Mulder Health Care Facility

F-F671 at the harm level during recertification survey on 4/14/25. The QAPI team did not have a plan in place for increased audits, education, or monitoring that interventions were in place and functioning appropriately in order to maintain nutritional/hydration status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility had a resident who required monitoring of their fluid and hydration status and the facility did not have a plan in place to ensure residents maintained their fluid and hydration intake. The facility did not Level of Harm - Minimal harm or complete education with staff, did not update the residents plan of care, and did not track the residents potential for actual harm hydration status to prevent decline and hospitalization .

Residents Affected - Many The facility did not utilize the QAPI process to identify this high-risk resident, identify risk factors related to

the care for residents who require hydration monitoring, ensure staff had the needed competencies and skillsets to care for residents who are at risk for dehydration. The facility did not identify an at-risk resident despite multiple hospitalization s for dehydration.

Example 4

Facility Assessment

The facility has been cited at

F-F700 of the State Operations Manual prior to installing bed rails/enabler bars.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49434 safety Based on observation, record review, and interview, the facility did not have sufficient staff with appropriate Residents Affected - Few competencies and skill sets to provide direct nursing and behavioral health related services to assure resident safety for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 sampled resident (Resident R11) and 1 of 1 supplemental residents reviewed (Resident R55).

Resident R11 had expressed suicidal ideations related to his chronic pain (phantom limb pain) multiple times in the two months preceding Resident R11 stabbing himself in the chest with scissors due to unrelieved pain. Resident R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as

a result of his suicide attempt. Following this incident, the resident returned to the facility and continued to express suicidal ideation and uncontrolled pain. Although Resident R11 has had sharp objects removed from his room since the incident on 5/24/24, adequate supervision has not been provided when Resident R11 expresses suicidal ideations.

Resident R55 expressed suicidal ideations multiple times between 8/5/24 and 4/10/25. Over this time, Resident R55 obtained sharp objects on occasions. On 4/10/25, scissors were removed from Resident R55's room, after which the resident stated that if he had them he would use them like this and proceeded to hold his hand up to his throat.

The facility's failure to provide residents with sufficient staffing that had the appropriate competencies and skill sets to provide direct nursing and behavioral health related services to assure safety needs were met to attain or maintain their highest practicable physical, mental, and psychosocial well-being to address behavioral health needs such as monitoring, on going assessments, and interventions to improve or stabilize Resident R11 or Resident R55's condition created a finding of immediate jeopardy that began on 5/30/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 4/10/25 at 2:46 PM. The immediate jeopardy was removed on 4/15/25. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.

This is evidenced by:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 The facility policy titled, Notification of Change, reviewed 1/2025, states in part: . The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident Level of Harm - Immediate experiences a change in condition, potential discharge, room transfer or death .Notification Parameters: jeopardy to resident health or [Corporation Name] has adopted the current INTERACT Tools Change in Condition: When to report to the safety MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant) . ASSESSMENT: 1. When made aware of a change in condition of a resident the Licensed nurse will perform an assessment based on their Residents Affected - Few professional judgement . NOTIFY THE PHYSICIAN IMMEDIATELY IF THE RESIDENT REQUIRES IMMEDIATE ACTION . NOTIFICATION: . 4. Document each attempt in the residents medical record. 5. Notify the Director of Nursing of the Residents condition change. 6. The Licensed nurse is to provide frequent checks on the residents condition while waiting for a call back from the Physician and or NP. Alert

the direct care givers of residents condition change and signs and symptoms to be watching for . 8. Inform

the physician of the services available in the facility vs. automatic transfer of the resident to the emergency room or admission to the hospital .

The facility policy titled, Pain Management Policy, reviewed 1/2025, states in part: . Purpose: to provide an approach to pain management that provides the resident with optimal comfort, dignity and quality of life. Resident experiencing pain will be treated using non-pharmacological and pharmacological methods to optimally control pain, maximize function and promote quality of life . 5. Each resident's plan of care will include interventions to effectively manage pain, including pharmacological and non-pharmacological interventions . 6. Pain will be reassessed after interventions to evaluate the effectiveness of the intervention and to recognize undesirable side effects and documented in the medical record. 7. The provider will be notified if comfort is not achieved following pain management interventions, for changes in pain characteristics and/or with new onset pain or breakthrough pain .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 The facility policy titled, Trauma Informed Care, reviewed 1/2025, states in part: . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using Level of Harm - Immediate approaches which are culturally-competent, account for experiences and preferences, and address the jeopardy to resident health or needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, safety series of events, or set of circumstances that is experienced by an individuals as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individuals' functioning and mental, Residents Affected - Few physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: . d. Physical, sexual, mental, and/or emotional abuse (past or present) e. Rape . i. Traumatic life events . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes

the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .Policy Explanation and Compliance Guidelines: 1. The facility will work to facilitate the principles of trauma informed care which include: a. Safety - Ensuring residents have a sense of emotional and physical safety . 2. The facility will use

a multi-pronged approach to identifying a resident's history of trauma . This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools . 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan .7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as . depression and anxiety . 10.

In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 The facility policy titled, Behavioral Health Services, reviewed 1/2025, states, in part: . It is the policy of this facility to ensure residents receive necessary behavioral health services to assist them in reach and maintain Level of Harm - Immediate their highest level of mental and psychosocial functioning. Policy Explanation and Compliance Guidelines: 1. jeopardy to resident health or The facility will ensure that necessary behavioral health care services are person-centered and provided to safety each resident. 2. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 3. Conditions that may require specialized services and supports Residents Affected - Few include, but are not limited to: a. Depression b. Anxiety . 4. The facility utilizes assessments for identifying and assessing a resident's mental and psychosocial status providing person-centered care. This process includes, but is not limited to: . b. Obtaining history regarding mental, psychosocial, and emotional health. c. Ongoing monitoring of mood and behavior. d. Care plan development and implementation. e. Evaluation . 6. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based

on the role of the staff member and resident needs identified through the facility assessment. Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following: a. Person-centered care and services that reflect the resident's goals of care. b. Interpersonal communication that promotes mental and psychosocial well-being. c. Meaningful activities which promote engagement and positive meaningful relationships. d. An environment and atmosphere that is conducive to mental and psychosocial well-being. e. Individualized, non-pharmacological approaches to care . 7. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions . 8. The Social Services Director shall serve as the contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists .

Surveyor reviewed the facility's assessment, last reviewed on 8/2/24, to determine the need for staff with skills and competencies in order to provide nursing and related behavioral health services to maintain safety for Resident R11 and Resident R55.

Facility assessment indicates: .Purpose

The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The use [sic] this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents at our facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.

The intent of the facility is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require.

The assessment is organized in three parts:

1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care

2. Services and care offered based on Resident needs (includes types of care your Resident population requires)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 3. Facility resources needed to provide competent care for Residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and Level of Harm - Immediate other resources, including agreements with third parties, health information technology resources and jeopardy to resident health or systems, a facility-based and community-based risk assessment, and other information that you may choose safety Part 1 of the facility assessment, titled, Our Resident Profile with sub-heading, Diseases/Conditions, physical Residents Affected - Few and cognitive disabilities indicates that the facility accepts residents with Psychiatric/Mood Disorders such as: Depression, Impaired Cognition, Mental Disorder, Bipolar Disorder (Mania/Depression), Post-Traumatic Stress Disorder (PTSD), Anxiety Disorder, Schizophrenia, Insomnia, Mood Adjustment Disorder, and Behavior that needs interventions. The facility is also able to accept residents with neurological disorders such as Alzheimer's Disease, Non-Alzheimer's Dementia, Down Syndrome, Traumatic Brain Injuries, Autism, Huntington's Disease, Tourette's Syndrome, and Cerebral Palsy.

Part 2 of the facility assessment, titled, Services and Care We Offer Based on our Residents' Needs, indicates that the facility can provide care for residents with mental health and behavior needs, to include: managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, and intellectual or developmental disabilities. This section also indicates that the facility can provide care for residents with a need for psycho/social/spiritual support, to include: finding out what resident's preferences and routines are, what makes a good day for the resident, what upsets him or her and incorporate this information into the care planning process, making sure staff care for the resident have this information, recording and discussing treatment and care preferences, supporting resident's emotional and mental well-being, supporting helpful coping mechanisms, providing opportunities for social activities and life enrichment, and identifying hazards and risks for residents.

In the section titled, Contingency Planning for Staff, the facility assessment indicates in case of an emergency event requiring additional staffing: the administrator will direct available department heads to contact available staff to elicit ability to work, non-nursing staff will complete tasks to alleviate burden from nursing staff as allowed without certification or license, contact company affiliated facilities to determine availability to assist, contact the Regional Director of Operations to approve use of current company agency staffing contracts and offer additional incentives for staff to pick up open shifts such as bonuses.

In the section titled, Staff training/education and competencies the facility assessment indicates various education, training, and competencies that are necessary for staff to provide the level and types of support and care needed for the facility's resident population. Trauma informed care is listed under the training section. Under annual competencies, the facility assessment indicates person-centered care, including care planning, resident and family education about treatments and medications, along with caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing non-pharmacological interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Surveyor requested training provided by the facility to staff regarding suicidal ideation and precautions since Resident R11's attempted suicide on 5/24/24. The education provided is print-outs of slide-show presentations titled, Level of Harm - Immediate Behavioral Health Services and Non-Pharmacological Interventions. jeopardy to resident health or safety Surveyor reviewed the document provided by the facility regarding staff education. This document is untitled and undated. The earliest Completion Date reviewed noted by Surveyor was 2/1/24 and the latest date noted Residents Affected - Few by Surveyor was 3/19/25. The Course Name of trainings include Behavioral Health Services, Non-Pharmacological Interventions (Pain and Behavior), and New Hire Behavioral Health. The titles of staff members include Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), Dietary staff, housekeeping staff, Activities Staff, and Maintenance Staff. Out of the 15 RNs reviewed, only 8 completed all three trainings, indicating a 53% training completion rate. Out of the 12 LPNs reviewed, 9 completed all three trainings, indicating a 75% training completion rate. Out of the 51 CNAs reviewed, 32 completed all three trainings, indicating a 63% training completion rate. SS N (Social Services) only completed the New Hire Behavioral Health training, according to the documentation provided.

(Of note: This list does not include any therapy or agency staff.)

According to the National Library of Medicine, risk factors for suicide include, in part: older populations, male, past suicide attempts, adverse childhood experiences, socioeconomic challenges, access to lethal means, recent diagnosis of terminal or chronic illnesses.

Example 1:

Resident R11 was admitted to the facility on [DATE REDACTED], with diagnoses that include: amputation of right toes, type 2 diabetes with diabetic polyneuropathy (damage to multiple peripheral nerves causing pain, tingling, burning, numbness, or sensitivity to touch), acquired absence of limb (amputation), phantom limb syndrome w/pain (sensation that limb is still attached to body and can include feelings of pain, numbness, tingling, or temperature changes), and other chronic pain.

