said, the moment CNA G left the room.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Mulder Health Care Facility from 2025-09-16 including all violations, facility responses, and corrective action plans.

Additional Resources


Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 28, 2026  ·  Our methodology

Quick Answer

MULDER HEALTH CARE FACILITY in WEST SALEM, WI was cited for abuse-related violations during a health inspection on September 16, 2025.

The incident happened on September 9, 2025, at Mulder Health Care Facility, a nursing home on Leonard Street in West Salem.

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.

Frequently Asked Questions

What happened at MULDER HEALTH CARE FACILITY?
The incident happened on September 9, 2025, at Mulder Health Care Facility, a nursing home on Leonard Street in West Salem.
How serious are these violations?
These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.
What should families do?
Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WEST SALEM, WI, (5) Report any new concerns directly to state authorities.
Where can I see the full inspection report?
The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MULDER HEALTH CARE FACILITY or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 525209.
Has this facility had violations before?
To check MULDER HEALTH CARE FACILITY's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.


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