WEST SALEM, WI - Federal inspectors issued immediate jeopardy citations to Mulder Health Care Facility following a massive gastrointestinal outbreak that affected 59% of residents and numerous staff members while revealing systemic infection control failures.
Outbreak Scope and Timeline
The outbreak began January 2, 2025, when two staff members and one resident developed gastrointestinal symptoms including nausea, vomiting, and diarrhea. Within days, the situation escalated dramatically, ultimately affecting 49 out of 83 residents and 37 staff members across all four units of the facility.
Despite the facility's own policies requiring immediate outbreak identification and response, administrators failed to recognize the outbreak until January 6 - four days after it began. The Department of Public Health wasn't notified until the outbreak had already spread throughout the facility.
The Centers for Medicare and Medicaid Services determined the facility's failures created immediate jeopardy conditions from January 3-14, 2025, meaning residents faced immediate risk of serious harm or death from inadequate infection control measures.
Critical Medication Management Failures
During the outbreak, the facility continued administering potentially harmful medications to symptomatic residents without proper monitoring. Multiple residents receiving diuretics like furosemide continued their prescribed doses despite experiencing vomiting and diarrhea, creating serious dehydration risks.
Resident R18, who was taking furosemide for chronic heart failure, continued receiving the diuretic throughout his illness period without any fluid monitoring. Similarly, Resident R34 received her 40mg furosemide dose for high blood pressure while experiencing gastrointestinal symptoms, again without fluid status assessment.
Laxatives posed another significant concern. Several residents continued receiving medications like Senokot and Miralax while already experiencing diarrhea. Resident R70 had standing orders to "hold for loose stools" but continued receiving Senokot-S twice daily during active symptoms.
These medication errors demonstrate a fundamental misunderstanding of how gastrointestinal illness affects medication safety. When residents experience vomiting and diarrhea, diuretics can cause dangerous dehydration and electrolyte imbalances, while laxatives can worsen fluid loss and intestinal distress.
Inadequate Symptom Monitoring
The facility's monitoring protocols proved insufficient for tracking outbreak progression and ensuring resident safety. While staff documented bowel movements, they failed to record crucial details about consistency and frequency - essential information for managing gastrointestinal illness.
Many residents didn't receive appropriate monitoring until after their documented "well dates," meaning staff weren't tracking symptoms during the acute illness phase. Resident R8 was added to the outbreak list January 3 with a well date of January 4, but monitoring orders weren't implemented until January 5-6.
This delayed response pattern repeated throughout the outbreak. Resident R60's monitoring for gastrointestinal symptoms didn't begin until her documented well date, essentially missing the entire acute illness period when close observation was most critical.
Infection Control Protocol Breakdowns
The facility's infection control measures failed at multiple levels during the outbreak. Isolation precautions weren't consistently maintained, with several residents removed from isolation before completing the required 48-72 hour symptom-free period mandated by the facility's own policies.
Documentation gaps made it impossible to verify appropriate isolation timing. The facility couldn't provide specific times for when residents' symptoms resolved, making it unclear whether isolation precautions were discontinued safely. This lack of precise tracking could have contributed to continued disease transmission.
Housekeeping protocols also broke down during the crisis. Staff failed to follow proper room cleaning sequences, potentially spreading contamination between symptomatic and non-symptomatic residents. Additionally, laundry handling procedures weren't followed, with staff sorting dirty linens without appropriate protective barriers.
Staff Return-to-Work Issues
The outbreak significantly impacted staffing, with 37 employees developing symptoms. However, the facility's return-to-work protocols weren't consistently followed. Several staff members returned to work without documented well dates or clear evidence they had completed the required 48-hour symptom-free period.
This created potential for continued disease transmission, as staff who hadn't fully recovered could spread the illness to vulnerable residents. The facility's own policies specifically require food service and direct care staff to remain off work until completely symptom-free for the required period.
Quality Assurance Program Failures
Beyond the immediate outbreak response, inspectors found the facility's Quality Assurance and Performance Improvement (QAPI) program failed to address systemic issues. Despite the major outbreak in January, administrators didn't convene special QAPI meetings to analyze what went wrong or develop prevention strategies.
The nursing home administrator acknowledged they had worked on antipsychotics and falls reduction in QAPI meetings but couldn't confirm whether the gastrointestinal outbreak was ever formally reviewed. This represents a missed opportunity to identify system failures and implement improvements.
The facility also failed to complete essential outbreak documentation, including timeline analysis and "lessons learned" reviews that could prevent future incidents. Without proper analysis of what caused the outbreak to spread so extensively, similar situations could recur.
Medical Consequences and Risks
Gastrointestinal outbreaks in nursing homes can have serious medical consequences, particularly for elderly residents with multiple chronic conditions. Dehydration from vomiting and diarrhea can rapidly become life-threatening in older adults, especially when combined with diuretic medications.
Electrolyte imbalances resulting from fluid loss can cause cardiac rhythm abnormalities, kidney dysfunction, and altered mental status. Residents with heart failure, like several affected during this outbreak, face particular risks when fluid balance becomes disrupted.
The facility's failure to properly monitor fluid status and adjust medications created conditions where these serious complications could have occurred. Prompt recognition of gastrointestinal illness and appropriate medication adjustments are essential for preventing hospitalization and death in nursing home residents.
Regulatory Response and Ongoing Concerns
Federal inspectors removed the immediate jeopardy finding on January 14, 2025, after the facility implemented corrective measures. However, the deficient practices continue at a lower severity level as administrators work to fully address systemic infection control weaknesses.
The facility must demonstrate sustained improvement in outbreak recognition, medication management during illness, and quality assurance processes. Regular monitoring will continue to ensure policies are properly implemented and staff receive necessary training.
This outbreak highlights the critical importance of robust infection control programs in nursing homes, where vulnerable residents depend on facility staff to recognize and respond appropriately to infectious disease threats. The scope of this outbreak - affecting nearly 60% of residents - demonstrates how quickly situations can deteriorate when basic protocols aren't followed.
The complete inspection report provides additional details about specific policy violations and corrective action requirements for Mulder Health Care Facility.
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.
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