According to the National Library of Medicine, phantom limb pain is the perception of pain or discomfort in a limb that is no longer there. This pain most commonly presents as a result of amputation. While the cause of

the pain is not completely understood, it is thought to originate with the trauma to the nerves surrounding the amputation site and involve neurons in both the spinal cord and brain as well. This pain is often described as tingling, throbbing, sharp, pins/needles in the limb that is no longer there. Pain severity varies and tends to be intermittent in frequency. Treatment has not been proven to be very effective for phantom limb pain and focuses on symptomatic control. Medication options include acetaminophen (Tylenol), ibuprofen, opioids, antidepressants, anticonvulsants (anti-seizure medications), beta blockers, topical anesthetics like Capsaicin, botulinum toxin injections, and local anesthetics. Phantom limb pain is very complex and difficult to treat and is best managed by an interprofessional team involving mental health professionals, pharmacists, and pain management physicians.

Resident R11's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 1/9/25, states that Resident R11 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that Resident R11 is cognitively intact. Section D indicates that Resident R11 never has self-isolating behavior. Section J indicates Resident R11 experiences pain frequently, the pain frequently interferes with his sleep and day-to-day activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Physician orders include: May be treated by house Psychiatrist as needed . Start date: 4/1/24. End date: 5/30/24. Start date: 5/30/24. Level of Harm - Immediate jeopardy to resident health or TENS (electrical current stimulates nerve cells and blocks the transmission of pain signals) unit may be safety applied for 20 minutes. Staff must assist resident with application and removal. TENS unit to be stored in med (medication) cart . Start date: 1/7/25 Residents Affected - Few Due to suicidal ideation and attempt check room for sharp objects and remove every shift. May complete with 2 staff if needed. Three Times A Day . Start date: 10/25/24.

Progress note each shift on resident status - include pain scale and mood/behaviors. Include nursing therapeutic interventions communication and interventions used. Every Shift . Start date: 5/31/24. End date: 9/9/24. Start date: 9/9/24.

Pain Assessment every 4 hours - MUST BE COMPLETED. Must offer PRN (as needed) interventions and document progress note with interventions if pain is over 6/10. Special Instructions: 0 - 10 Scale. 0 = No Pain, 1-3 Mild, 4-6 Moderate, 7-10 Severe. Every Shift . Start date: 5/30/24.

Behavior Monitoring: Yelling=1, Refusal of Care/Services=2, Combative=3, Hallucinations=4, Agitation=5, Delusions=6, Other=7 (if other please note specific behavior), None=8. Special Instructions: Interventions=calm/slow approach=1, avoid over-stimulation=2, reassurance=3, re-approach=4, re-direct=5, diversional activity=6, offer toileting/snack/drink=7, exercise=8, pain relief=9, other=10, n/a (not applicable)=11. Every Shift . Start date: 5/30/24.

Resident R11's current Comprehensive Care Plan indicates, in part:

Problem: Resident displays physical and verbal behavioral symptoms that impact resident by putting them at risk for physical injury, interferes with participation in activities or social interactions and impacts others (staff and residents) by placing them at risk of physical injury and disrupts care or living environment. Start date: 9/23/24 .

Interventions: Approach: Obtain a psych consult/psychosocial therapy as needed. Start: 9/23/24. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Start: 9/23/24. Approach: Maintain a calm environment and approach to the resident. Start: 9/23/24. Approach: Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Start: 9/23/24. Approach: Observe for changes in behavior, document, and report to doctor. Start: 9/23/24. Approach: Observe for change in mental status, document and notify physician. Start: 9/23/24. Approach: Offer reassurance to resident as necessary. Start: 9/23/24. Approach: Allow distance in seating other residents around resident. Start: 9/23/24. Approach: Remove resident from group activities when behavior is unacceptable. Start: 9/23/24. Approach: Provide opportunity for resident to vent feelings. Listen in non-judgmental manner. Start: 9/23/24. Approach: Prepare and organize supplies before caring for resident. Avoid delays and interruptions in care. Start: 9/23/24. Approach: When resident becomes physically abusive, move resident to a quiet, calm environment. Start: 9/23/24. Approach: Maintain a calm, slow, understandable approach with the resident. Start: 9/23/24

Approach: When resident becomes physically abusive, keep distance between resident and others: staff, other residents, visitors. Start: 9/23/24. Approach: Seat resident where frequent observation is possible. Start: 9/23/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Approach: Avoid over-stimulation: added noise, crowding, other physically active residents. Start: 9/23/24. Approach: Encourage (Resident R11) to NOT use his motorized wheelchair when intoxicated. Assist to provide him Level of Harm - Immediate alternate mobilization. Start: 9/23/24 jeopardy to resident health or safety Problem: Resident has expressed thoughts of being better off dead. Start date: 4/5/24. Last revised: 1/17/25 Interventions: Approach: Resident to be placed on 15 minute checks. To be completed if/when resident is Residents Affected - Few making suicidal comments. Start date: 4/5/24. Approach: Provide 1:1 sessions with staff as needed. Start date: 4/5/24. Approach: Monitor for decline in resident's mood and report to physician for evaluation as needed. Start date: 4/5/24 Approach: Obtain a psych consult/psychosocial therapy PRN. Start date: 4/5/24 Approach: During acute phase, do not make demands on resident. Remove excess stimulation. Start date: 4/5/24. Approach: Convey an attitude of acceptance toward the resident. Start date: 4/5/24. Approach: Maintain a calm environment and approach to the resident. Start date: 4/5/24. Approach: Assess if mood endangers the resident and/or others. Intervene if necessary. Start date: 4/5/24. Approach: Encourage to verbalize feelings, concerns and fears. Clarify misconceptions. Start date: 4/5/24. Approach: Establish a trusting relationship with the resident and family. Start date: 4/5/24. Approach: Use distraction, relaxation, breathing techniques, etc. during acute phases. Monitor and record effectiveness. Start date: 4/5/24. Approach: Provide reassurance and comfort during acute periods. Start date: 4/5/24. Approach: Resident has a history of making thoughts of being better off dead, these statements are often made when experiencing pain. Offer pain interventions when states are made. Start date: 5/8/24. Approach: When resident makes suicidal ideation statements, contact provider (on-call during off hours). Start date: 10/24/24. Approach: Resident's room to be assessed every shift for sharp objects or other objects or forms of hurting oneself. May be completed with 2 staff as needed. Start date: 11/11/24

Problem: Resident has pain R/T: phantom limb syndrome with pain. Start date: 4/2/24. Last Revised/Reviewed: 1/17/25 Interventions: Approach: Monitor and record any non-verbal signs of pain: guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal. Start date: 4/2/24

Approach: Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Start date: 4/2/24 Approach: Allow sufficient uninterrupted rest periods. Start date: 4/2/24 Approach: Handle gently and try to eliminate any environmental stimuli. Start date: 4/2/24 Approach: Position for comfort with physical support as necessary. Start date: 4/2/24 Approach: Administer medications as ordered. Monitor and record effectiveness. Start date: 4/2/24 Approach: Use pain relief measures such as distraction, imagery, relaxation, heat/cold, massage, etc. Monitor and record effectiveness. Start date: 4/2/24 Approach: Assess past effective and ineffective pain relief measures. Start date: 4/2/24 Approach: Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors. Start date: 4/2/24 Approach: Resident to have a pain assessment done every 4 hours. Start date: 5/31/24

Approach: Resident will hit his lower extremities and reports that this behavior is to treat the phantom pain he experiences. Offer pharmacological and non-pharmacological interventions when he is doing this. Resident often refuses additional interventions when displaying this behavior. Start date: 10/24/24

Approach: TENS Unit for Pain Relief: Resident is independent with use of TENS Unit for pain management of right foot phantom limb pain. Assist with charging unit as needed. Start date: 12/4/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 On 4/1/24, Resident R11 was admitted to the facility with orders that indicate in part: capsaicin cream, 0.025%, scheduled to apply to right foot four times a day for pain, along with an order to apply to Resident R11's skin as Level of Harm - Immediate needed once a day for pain. Nortriptyline 25 mg scheduled every evening for nerve pain. Venlafaxine jeopardy to resident health or capsule, 24 hour extended release, for a total amount of 187.5 mg, scheduled daily. Acetaminophen safety (Tylenol) 1,000 mg, every 6 hours as needed for pain, Max dosing 3,000 mg in 24 hours. Diclofenac sodium get 1%, apply 4 grams to skin four times daily as needed for joint damage causing pain and loss of function. Residents Affected - Few Complete a pain assessment every shift with a scale of 0-10, with 0 indicating no pain, 1-3 indicating mild pain, 4-6 indicating moderate pain, and 7-10 indicating severe pain.

On 4/2/24 at 5:00 PM, a Progress Note was written by ADON K (Assistant Director of Nursing) that states, in part: Provider, [NP L's Name], NP (Nurse Practitioner) notified of resident's request to keep pain creams at bedside and to have a PRN muscle relaxant. Provider notified staff that the resident has an appointment with pain medicine on April 9th, the resident is willing to wait until this appointment to address muscle relaxer and medication management of pain .

On 4/3/24, Resident R11's Medication Administration Record (MAR) indicates Resident R11 reported 7 out of 10 pain to Day shift.

On 4/3/24 at 10:46 PM, Resident R11's MAR indicates Resident R11 received 1000 mg of PRN acetaminophen which was indicated to be Not Effective.

On 4/3/24, MAR indicates Resident R11 reported 7 out of 10 pain to Evening shift.

On 4/4/24 at 12:30 AM, Resident R11's MAR indicates Resident R11 received 1000 mg of PRN acetaminophen for 9 out of 10 pain, which was indicated to be Somewhat Effective. 4 grams of diclofenac gel was also administered and marked to be Not Effective.

On 4/4/24, Resident R11's MAR indicates Resident R11 reported 7 out of 10 pain to Day shift.

On 4/4/24 at 7:55 AM, Resident R11's MAR indicates Resident R11 received 1000 mg of PRN acetaminophen for 7 out of 10 pain, which was indicated to be Not Effective.

On 4/4/24 at 11:56 AM, a Progress Note was written by RN M (Registered Nurse), that states, in part: Resident c/o (complaining) of [sic] 9/10 R (right) foot/ankle pain in his R foot. Resident was heard hollering and yelling out in pain, and when this writer went into room to assess, resident was moaning and crying. Stated that he couldn't take the pain anymore, and stated he just wants the lord to take him, he can't live like this, it's been like this for years. Resident said that he hasn't slept in 3 days, since he's been here, and the Tylenol and cream you guys hive [sic] me doesn't do f**king s**t. Asked resident if there is anything that has worked in the past, and resident replied oxycodone (opioid medication) has helped me sleep and taken the pain away before. Resident was provided diclofenac (non-steroidal anti-inflammatory drug) cream as well,

this did help resident. Reduced pain from 9/10, down to a 3/10 in about 10-15 minutes. Resident then requested more of it because pain was coming back. The writer asked resident what he meant by he wants

the lord to take him, and he stated this pain makes me suicidal. This writer asked him if he had a plan, he replied no he did not, but this has been going on for years and none of these f**king doctors understand that

this pain makes me not want to be alive anymore. DON (Director of Nursing), ADON, and social worker all updated about these comments, as well as APNP (Advanced Practice Nurse Prescriber) [NP L's Name] .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 On 4/4/24 at 12:15 PM, a Progress Note was written by DON B, that states, in part: Writer notified of resident's suicidal comments made this shift. Writer had 1:1 conversation with resident. Resident stated this Level of Harm - Immediate pain is so bad, I just want to die. Resident denied having a plan. Resident sitting up in bed, with flat affect jeopardy to resident health or during conversation. Resident stated this isn't new to me, it happens all the time. Resident placed on 15 safety minute checks. [NP L's Name] NP aware and met with resident in house. NP reviewed residents history, and stated these comments and c/o pain are not new for resident. Resident is followed by pain clinic and has Residents Affected - Few appointment next week. New orders received from [NP L's Name] .

On 4/4/24, Resident R11's Physician Orders indicate new orders were placed for: acetaminophen (Tylenol) 650 mg, scheduled three times a day for pain, not to exceed 4,000 mg in 24 hours. Voltaren (diclofenac sodium) gel, 1% apply 2 grams to the right lower extremity four times a day as needed for pain.

On 4/4/24 at 3:49 PM, a Progress Note was written by SS N (Social services), that states: The writer followed up with resident regarding the suicidal ideation comments. Resident stated that he is in pain and the medication he is receiving is not helping. This writer made sure resident does not have a plan.

(Of note: No PHQ-9 (Patient Health Questionnaire-9, a screening tool for depression) was completed at this time.)

On 4/4/24, MAR indicates Resident R11 reported 7 out of 10 pain to Evening shift.

On 4/5/24, Resident R11's Comprehensive care plan problem is created for, Resident has expressed thoughts of being better off dead. Interventions as noted above, including initiating 15 minute checks when Resident R11 makes suicidal comments.

On 4/5/24, MAR indicates Resident R11 reported 9 out of 10 pain to Day shift.

On 4/5/24 at 7:31 AM, Resident R11's MAR indicates Resident R11 received 4 grams of diclofenac gel and is marked to be Effective.

On 4/7/24 at 3:13 PM, a Progress Note was written by LPN O (License Practical Nurse), that states: Resident reported 8/10 pain to right stump most of the shift. Rubbing stump occasionally in an attempt to minimize pain. Scheduled and PRN creams applied, resident reports not effective. Resident insisted he had

a cream that is now used up that did work but not sure the name of that medication. Resident became upset when writer unable to provide him with the name or tube of medicated cream that he reported was effective. Resident reported he thought it may be lidocaine; however, he does not currently have order for Lidocaine ointment. Left note with resident's request for provider to follow up on

(Of note: Resident R11's MAR indicates the resident reported pain of 1/10, 3/10, and 0/10 for each shift of 4/7/24)

On 4/8/24, MAR indicates Resident R11 reported 8 out of 10 pain to Day shift.

On 4/8/24 at 3:41 AM, Resident R11's MAR indicates Resident R11 received 1000 mg of PRN acetaminophen for 8 out of 10 pain, which was indicated to be Somewhat Effective.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 On 4/8/24 at 6:49 PM, a Progress Note was written by ADON K that states: Resident tearful and voiced depressive statements to staff prior to supper tonight. Resident stated I would be better off dead than deal Level of Harm - Immediate with this pain, and Just kill me, it would hurt less. Writer did sit with resident who immediately stated, I don't jeopardy to resident health or want to hurt myself, I just don't want to hurt anymore. Resident denied having a plan to self harm when safety asked by writer. Writer did discus[TRUNCATED]

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49434 potential for actual harm Based on observation, interview, and record review, the facility did not provide medically related social Residents Affected - Few services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 sampled resident (Resident R11) and 1 of 1 supplemental resident (Resident R55).

Resident R11 stabbed himself with a pair of scissors after experiencing uncontrolled phantom limb pain. Prior to this, Resident R11 had expressed suicidal ideations related to his chronic pain multiple times in the two months prior to this event. Resident R11 was hospitalized for a self-inflicted stab wound to his chest and placed on an emergency psychiatric detention as a result of his suicide attempt. Following this incident, the resident returned to the facility and continued to express suicidal ideation and uncontrolled pain. No trauma assessment was completed or PHQ-9s (depression screening) following suicidal statements.

Resident R55 expressed suicidal ideations multiple times between his admitted [DATE REDACTED] and his discharge date of [DATE REDACTED]. Over this time, the resident obtained sharp objects on occasions. On 4/10/25, scissors were removed from the resident's room, after which the resident stated that if he had them he would use them like

this and proceeded to hold his hand up to his throat. No trauma assessment was completed. PHQ-9s (depression screening) were not completed following suicidal statements.

This is evidenced by:

The facility policy entitled, Behavioral Health Services, reviewed 1/2025, states, in part: . It is the policy of

this facility to ensure residents receive necessary behavioral health services to assist them in reach and maintain their highest level of mental and psychosocial functioning. Policy Explanation and Compliance Guidelines: 1. The facility will ensure that necessary behavioral health care services are person-centered and provided to each resident . 3. Conditions that may require specialized services and supports include, but are not limited to: a. Depression b. Anxiety . 4. The facility utilizes assessments for identifying and assessing

a resident's mental and psychosocial status providing person-centered care. This process includes, but is not limited to: . b. Obtaining history regarding mental, psychosocial, and emotional health. c. Ongoing monitoring of mood and behavior. d. Care plan development and implementation. e. Evaluation . 6. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified through the facility assessment. Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following: a. Person-centered care and services that reflect the resident's goals of care. b. Interpersonal communication that promotes mental and psychosocial well-being. c. Meaningful activities which promote engagement and positive meaningful relationships. d. An environment and atmosphere that is conducive to mental and psychosocial well-being. e. Individualized, non-pharmacological approaches to care . 8. The Social Services Director shall serve as the contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 The facility policy entitled, Trauma Informed Care, reviewed 1/2025, states in part: . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using Level of Harm - Minimal harm or approaches which are culturally-competent, account for experiences and preferences, and address the potential for actual harm needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individuals as physically or emotionally Residents Affected - Few harmful or life threatening and that has lasting adverse effects on the individuals' functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: . d. Physical, sexual, mental, and/or emotional abuse (past or present) e. Rape . i. Traumatic life events . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes

the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .Policy Explanation and Compliance Guidelines: 1. The facility will work to facilitate the principles of trauma informed care which include: a. Safety - Ensuring residents have a sense of emotional and physical safety . 2. The facility will use

a multi-pronged approach to identifying a resident's history of trauma . This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools . 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan .7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as . depression and anxiety . 10.

In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

Example 1:

Resident R11 was admitted to the facility on [DATE REDACTED], with diagnoses that include, in part: type 2 diabetes with diabetic polyneuropathy (damage to multiple peripheral nerves causing pain, tingling, burning, numbness or sensitivity to touch), acquired absence of limb (amputation), phantom limb syndrome w/ pain (sensation that limb is still attached to body and can include feelings of pain, numbness, tingling, or temperature changes), and other chronic pain.

Resident R11's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 1/9/25, states that Resident R11 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that Resident R11 is cognitively intact. Section D indicates the Resident R11 never has self-isolating behavior. Section J indicates Resident R11 experiences pain frequently, the pain frequently interferes with his sleep and day-to-day activities.

Resident R11's current Comprehensive Care Plan indicates, in part:

Problem: Resident has expressed thoughts of being better off dead. Start date: 4/5/24. Last revised: 1/17/25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Interventions: Approach: Obtain a psych consult/psychosocial therapy PRN. Start date: 4/5/24 .Approach: Monitor for decline in resident's mood and report to physician for evaluation as needed. Start date: 4/5/24 . Level of Harm - Minimal harm or potential for actual harm Surveyor requested Resident R11's trauma assessment. The facility indicated that no trauma assessment was conducted for Resident R11. Residents Affected - Few Surveyor reviewed Resident R11's PHQ-9 assessments. The only PHQ-9 assessments that could be found were associated with Resident R11's Minimum Data Set (MDS) assessments on the following dates: 4/8/25 (Admission MDS), 6/3/24, 7/9/24, 7/15/24, 10/9/24, 1/9/25. Resident R11 scored a zero on all of these assessments, indicating minimal depression.

On 4/4/24 at 11:56 AM, a Progress Note is written by RN M (Registered Nurse), that states, in part: Resident c/o (complaining) of [sic] 9/10 R (right) foot/ankle pain in his R foot. Resident was heard hollering and yelling out in pain, and when this writer went into room to assess, resident was moaning and crying. Stated that he couldn't take the pain anymore, and stated he just wants the lord to take him, he can't live like this, it's been like this for years. Resident said that he hasn't slept in 3 days, since he's been here, and the Tylenol and cream you guys hive me doesn't do f**king sh*t .

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 making this statement).

On 4/8/24 at 6:49 PM, a Progress Note is written by ADON K (Assistant Director of Nursing) that states: Resident tearful and voiced depressive statements to staff prior to supper tonight. Resident stated I would be better off dead than deal with this pain, and Just kill me, it would hurt less. Writer did sit with resident who immediately stated, I don't want to hurt myself, I just don't want to hurt anymore. Resident denied having a plan to self harm when asked by writer .

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 making this statement).

On 5/8/24 at 11:02 PM, a Progress Note is written by MR (Medical Records) S that states: Went into resident's room to speak with him about appointments and questions he had. Resident started crying and saying he was in so much pain and thinking suicidal thoughts because he didn't like being in so much pain.

He made comments about the pain being at a 7-8. Resident kept saying he just wanted the pain to go away, and he didn't want to be here anymore so the pain would go away. He made comments about hanging his head out of the window .

On 5/8/24 at 12:59 PM, a Progress Note is written by SS N (Social Services) that states: This writer spoke with resident regarding the suicidal thoughts. Resident stated he does not have a plan. Resident stated that

the Tylenol and pain cream he is receiving is not enough for the pain. Resident mentioned strong medication such as Oxycodone to keep the pain below a 5. Followed up with charge nurse who is addressing concerns with provider. Another appointment for pain management was scheduled.

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 making this statement and SS N following up with Resident R11).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 On 5/24/24 at 10:23 PM a Progress Note is written by RN W that Resident R11 attempted suicide by stabbing himself with a pair of scissors. As a result, Resident R11 was hospitalized and placed on an emergency psychiatric hold. Level of Harm - Minimal harm or potential for actual harm On 11/11/24 at 9:54 AM, a Progress Note is written by DON B, that states, in part: . Writer had 1:1 conversation with resident and resident stated Writer asked to speak with resident this AM regarding resident Residents Affected - Few yelling out at staff and refusing medication. Writer has 1:1 conversation with resident .Resident stated give me a gun and get it over with. Resident then stated give me a knife so I can use it on my leg to cut it off. resident was immediately placed on 1:1 . NP in house and immediately updated . New order received to send resident to [Hospital Name] ER due to pain and suicidal ideation .

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 making this statement and SS N following up with Resident R11).

On 4/7/25 at 1:58 AM, a Progress Note is written by LPN Y (Licensed Practical Nurse), that states, in part: . nurses performed a safety check in residents room where metal utensil and a pair of scissors were found.

The scissors were hidden in 2 socks [sic] and put under bed

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of finding sharp objects hidden in Resident R11's room and no evidence of SS N following up with Resident R11).

On 4/9/25 at 11:03 AM, Surveyor entered Resident R11's room for an interview. Surveyor observed Resident R11 holding his right leg, rocking back and forth, crying, with his noted favorite music playing on his television. Surveyor asked Resident R11 if he needed a nurse. Resident R11 indicated his pain treatments don't help so he did not want a nurse. Surveyor asked Resident R11 if they could ask a few questions. Resident R11 indicated he did not mind, put his leg back down and lay still on the bed. Surveyor asked Resident R11 where he obtained the scissors when he hurt himself in May. Resident R11 indicated the scissors were left on the windowsill next to his bed. Before Surveyor could ask another question, Surveyor observed Resident R11's affect become flat, and his voice monotone as he indicated that he was laying in bed and squeezing a washcloth because his pain was overwhelming and excruciating, he had just had enough, he reached out, grabbed the scissors, and stabbed himself. Resident R11 also indicated that he just didn't want to live like this anymore. Resident R11 looked at Surveyor, with a flat affect and monotone voice, and stated, You know . I'm just disappointed the scissors were so small, and it didn't cut me deep enough. Resident R11 looked back at the ceiling and Surveyor asked Resident R11 if staff were still leaving scissors in his room. Resident R11 indicates they are, and that he is disappointed that he can't do activities or play cards because he is worried about bothering the other residents if he needs to grab his foot to soothe his pain. Surveyor asked if Resident R11 would tell Surveyor were he is still getting scissors and other sharp objects from. Resident R11 indicates staff leave them in his room and that he takes them off maintenance carts and the facility desks. Surveyor also notes Resident R11's roommate receives metal silverware with his meals that he eats in his room.

Immediately following this conversation, Surveyor approached RNC (Regional Nurse Consultant) C and advised her that Resident R11 is still obtaining sharp objects and that Surveyor is concerned for his safety. RNC C indicated staff would ensure Resident R11's safety.

On 4/9/25 at 3:15 PM, a Progress Note is written by CNA J that states: Writer notified by administrator that a state surveyor observed scissors in resident room. The writer and administrator went to resident's room and did an assessment on the room to locate scissors. No scissors were found.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 (Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 making this statement and SS N (Social Services) following up with Resident R11). Level of Harm - Minimal harm or potential for actual harm On 4/9/25 at 4:38 PM, Surveyor interviewed SS N. Surveyor asked SS N what her process is for monitoring residents with depression. SS N indicates she completes a PHQ-9 on admission along with a BIMS score. Residents Affected - Few SS N also indicates if the resident triggers they do a care plan and monitor for one week. SS N indicates her monitoring also depends on which resident it is, sometimes its venting, sometimes its figuring out a plan, and for residents with amputations she tries to reconnect and help them achieve a level of peace. Surveyor asked SS N how often she conducts PHQ-9 assessments. SS N indicates she does them every 3 months, with a change of status, and if a nurse reports signs and symptoms of depression. SS N also indicates she talks with the resident about activities, brainstorms with them to see how she can help, tries to identify residents with specific triggers, monitor residents who are on medications, monitors residents' mood, and refers residents to behavior health services if it is appropriate. Surveyor asked SS N if she conducts trauma assessments. SS N indicates she completes a trauma assessment on admission if the resident has a history of PTSD. Surveyor asked SS N about Resident R11's day-to-day mood. SS N indicates Resident R11 has spurts of depression related to not being able to go home, his significant other having financial difficulties, difficulties with his financial applications, feeling defeated about not being able to discharge from the facility, and his pain levels. Surveyor asked SS N who is responsible for monitoring Resident R11's depression. SS N indicates it is the clinical team's responsibility.

(of note: SS N indicated she is aware of Resident R11 having spurts of depression, and has not provided additional services or monitoring for Resident R11.)

On 4/10/25 at 7:58 AM, Surveyor interviewed SS N. Surveyor asked SS N (Social Services) if a resident makes suicidal ideation statements, should a PHQ-9 be conducted. SS N indicates depending on the statements she follows up and that she doesn't necessarily conduct the assessment but tries to ask them what's going on and try to assist with stressors. Surveyor asked SS N when Resident R11 makes suicidal ideation statements, should a PHQ-9 be conducted. SS N indicates she does not know and is unsure if it would beneficial since he doesn't trigger. Surveyor asked SS N if she conducts the PHQ-9 or the PHQ- 2. SS N indicates she is unsure but will ask all the questions on the PHQ-9 since Resident R11 has a significant difference between his PHQ-9 results and his mood and behavior. Surveyor asked SS N if Resident R11 received a trauma assessment upon admission. SS N indicates, no. Surveyor asked SS N if Resident R11 should have received a trauma assessment. SS N indicates, he probably should have. Surveyor asked SS N if she is aware Resident R11 has

a significant history of childhood abuse. SS N indicates, no. Surveyor asked SS N since it is noted that Resident R11 told a staff member about his history of abuse, would she have expect to have been notified. SS N indicates, yes. Surveyor asked if SS N has access to residents' psychiatric notes. SS N indicates she probably has access. Surveyor asked SS N who is responsible for reviewing the psychiatric notes. SS N indicates DON B and ADON K are usually the ones who check in with residents after appointments. Surveyor asked SS N why

it would be important for her to be aware of a resident's history of trauma. SS N indicates because she would be able to have a trauma care plan, assist the resident with things they need, and provide trauma-informed care. Surveyor asked SS N if she thinks Resident R11's history of trauma could be playing a part into Resident R11's mood and behavior. SS N indicates, yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 On 4/10/25 at 8:53 AM, Surveyor interviewed DON B and NHA A. Surveyor asked DON B if all residents should have a trauma assessment completed. DON B indicates she does not know. NHA indicates all Level of Harm - Minimal harm or residents should have a trauma assessment completed on admission. Surveyor asked if DON B was aware potential for actual harm Resident R11 had a significant history of childhood abuse. DON B indicates she was not until he went to his psychiatrist appointment. Surveyor asked DON B if SS N should be aware of Resident R11's significant history of Residents Affected - Few childhood abuse. DON B indicates, yes. Surveyor asked DON B if a resident makes suicidal ideation statements, should a progress note be written. DON B indicates, yes, based on orders. Surveyor asked DON B and NHA A if a resident makes a suicidal ideation statement, should a PHQ-9 be reassessed. NHA indicates, yes.

Facility failed to provide sufficient and appropriate medically related social services that met Resident R11's needs.

Example 2:

Resident R55 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: centrilobular emphysema (chronic lung disease that causes damage to the upper lobes of the lungs), chronic respiratory failure with hypercapnia (high levels of carbon dioxide in blood due to respiratory failure), chronic obstructive pulmonary disease, dysphagia (difficulty swallowing), heart failure, unspecified intellectual disabilities, Barrett's esophagus without dysplasia (tissue lining of esophagus changes due to long-term irritation causing symptoms of difficulty swallowing, heartburn, and chest pain), and anxiety disorder.

R55s most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 2/12/25, states that Resident R55 has a BIMS (Brief Interview for Mental Status) of 13 out of 15, indicating that Resident R55 is cognitively intact. Section D indicates the Resident R55 never has self-isolating behaviors.

Resident R55's Level 2 Preadmission Screening and Resident Review (PASRR) evaluation summary indicates that a nursing facility may choose to admit or retain Resident R55 because it was decided that Resident R55 is appropriate for nursing facility placement.

Resident R55's Comprehensive Care Plan indicates, in part:

Problem: Impaired psychosocial well-being: resident has expressed/displayed that doing favorite activity is not important to them. Start date: 8/16/24.

(Of note: Interventions for this problem are not individualized to the resident's favorite activity, which is watching his favorite TV shows as indicated by the care plan.)

Problem: Resident has expressed suicidal comments and thoughts. Start date: 9/30/24.

.Approach: Social worker contacted Hospice in regard to resident's request for additional social interaction. Start date: 11/25/24 .

Resident R55's Hospital Document entitled, Discharge Summary, dated 8/5/24, states, in part: . Primary Discharge Diagnosis . Hemoptysis (coughing up blood) . Pneumonia (infection of the air sacs in the lungs) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Resident R55's Hospital Document entitled, History and Physical - UW Hospital Medicine Survey, dated 7/14/14, states, in part: . Update: Per nursing, patient had informed them of thoughts of self harm several weeks ago Level of Harm - Minimal harm or but no active thoughts of SI (suicidal ideation). Will continue to monitor and readdress with patient and family potential for actual harm while inpatient .

Residents Affected - Few On 8/12/24, Resident R55's PHQ-9 (Depression Scale) score was 0 indicating minimal depression.

(Of note: This PHQ-9 was completed as part of the Minimum Data Set (MDS) process and was not conducted as a result of any of Resident R55's behaviors.).

On 9/29/24 at 2:05 PM, a Progress Note is written by LPN AAA (Licensed Practical Nurse), that states: [Resident Name] stated this shift he wished he would die. He stated he is tired, in pain, has difficulty breathing and eating and is ready to be done. He asked the GPT nurse if there is anything she could give him for this. She did assess him for pain and administered Morphine per PRN orders. This nurse approached [Resident Name] and offered some follow up conversation. [Resident Name] does not have a plan, he stated

he would not do anything at this time. He reiterated that he is tired and it's hard for him to do anything. He said he was feeling sorry for himself. It's noted that [Resident Name] is on hospice, he is end of life and comfort is his goal at this time. He was tearful and appreciative of the talk. He agreed to rest and let the morphine kick in. This nurse updated the ADON and the on-call MD. Intervention at this time is to initiate 15-minute checks for his safety, continue to offer PRN's for his comfort and re-evaluate with clinical team in

the morning 9/30/2024. On call MD [Doctor's Name] in agreement with this plan. TP charting initiated. [Hospice Name] on call Nurse also updated.

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 making this statement).

On 9/30/24, Resident R55's Comprehensive Care Plan was updated to include the problem and interventions for Resident R55 expressing suicidal comments and thoughts.

(Of note: Resident R55's initial care plan had the same interventions as Resident R11's (above).)

On 11/25/24 at 12:48 PM, a Progress Note is written by SS N, that states: The writer contacted Hospice to have additional social interaction. Writer also encouraged resident to join activities of interest in common area with others. Writer spoke with activities director to have him added to 1:1 activity for more social interaction. Care plan updated.

On 12/9/24 at 1:51 PM, a Progress Note is written that states: Removed knife that was bungee corded to walker during am (day) shift due to safety concerns and prior suicidal comments. Placed in top right drawer of med (medication) cart.

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of the Resident R11 possessing a knife).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 On 12/15/24 at 2:16 PM, a Progress Note is written by LPN O that states, in part: Staff reported observing bright red blood coming from resident's urethra during toileting. Staff reported she noted a bloody wooden Level of Harm - Minimal harm or part of a Q-tip on resident's bedside table. While resident still sitting on toilet, this writer inspected resident's potential for actual harm penis, noted scant amount of pink drainage coming from urethra. see, it's bleeding, I don't know what happened, but it's bleeding. Denied pain/tenderness. Denied knowledge of cause. Denied inserting any kind Residents Affected - Few of object into urethra. During conversation with resident, resident insisted the bloody wooden stick was from

after he touched his penis, got blood on in his hand then touched the wooden stick. Denied inserting the wooden stick into his pennis/urethra. Discarded the bloody wooden Q-tip piece. Found other sharp objects

on top of resident's bedside table and in top drawer. All visible sharp objects in resident's room were removed and placed inside a ziplock bag with resident's name, the bag is locked in unit 100 medcart . When asked if resident had any thoughts of hurting himself, resident responded, I can't do what I want to do. When asked what it was that he wanted to do, resident responded like, I want to go outside but I can't. 15 minute checks implemented. Nu further unsafe actions noted this afternoon .

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of Resident R11 conducting self-harm behaviors and statements).

On 1/19/25 at 11:11 PM, a Progress Note is written that states, in part: resident was seen wrapping silverware in a napkin. He was unaware I was in room. he then placed in top drawer. He took all meds (medications) very pleasant. I did remove silverware. He then started [sic] to swear and throw other items .

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of Resident R11 intentionally hiding sharp objects).

On 4/10/25 at 9:59 AM, a Progress Note is written by RN M that was edited at 2:09 PM, that states, in part: Room check complete. Staff found a pair of safety scissors and these were removed. This afternoon, around 1330 (1:30 PM), resident became upset that his scissors were taken and stated that if he had them [sic], he would use them like this and proceeded to hold his hand up to his throat. Nursing assistant that was with resident stayed with him and made sure he was safe . This writer asked what resident would use scissors for, resident replied that he just wanted to cut out my papers coloring books [sic] because sometimes they don't fit in my binder. I would never cut myself or hurt myself like they do on TV. Resident denied having thoughts/ideation of self harm or having a plan .

(Of note: Surveyor conducted record review and was unable to find a PHQ-9 that was conducted as a result of Resident R11 making these statements or related behaviors).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 On 4/14/25 at 11:18 AM, Surveyor interviewed SS N. Surveyor asked SS N if a trauma assessment was completed for Resident R55. SS N indicates, no. Surveyor asked SS N if a trauma assessment should have been Level of Harm - Minimal harm or completed. SS N indicates she probably should have done one but moving forward they will be doing one for potential for actual harm every resident upon admission. Surveyor asked SS N why she wrote the note on 11/25/24 regarding Resident R55 needing additional social interaction. SS N indicates she doesn't know why she wrote the note, but maybe it Residents Affected - Few was related to the family reporting Resident R55 was bored and that he was spending a lot of time in his room. Surveyor asked SS N if this information should be contained in the note. SS N indicates, probably for this reason. Surveyor asked if a PHQ-9 was conducted after this note was written. SS N indicates it was not, but that he scored a zero on 11/12/24. Surveyor asked SS N if a PHQ-9 was conducted after Resident R55 was found with a knife bungee-corded to his walker. SS N indicates, no. Surveyor asked SS N if a PHQ-9 should have been conducted at that time. SS N indicates, probably. Surveyor asked SS N if she recalls any of the details surrounding Resident R55 being found with a knife bungee corded to his walker. Resident R55 indicates it was a pocketknife and she believed it belonged to a relative who had passed away.

On 4/14/25 at 11:59 AM, Surveyor interviewed DON B. Surveyor asked DON B if the incident of finding Resident R55 with a knife bungee corded to his walker was discussed at his care conference. DON B indicates, no. Surveyor asked DON B if a resident who has made suicidal statements and found with a knife, should that be included in a care conference. DON B indicates, yes. Surveyor asked DON B if she would expect that care conference conversation to be included in the care conference note. DON B indicates, yes. Surveyor asked DON B if she would expect the social worker to work with activities if there is a concern for additional social interaction. DON B indicates, yes, but that her guess is that it was a request for possible volunteers to assist with social interaction. Surveyor asked DON B if those volunteers are not available, would it be the facility's responsibility to provide additional social interaction. DON B indicates, yes. Surveyor asked DON B if she would expect the social worker to write a note about what prompted her request for additional social interaction. DON B indicates, yes. Surveyor asked if this could be a sign of worsening depression. DON B indicates, yes. Surveyor asked DON B what nursing staff could have done had they been aware of Resident R55's increased need for social interaction. DON B indicates, staff could offer more 1:1 in house interactions, encouraged activities, and provide additional activities of choice.

Facility failed to provide sufficient and appropriate medically related social services that met Resident R55's needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29360 potential for actual harm Based on observation, interview and record review, the facility did not ensure that each resident receives Residents Affected - Some food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect more than a minimal number of residents residing at the facility.

Residents voiced concerns with hot foods being served cold. (Resident R45, Resident R25, Resident R14, and Resident R11)

3 of 3 test trays were observed to not be served at desirable temperatures.

Evidenced by:

The facility Resident Council Minutes included, in part, the following:

3/3/25: Dietary: resident specific requests. Note there was no further explanation what the requests were.

12/2/24: Cold food, has improved.

11/4/24: Food coming cold.

Example 1

Resident R45 was admitted to the facility 11/8/24. Resident R45's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/14/25 indicates Resident R45 is cognitively intact.

On 4/7/25 at 2:10 PM Surveyor interviewed Resident R45 about his meals. Resident R45 stated the food was often served cold and tasted awful. Resident R45 stated he has told multiple staff on numerous occasions with no changes.

Example 2

Resident R25 was admitted on [DATE REDACTED]. Resident R25's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/7/25 indicates Resident R25 is cognitively intact.

On 4/10/25 at 12:15 PM Surveyor interviewed Resident R25 about her meals. Resident R25 stated the food and coffee were served cold. Resident R25 also stated she would like to have meat with her breakfast meals, has asked for meat for breakfast but not received any.

Example 3

On 4/8/25 at 8:15 AM Surveyor received the last tray served on the 400 unit hall cart. The following foods and drinks were served as part of the meal. Scrambled eggs temped at 96.1, toast cool and soggy. The scrambled eggs and toast were cold and not palatable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 On 4/8/25 at 12:32 PM Surveyor received the last tray served on the 200 unit hall cart. The following foods and drinks were served as part of the meal. Carrots temped at 108 degrees and coffee temped at 103.6. The Level of Harm - Minimal harm or carrots and coffee were cold and not palatable. potential for actual harm

On 4/9/25 at 8:34 AM Surveyor received the last tray served on the 200 unit hall cart. The following foods Residents Affected - Some and drinks were served as part of the meal. Scrambled eggs temped at 116, Biscuits and gravy temped at 121, and coffee temped at 102.6. The scrambled eggs, biscuits and gravy and coffee were cold and not palatable.

On 4/9/25 at 10:12 AM Surveyor interviewed DM FFF (Dietary Manager). Surveyor explained the findings from the test trays to DM FFF. DM FFF stated foods and drinks served should be at the appropriate temperatures and palatable.

36253

Example 4

Resident R14 was admitted to the facility on [DATE REDACTED].

On 4/7/25 at 10:41 AM, Resident R14 stated to Surveyor that the scrambled eggs at the facility were terrible and that

they were often cold.

49434

Example 5

Resident R11 was admitted to the facility on [DATE REDACTED].

Resident R11's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 1/9/25, states that Resident R11 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that Resident R11 is cognitively intact.

On 4/7/25 at 10:10 AM, Surveyor interviewed Resident R11. Surveyor asked Resident R11 about the food served by the facility. Resident R11 states the food is cold when he receives it.

Residents voiced concerns regarding palatability of the food, 3 or 3 rest trays were not palatable as food was cold.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30992

Residents Affected - Few Based on interview and record review the facility did not provide food prepared in a form designed to meet individual needs for 1 of 1 sampled resident (Resident R48).

The facility has not reassessed Resident R48's swallowing ability after she was unable to wear her lower denture due to an abscess to ensure she receives food prepared in a form that meets her needs.

As evidenced by

The facility's policy, Diet Order, revised 1/2025, documents, in part, as follows: During the course of the resident's stay, any diet change as recommended by the Dietician, Diet Technician, Speech Language Pathologist, or Nurse should be communicated to the attending M.D. (Medical Doctor). for consideration. Nursing may downgrade a diet texture temporarily for example: oral problems, difficulty swallowing/chewing, mouth sores, etc.

Resident R48 was admitted to the facility on [DATE REDACTED] with diagnoses including, but not limited to, as follows: diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar which also impedes wound healing), anxiety (feelings of worry or nervousness), and bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs).

Resident R48's Admission Minimum Data Set (MDS) dated [DATE REDACTED] indicates Resident R48 has a Brief interview of Mental Status (BIMS) of 15 out of 15 indicating she is cognitively intact. Resident R48 is her own decision maker.

On 3/10/25, Resident R48's physician examined Resident R48 noting, in part, as follows: .res c/o (complained of) of cold sore in mouth. She has Oragel next to her which she has been applying. She is not sure this is helping much. As I examine her mouth takes out her lower denture and has multiple food products that have gotten stuck underneath between her gum and her denture.

On 3/24/25 Resident R48 was seen by Dentist. The Dentist documented the following:

Type of Exam: limited

Rason for visit: mass on lower lip

Diagnosis: pt (patient) would need a biopsy for proper diagnosis

Recommended treatment: referral to oral surgeon

Reason for visit: patient has traumatized soft tissue by the implant on #27-inner soft tissue of lower right lip indentation by the implant - implants on #22, 27 were placed by OS (Oral Surgeon) at (facility name).

Diagnosis: patient's implants on bottom were displacing her tissue causing a hole and irritation on the lip and tissue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Recommended treatment: referred to OS (Oral Surgeon) for evaluation, patient was prescribed pain medication and antibiotic. Level of Harm - Minimal harm or potential for actual harm On 3/6/25 RD G (Registered Dietician) documented the following: Resident R48's Nutritional Status includes the following: Diet per doctor's orders. CHO (consistent carbohydrate diet used to manage blood sugar levels) Residents Affected - Few with whole/thin textures. Provide adaptive equipment in line with therapy recommendations.

On 3/25/25, the Nurse Practitioner assessed Resident R48, documenting, in part, as follows: .Area of concerns on the inner lower lip. She has no upper or lower teeth. She does have 2 metal spikes noted in the lower gumline. Abscessed area is right next to 1 of the spikes. Patient unable to wear dentures. Abscess has ruptured.

On 4/7/25 at 10:00 AM, Surveyor spoke to Resident R48. Resident R48 stated she has an abscess from her lower denture. Resident R48 stated she has not been wearing her dentures for approximately 5-6 weeks. Resident R48 stated the abscess is painful. Resident R48 added, she knows what she can and cannot eat.

On 4/8/25 at 4:57 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, is Resident R48 having any issues in her mouth. DON B stated, she was and she will need to look for a diagnosis from the physician. DON B stated, Resident R48 declines to wear her dentures as the metal part was rubbing on her lip, that's how Resident R48 explained it to DON B. DON B stated, Resident R48 followed up with the dentist and she is not sure what came of that. DON B stated, she will obtain the documentation that is not scanned into Resident R48's medical record.

On 4/9/25 at 8:35 AM, Surveyor spoke with RN M (Registered Nurse). Surveyor asked RN M, does Resident R48 have any areas of concern in her mouth. RN M stated, Resident R48 has pain to the right lower gum, Resident R48's dentures are not fitting right or rubbing. RN M stated, she is receiving an antibiotic, and went out to a couple appointments. RN M added, Resident R48 is using Magic Mouthwash, salt water rinse, and a lidocaine viscous she is almost constantly c/o pain to that area.

On 4/9/25 at 10:35 AM, Surveyor spoke with RD G (Registered Dietician). Surveyor asked RD G, does Resident R48 have areas of concern in her mouth. RD G stated, I'll have to look at her more closely. Surveyor asked RD G, if a resident is unable to wear dentures what do you expect staff to do. RD G stated, staff should let culinary staff know along with RM GGG (Rehab Manager). RD G stated, RM GGG will delegate to the appropriate staff. Surveyor asked RD G, has anybody notified you that Resident R48 is unable to wear her lower dentures. RD G stated, no, that I will need to look into [sic]. Surveyor asked RD G, if a resident is unable to wear dentures what are the concerns you would have. RD G stated, she wants to make sure the resident can chew their foods appropriately to make sure we're meeting them where they're at. Surveyor asked RD G, is this a choking risk. RD G stated, That is a potential.

On 4/9/25 10:57 AM and 11:45 AM, Surveyor spoke with RD G (Registered Dietician) and RM GGG (Rehab Manager). RM GGG stated she spoke with Resident R48 two times this week regarding her chewing ability specifically with her pain. RM GGG stated, she asked Resident R48 if pain has impacted her chewing. Surveyor asked RD G, what dates did you speak with Resident R48. RM GGG stated, she spoke with Resident R48 on 4/7/25 and 4/8/25. RM GGG stated, because Resident R48 stated she was not having any issues she did not document this. RM GGG, stated, she should have documented the conversations. RM GGG stated, Resident R48 told her she was not having any issues and did not want to eat baby food (pureed). RM GGG did not document any conversations with Resident R48.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 On 4/10/25 at 8:30 AM, Surveyor spoke with Resident R48. Resident R48 stated, she is currently taking an antibiotic and will be seeing the Oral Surgeon on 4/14/25. Resident R48 stated she would liked her food minced or cut in small pieces so it Level of Harm - Minimal harm or is easier for her to eat. Surveyor asked Resident R48, is she is getting enough to eat. Resident R48 stated, yes. Resident R48 stated, on potential for actual harm 4/9/25 at approximately 4:30 PM, RM GGG (Rehab Manager) discussed the form of food she would like to eat. Surveyor asked Resident R48, have any staff member talked to you before yesterday about the form of food you Residents Affected - Few would like to eat since having this issue with your dentures/abscess. Resident R48 stated, No, I'm glad something is finally going to be done. Resident R48 stated, the facility is going to have to do something because she's sick of it (abscess and difficulty eating). Resident R48 added, I'm finally getting some help, thank you so much.

On 4/10/25 at 1:30 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, given that Resident R48 has an abscess in her mouth and is unable to wear her lower dentures, would you expect staff to reassess Resident R48's ability to chew and swallow her food safely. DON B stated, yes. Surveyor asked DON B, would you expect RM GGG (Rehab Manager) to document conversations with Resident R48. DON B stated, yes. Surveyor stated, Resident R48 requested that her food be cut up in small pieces to make it easier for her to eat. DON B stated, as soon as we are done talking she will pass this information along.

Staff were aware that Resident R48 had an abscess and was not able to wear her dentures, staff did not re-assess Resident R48 to ensure Resident R48 was provided food prepared in a form designed to meet her needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct 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. Level of Harm - Minimal harm or potential for actual harm 49434

Residents Affected - Many Based on interview and record review, the facility did not ensure the facility wide assessment developed by

the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 76 residents residing in the facility.

The facility assessment does not indicate:

- How many residents the facility can safely care for with suicidal ideation

- How many residents the facility can safely care for with PTSD or a history of trauma

- How many staff members are required to safely care for residents with suicidal ideation

- How many staff members are required to safely care for residents with PTSD or a history of trauma

- Staff training required to care for residents with suicidal ideation and/or PTSD or a history of trauma

This is evidenced by:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 The facility's policy titled Facility Assessment, dated 1/2025 states in part: Policy: This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents Level of Harm - Minimal harm or competently . Policy Explanation and Compliance Guidelines: 1. The facility assessment will, at a minimum, potential for actual harm address or include: a. The facility's resident population, including but not limited to: i. Number of residents and the facility's capacity; ii. The care required by the resident population, using evidence-based, data-driven Residents Affected - Many methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments; iii. The staff competencies and skillsets that are necessary to provide the level and types of care needed for the resident population; . b. The facility's resources, including but not limited to; . iii. Services provided, such as physical therapy, pharmacy, behavioral health and specific rehabilitation therapies; iv. All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care . 3. The facility will use the facility assessment to: a. Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. b. Consider staffing needs for the facility and adjust as necessary based on changes to its resident population and needs . 8. Based on the assessment of resident characteristics, the facility will determine what care/services, staff competencies, and staffing needs are required to meet the needs of our residents. This will be compared to the specific care/services, including by contract, and training

we provide. Action plans will be implemented as necessary . 10. The facility assessment will be reviewed and updated as necessary and at least annually .

Surveyor reviewed the facility assessment, dated 8/2/24, to determine the need for staff with skills and competencies in order to provide nursing and related behavioral health services to maintain resident safety and psychosocial well-being.

.Purpose

The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents at our facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.

The intent of the facility is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require.

The assessment is organized in three parts:

1. Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care

2. Services and care offered based on Resident needs (includes types of care your Resident population requires)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 3. Facility resources needed to provide competent care for Residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and Level of Harm - Minimal harm or other resources, including agreements with third parties, health information technology resources and potential for actual harm systems, a facility-based and community-based risk assessment, and other information that you may choose

Residents Affected - Many Part 1 of the facility assessment, titled, Our Resident Profile with sub-heading, Diseases/Conditions, physical and cognitive disabilities indicates that the facility accepts residents with Psychiatric/Mood Disorders such as: Depression, Impaired Cognition, Mental Disorder, Bipolar Disorder (Mania/Depression), Post-Traumatic Stress Disorder (PTSD), Anxiety Disorder, Schizophrenia, Insomnia, Mood Adjustment Disorder, and Behavior that needs interventions. The facility is also able to accept residents with neurological disorders such as Alzheimer's Disease, Non-Alzheimer's Dementia, Down Syndrome, Traumatic Brain Injuries, Autism, Huntington's Disease, Tourette's Syndrome, and Cerebral Palsy.

Part 2 of the facility assessment, titled, Services and Care We Offer Based on our Residents' Needs, indicates that the facility can provide care for residents with mental health and behavior needs, to include: managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, and intellectual or developmental disabilities. This section also indicates that the facility can provide care for residents with a need for psycho/social/spiritual support, to include: finding out what resident's preferences and routines are, what makes a good day for the resident, what upsets him or her and incorporate this information into the care planning process, making sure staff care for the resident have this information, recording and discussing treatment and care preferences, supporting resident's emotional and mental well-being, supporting helpful coping mechanisms, providing opportunities for social activities and life enrichment, and identifying hazards and risks for residents.

In the section titled, Contingency Planning for Staff, the facility assessment indicates in case of an emergency event requiring additional staffing: the administrator will direct available department heads to contact available staff to elicit ability to work, non-nursing staff will complete tasks to alleviate burden from nursing staff as allowed without certification or license, contact company affiliated facilities to determine availability to assist, contact the Regional Director of Operations to approve use of current company agency staffing contracts and offer additional incentives for staff to pick up open shifts such as bonuses.

In the section titled, Staff training/education and competencies the facility assessment indicates various education, training, and competencies that are necessary for staff to provide the level and types of support and care needed for the facility's resident population. Trauma informed care is listed under the training section. Under annual competencies, the facility assessment indicates person-centered care, including care planning, resident and family education about treatments and medications, along with caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing non-pharmacological interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 On 4/10/24 at 4:34 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what behavioral health training has been provided to staff. DON B indicated she is unsure, but that she knows it is Level of Harm - Minimal harm or done at least annually. Surveyor asked DON B if she has enough staff with the appropriate competencies to potential for actual harm care for residents with mental health concerns. DON B indicated for 15-minute checks yes, but for 1:1s we find the staff. Residents Affected - Many

On 4/14/25 at 11:59 AM, Surveyor interviewed DON B. Surveyor asked DON B how many residents the facility can safely care for with suicidal ideation. DON B indicated she does not know. Surveyor asked DON B how many residents the facility can safely care for with PTSD or a history of trauma. DON B indicated she does not know. Surveyor asked DON B if this information should be a part of the facility assessment. DON B indicated yes. Surveyor asked DON B, what skills and competencies are needed to effectively care for residents with suicidal ideation and/or PTSD or a history of trauma. DON B indicated, the training the facility held over the weekend along with effective communication. Surveyor asked DON B how staff are trained to provide non-pharmacological interventions to residents with suicidal ideation and/or PTSD or a history of trauma. DON B indicated, the training the facility held over the weekend and the interventions are listed on care plans. Surveyor asked DON B if prior to this survey, there was a process in place to train staff on these topics. DON B indicated no, but care plans were updated with suicidal ideation and intentions. Surveyor asked DON B where can staff find appropriate interventions for each resident who has experienced or is experiencing suicidal ideation and/or PTSD or a history of trauma. DON B indicated the resident care plans. Surveyor asked DON B if this information should be included in the facility assessment. DON B indicated yes. Surveyor asked DON B, what process do you have in place to ensure staff competency in the care of residents with suicidal ideation, PTSD, or a history of trauma. DON B indicated the facility did not have one but moving forward the facility will have a process to ensure everyone, including new hires, are trained and follow-up with continuing education. Surveyor asked DON B if she made observations of staff providing 15-minute checks, 1:1 observation, person-centered interventions such as assessing the room for sharp objects. DON B indicated she was for 15-minute checks. Surveyor asked DON B if she makes observations of the staff ability to communicate and interact with residents. DON B indicated yes. Surveyor asked DON B if any of those observations are documented. DON B indicated no.

On 4/14/25 at 1:54 PM, Surveyor interviewed RNC C (Registered Nurse Consultant). Surveyor asked RNC C how many residents the facility can safely care for with suicidal ideation. RNC C indicated the facility staff has not had a chance to meet regarding residents with these needs, but that she will be reviewing all future referrals to the facility. Surveyor asked RNC C if this information be a part of the facility assessment. RNC C indicated that giving a specific number is not always accurate for who you actually have in house, and that

the facility does not have an actual number.

The facility assessment did not determine what resources were necessary to care for residents with suicidal ideations and behavioral health needs. The facility assessment did not address the number of residents and

the facility's resident capacity. The care required by the resident population, using evidence-based, data-driven methods for residents behavioral health needs, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 39713

Residents Affected - Many Based on observation, interview, and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies. This is evidenced by the number and seriousness of citations during

this recertification survey, which has the potential to affect all 76 residents who reside in the facility.

During this recertification survey from 4/7/25 through 4/14/25, the facility had multiple citations including

F-F741)

The facility did not utilize the QAPI process to identify this high-risk resident population, identify risk factors related to the care for residents with suicidal ideations, monitor the care provided for these residents, ensure staff had the needed competencies and skillsets to care for these residents.

Example 3

Nutrition/hydration Status Maintenance

The facility has been cited at

F-F838 at the no actual harm/widespread level during recertification survey on 4/14/25. The facility has not used the QAPI process to review their facility assessment and ensure all components of the facility assessment are included in their facility wide assessment including the diagnosis, type, resident number, and staff needed to care for certain populations within the facility. The facility assessment did not identify the competencies and number of staff needed to care for resident populations. If

the facility assessment were reviewed in QAPI and the facility identified at risk areas within the facility the facility should have identified these areas as not being included in their facility assessment.

Despite the large GI outbreak in January the facility did not review and identify deficiencies needing improvement or take the outbreak to the QAPI team for review to help identify system failures needing improvement. The facility did not identify or take to the QAPI team concerns related to suicidal ideation even

after one resident was able to harm himself with an item that was left in his room. The facility did not identify or take concerns of nutrition and hydration to the QAPI team when a resident was noted to have been hospitalized on more than one occasion for nutrition and hydration status.

On 4/14/25 at 4:11 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A how the facility identifies areas of concern to be reviewed by the QAPI committee. NHA A stated, they are identified by chart review, trends in grievances, and staff. Surveyor asked NHA A how the facility decides what areas of concern they are going to work on in QAPI. NHA A stated, we decide to work on area that is trending on time. Last couple have been antipsychotics, before that, it was falls, and GI outbreak before that. Surveyor asked NHA A how the facility determines it is effective in making changes in QAPI. NHA A stated, continue to tract the trend. An example is in January we had 21 falls, we then looked at falls in February to see if the plan is working or if we need to adjust if not showing much improvement. Surveyor asked NHA A if

the facility reviewed in QAPI the GI outbreak in January. NHA A indicated the facility did look at the outbreak. Surveyor asked NHA A if the QAPI team ever looked at residents for suicidal ideation following one resident injuring himself with a pair of scissors left in his room by staff. NHA A stated, they had a QAPI meeting

before I started and can't say what was done before me but know we have not discussed them specifically.

The facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies or remain in compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Immediate 39713 jeopardy to resident health or safety Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and Residents Affected - Many infections. This had the potential to affect all residents residing within the facility at the time of an outbreak on 1/2/25. This outbreak involved 49 out of 83 residents and 37 staff.

As of 1/2/25, the facility was in a GI (gastrointestinal) outbreak with 2 staff and 1 resident with noted signs and symptoms of GI outbreak.

- Facility staff line listings were not completed contemporaneously.

- Temporary Care plans were not started for residents with GI signs and symptoms.

- Residents with orders for Laxatives and Diuretics continued to take their prescribed medication without any monitoring for dehydration or bowel movement consistency and frequency.

- Staff returned to work too soon following GI signs and symptoms.

- Facility does not indicate when residents were taken off precautions following GI signs and symptoms.

- Housekeeping did not ensure they cleaned non symptomatic resident rooms prior to those residents with GI signs and symptoms.

- Housekeeping did not use any type of clothing barrier (e.g., apron) when sorting dirty laundry.

- Facility did not notify DPH (Department of Public Health) of the outbreak until 1/6/25. The outbreak started

on 1/2/25.

- Facility did not complete a timeline of the outbreak.

- Facility did not complete lessons learned following the GI outbreak.

- Facility did not have an Ad Hoc QAPI meeting to discuss the GI outbreak.

The facility's failure to mitigate the spread of the GI outbreak created a finding of immediate jeopardy that began on 1/3/25. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 4/10/25 at 2:46 PM. The immediate jeopardy was removed on 1/14/25; however, the deficient practice continues at a severity/scope level of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan.

This is evidenced by:

The facility policy titled, Norovirus Prevention and Control, last reviewed 1/2025, states in part .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Policy: This facility will implement infection control measures to prevent the transmission of norovirus infection. Level of Harm - Immediate jeopardy to resident health or Procedure: 1. Place residents with symptoms of norovirus gastroenteritis on Contact Precautions in a private safety room. If a private room cannot be accommodated efforts must be attempted to separate symptomatic resident from asymptomatic residents. 2. Residents with norovirus gastroenteritis will be placed on Contact Residents Affected - Many Precautions for a minimum of 48-72 hours after the resolution of symptoms. Longer periods of isolation or cohorting for medically complex residents may be considered. 3. Minimize symptomatic resident's movements within the unit; restrict recovering residents during 48-72 hour recover time frame also from leaving the resident-care area unless it is for essential care or treatment; and suspend group activities (e.g., dining events) for the duration of an outbreak. 4. During outbreak, frequent hand hygiene after providing care or having contact with residents suspected or confirmed with norovirus gastroenteritis. 5. Transfers may be limited to Contact Precautions are not able to be maintained; or transfers may be postponed until residents no longer require Contact Precautions. 6. Perform additional cleaning and disinfection of frequently touched environmental surfaces and equipment in resident care areas, resident with isolation and cohorted areas, as well as high-traffic clinical areas. Frequently touched surfaces include, but not limited to, commodes, toilets, faucets, hand/bed railing, telephones, door handles, computer equipment, and kitchen preparation surfaces. Clean and disinfect shared equipment between residents using EPA-registered products with label claims for use in healthcare which lists activity against norovirus. Follow the manufacturer's recommendations for application and contact times. 7. Clean and disinfect surfaces starting from the areas with a lower likelihood of norovirus (e.g., toilets, bathroom fixtures). Change mop heads when a new bucket of cleaning solution is prepared or after cleaning large spills of emesis or fecal material. 8. During outbreaks, change privacy curtains when they are visibly soiled and upon resident discharge or transfer. 9. Handle soiled linens carefully, without agitating them, to avoid dispersal of virus. Use Standard Precautions, including the use of appropriate PPE (e.g., gloves and gowns), to minimize the likelihood of cross-contamination. 10. Staff who work with, prepare or distribute food will be excluded from duty immediately if they develop symptoms of acute gastroenteritis. Any staff presenting with norovirus symptoms will be off work and not to return until a minimum of 48 hours after the resolution of symptoms or longer upon recommendation from Infection Control Preventionist or Infection Control Committee.

The facility policy titled, Infection Control Program Introduction, last reviewed 1/2025, states in part .

Introduction: Infections are among the most frequent and significant problems facing nursing facility residents today. They account for a large proportion of morbidity and mortality, and for many hospital transfers. This Infection Control Manual will provide information for the essential functions and practices of the facility and also be flexible enough to fit a facility's specific environment and able to accommodate new issues or requirements.

Purpose of Infection Control Program: The major purposes of Infection Control Programs in the nursing facility are to minimize the effects of infections on residents and employees, and to educate the staff. A successful Infection Control Program requires an underlying commitment and facility-wide participation. It should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve and prevent problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Coordination and Oversight: The Director of Nursing has the responsibility of coordination and oversight of

the Infection Control Program. The Director of Nursing may appoint a clinical staff person with interest and Level of Harm - Immediate additional training in infection prevention and control to assist in the coordination and oversight of the jeopardy to resident health or Infection Control Program. safety All infections are tracked and logged regularly. The Infection Control Committee or its equivalent should Residents Affected - Many review

Elements of an Infection Control Program: The success of this Infection Control Program is base as facility-wide effort involving all disciplines and individuals. It should also be considered an integral part of a facility's overall quality assurance and performance improvement program, and have the active support of administration, residents, families, clinical, support staff, and attending physicians. The Centers for Medicare & Medicaid Services (CMS) require the long-term care facilities to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

All infections are tracked and to be logged regularly. The Infection Control Committee or its equivalent should

review summaries of this information at least quarterly.

Policies and Procedures: This review should also assess how well and how consistently the staff has complied with existing policies and regulations, and any trends or significant problems since the previous review.

Surveillance: Surveillance refers to a system for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications.

Prevention and treatment begin with recognizing the kinds of infections that occur and the signs and symptoms of their onset. Infections among the residents are not always obvious. Therefore, medical criteria and standardized definitions of infections are needed to help recognize and manage infections, (Corporation Name) will utilize McGeer's criteria to assist in the recognition of infections and ensure antibiotic usage is appropriate as part of their Stewardship program.

The facility policy titled, Cleaning and Disinfecting Residents' Rooms, undated, states in part . Resident Room Cleaning: 9. When possible, precaution/isolation rooms should be cleaned last, and water discarded

after cleaning room. 11. Clean curtains, window blinds and walls when they are visibly soiled and dirty.

The facility policy titled, Standard Precautions, undated, states in part . Gowning: Wear a gown that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and resident-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. Appropriated handling of laundry: Handle, transport, process used linen to avoid contamination of air, surfaces and persons. All soiled linens should be bagged prior to exiting room. Washing of linens will be in accordance with CMS (Centers for Medicare and Medicaid) requirements and per Chapter 5, Water Temperatures; Maintenance Manual.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 12/31/24, two staff members developed signs and symptoms related to GI outbreak. CNA (Certified Nursing Assistant) Q (NOC shift) was placed on the line list with vomiting and diarrhea and BOM (Business Level of Harm - Immediate Office Manager) P was placed on the line list for diarrhea. jeopardy to resident health or safety On 1/2/25, Resident R17, a resident on the 200 wing was placed on the line list for GI (gastrointestinal) s/sx (signs and symptoms). Resident R17's symptoms included nausea, vomiting, and diarrhea. Surveyor reviewed Resident R17's eMAR Residents Affected - Many (electronic medication administration record) and eTAR (electronic treatment administration record) and noted that the facility was monitoring Resident R17's bowel movements but not the consistency or frequency.

On 1/3/25, Resident R8, Resident R18, Resident R34, Resident R64, and Resident R70, were all noted to have GI s/sx. These five residents encompassed all 4 units of the facility.

Surveyor reviewed Resident R8's eMAR and eTAR. Resident R8 had orders for Senokot tablet 8.6 mg (milligrams). Give 1 tablet PO (by mouth) daily for constipation, once daily. During the period in which Resident R8 was experiencing s/sx of GI outbreak she continued to receive her Senokot without bowel monitoring in place for frequency and consistency. The facility did not update the physician or consider holding the medication while Resident R8 was experiencing GI related s/sx. Resident R8 had orders in the eMAR and eTAR to enter a progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/6/25. Resident R8 was noted to be added to the line list for the GI outbreak on 1/3/25 with a well date of 1/4/25, indicating Resident R8 was not being monitored for GI s/sx until after her well date.

Surveyor reviewed Resident R18's eMAR and eTAR. Resident R18 had orders for furosemide tablet 20 mg (a diuretic.) Take 1 tablet by mouth daily for fluid in the lungs due to chronic heart failure. During the period in which Resident R18 was experiencing s/sx of GI outbreak he continued to receive his furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while Resident R18 was experiencing GI related s/sx. Resident R18's eMAR and eTAR note that the facility was monitoring Resident R18's bowel movements but not the consistency or frequency.

Surveyor reviewed Resident R34's eMAR and eTAR. Resident R34 had orders for furosemide tablet 40 mg. Give 1 tablet daily for high blood pressure. During the period in which Resident R34 was experiencing s/sx of GI outbreak she continued to receive her furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while Resident R34 was experiencing GI related s/sx. Resident R34's eMAR and eTAR note that the facility was monitoring Resident R34's bowel movements but not the consistency or frequency. Resident R34 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/7/25.

Resident R34 was noted to be added to the line list for the GI outbreak on 1/3/25 with a well date of 1/5/25, indicating Resident R34 was not being monitored for GI s/sx until after her well date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed Resident R64's eMAR and eTAR. Resident R64 had orders for Senna-S tablet 8.6-50 mg. Take 1 tablet by mouth daily for constipation. During the period in which Resident R64 was experiencing s/sx of GI outbreak she Level of Harm - Immediate continued to receive her Senna-S without bowel monitoring in place for frequency and consistency. The jeopardy to resident health or facility did not update the physician or consider holding the medication while Resident R64 was experiencing GI safety related s/sx. eMAR and eTAR note that the facility was monitoring Resident R64's bowel movements but not the consistency or frequency. Resident R64's eMAR and eTAR also include orders to monitor GI symptoms: Monitor lung Residents Affected - Many sounds, vitals, and for additional symptoms Q (every) shift x (times) 72 hours TID (three times a day), start date 1/5/25 and end date 1/7/25. Resident R64's GI s/sx started on 1/3/25 with a well date of 1/6/25, indicating Resident R64 was not being monitored for GI s/sx until 2 days after he began experiencing s/sx.

Surveyor reviewed Resident R70's eMAR and eTAR. Resident R70 had orders for Senokot-S tablet 8.6-50 mg. Give 2 tablets by mouth 2 times a day for constipation prevention. Hold for loose stools. During the period in which Resident R70 was experiencing s/sx of GI outbreak he continued to receive his Senokot-S without bowel monitoring in place for frequency and consistency. The facility did not update the physician or consider holding the medication while Resident R70 was experiencing GI related s/sx. Resident R70 has orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/6/25. Resident R70 was noted to be added to

the line list for the GI outbreak on 1/3/25 with a well date of 1/4/25, indicating Resident R70 was not being monitored for GI s/sx until after her well date.

On 4/9/25 at 9:30 AM, Surveyor interviewed RNC/IP C (Regional Nurse Consultant/infection preventionist). Surveyor asked RNC/IP C when outbreak should have been called. RNC/IP C stated, after the second resident but can't give you the date. Surveyor gave RNC/IP C the infection control logs to review. RNC/IP C stated, 1/2/25 would have been the outbreak but I was not the IP at that time and cannot say when she called the outbreak. I was not notified of any outbreak until 1/4/25.

Note: The facility should have considered this an outbreak starting on 1/2/25. However, the facility has no evidence they identified the outbreak until they contacted DPH (Department of Public Health) on 1/6/25.

Note: Facility has no timeline or documentation to show when the outbreak was identified.

Note: The facility has no documentation that shows that they updated any of the residents' PCPs (Primary Care Physicians) or the Medical Director of the outbreak.

On 1/4/25, Resident R1, Resident R12, Resident R38, Resident R40, Resident R46, Resident R50, Resident R60, Resident R71, and Resident R240 were all noted to be experiencing GI s/sx.

These nine residents encompassed the 200, 300, and 400 units of the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed Resident R1's eMAR and eTAR. Resident R1's eMAR and eTAR note that the facility was monitoring Resident R64 's bowel movements but not the consistency or frequency. Resident R1's eMAR and eTAR include orders to monitor for Level of Harm - Immediate 72 hours lung sounds and VS (vital signs) due to GI illness starting on 1/4/25 and ending on 1/5/25 and to jeopardy to resident health or enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: safety nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/7/25. Resident R1 was noted to be added to the GI outbreak line list on 1/4/25 with a well date of 1/8/25, indicating monitoring of Resident R1 did not start Residents Affected - Many until the day after sx began and ended a day prior to symptoms ending. Resident R1's eMAR and eTAR also indicate Resident R1 was placed on contact precautions on 1/4/25 and precautions were discontinued on 1/7/25. Resident R1 had a well date of 1/8/25, indicated precautions were stopped the day prior to Resident R1's well date.

Surveyor reviewed Resident R12's eMAR and eTAR. Resident R12 had orders for furosemide tablet 20 mg, give 1 tablet PO daily for visible water retentions and furosemide 0.5 mg tablet (10 mg) PO in the afternoon for visible water retention. During the period in which Resident R12 was experiencing s/sx of GI outbreak she continued to receive all but one dose of her furosemide without fluid monitoring. The facility did not update the physician or consider holding the medication while Resident R12 was experiencing GI related s/sx. Resident R12's eMAR and eTAR note that the facility was monitoring Resident R12's bowel movements but not the consistency or frequency. Resident R12 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/8/25. Resident R12 was noted to be added to the line list for the GI outbreak on 1/4/25 with a well date of 1/9/25, indicating Resident R12's monitoring did not start until the day after sx began and ended a day prior to symptoms ending.

Surveyor reviewed Resident R38's eMAR and eTAR. Resident R38 had orders for Miralax 17 gram/dose, dissolve 17 grams into at least 8 ounces of beverage of choice and drink daily for bowel management, hold for loose stools/high volume ostomy output, increase to 2x (two times) daily if constipation and Sennosides-docusate sodium tablet 8.6-50 mg, take 1 tablet by mouth 2 times a day for bowel management, hold for loose stools/high volume ostomy output. During the period in which Resident R38 was experiencing s/sx of GI outbreak he continued to receive his Miralax and Sennosides-docusate sodium without bowel monitoring in place for frequency and consistency. Resident R38's eMAR and eTAR note that the facility was monitoring Resident R38's bowel movements but not the consistency or frequency. Resident R38 had orders in the eMAR and eTAR for GI symptoms: Monitor for and chart symptoms and temp Q shift x72 hours, start 1/7/25 to 1/7/25. Resident R38 was noted to be added to the line list for

the GI outbreak on 1/4/25 with a well date of 1/5/25, indicating Resident R38's monitoring did not start until 3 days

after s/sx began and 2 days after Resident R38's well date. Resident R38's eMAR and eTAR also indicate that Resident R38's isolation precautions were discontinued on 1/7/25. Facility does not have time of well date for discontinuation of isolation precautions, unable to determine from documentation and interviews if precautions discontinued appropriately.

Surveyor reviewed Resident R40's eMAR and eTAR. Resident R40 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 to 1/6/25. Resident R40 was noted to be added to the line list for the GI outbreak on 1/4/25 with a well date of 1/5/25, indicating Resident R40's monitoring did not begin until her well date and ended the following day. Resident R40's eMAR and eTAR also indicates that Resident R40's isolation precautions were discontinued on 1/7/25. Facility does not have time of well date for discontinuation of isolation precautions, unable to determine from documentation and interviews if precautions discontinued appropriately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed Resident R46's eMAR and eTAR. Resident R46's eMAR and eTAR note that the facility was monitoring Resident R46's bowel movements but not the consistency or frequency. Resident R46 also has orders to encourage fluids each Level of Harm - Immediate shift, this is signed out every shift but does not include amounts of intake. Resident R46's eMAR and eTAR orders jeopardy to resident health or include GI Symptoms: Monitor lung sounds, vitals, and for additional symptoms Q shift x 72 hours, start safety 1/5/25 to 1/7/25. Resident R46 was added to the line list for the GI outbreak on 1/4/25 with a well date of 1/5/25, indicating Resident R46's monitoring did not start until her well date. Residents Affected - Many Surveyor reviewed Resident R50's eMAR and eTAR. Resident R50 had orders for Miralax 17 gram/dose. Give 17g (grams) PO BID (twice a day) for emptying of the bowel, titrate to have 1 BM (bowel movement) per day and Senokot-S tablet, 8.6-50 mg, take 1 tab PO BID for constipation. Resident R50 was added to the GI line list for s/sx on 1/4/25 with

a well date of 1/5/25. During the time that Resident R50 was experiencing GI s/sx she continued to receive Miralax and Senokot-S BID. Resident R50's eMAR and eTAR note that the facility was monitoring Resident R50's bowel movements but not the consistency or frequency. Resident R50 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/7/25 on PM shift. Resident R50's eMAR and eTAR also includes vitals x 72 hours each shift, plus lung sounds, start date 1/4/25 at 11:00 PM and ending

on 1/5/25 at 11:00 PM. According to eMAR and eTAR Resident R50's isolation precautions were discontinued on 1/7/25. Facility did not document the time of Resident R50's last symptoms making it difficult to determine if isolation precautions were discontinued appropriately.

Surveyor reviewed Resident R60's eMAR and eTAR. Resident R60 had orders for furosemide 20 mg, administer 1 tablet (20 mg) by mouth daily for hypertension. Resident R60 was added to the GI line list for s/sx on 1/4/25 with a well date of 1/5/25. During the period in which Resident R60 was experiencing s/sx of GI outbreak she continued to receive all doses of her furosemide without fluid monitoring. The facility did not update the physician or consider holding

the medication while Resident R60 was experiencing GI related s/sx. Resident R60's eMAR and eTAR note that the facility was monitoring Resident R60's bowel movements but not the consistency or frequency. Resident R60's eMAR and eTAR includes

an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/5/25 and end date of 1/7/25. Resident R60's eMAR and eTAR note that the facility was monitoring bowel movements but not the consistency or frequency.

Note: Resident R60's monitoring for GI symptoms did not begin until her well date.

Surveyor reviewed Resident R71's eMAR and eTAR. Resident R71 was added to the facility line listing for GI s/sx on 1/4/25 and

a well date of 1/5/25. Resident R71's eMAR and eTAR note that the facility was monitoring Resident R71's bowel movements but not the consistency or frequency. Resident R71 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/7/25 on NOC (night) shift. Resident R71's well date on the GI line list is documented as 1/5/25. Resident R71's monitoring did not begin until the date of his listed well date. Resident R71's eMAR and eTAR indicates Vitals x 72 hours each shift, plus lung sounds each shift, start date 1/4/25 and end date 1/5/25.

Note: The vitals monitoring for Resident R71 were started on 1/4/25 but only completed on 1/5/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed Resident R240's eMAR and eTAR. Resident R240 was added to the facility line listing for GI s/sx on 1/4/25 and a documented well date 1/5/25. Resident R240's eMAR and eTAR note that the facility was monitoring Resident R240's Level of Harm - Immediate bowel movements but not the consistency or frequency. Resident R240 had orders in the eMAR and eTAR to enter jeopardy to resident health or progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, safety vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/7/25 on PM shift. Facility does not have time of well date for discontinuation of isolation precautions, unable to determine from Residents Affected - Many documentation and interviews if precautions discontinued appropriately.

On 1/5/25, Resident R10, Resident R56, and Resident R239 were noted to be experiencing GI s/sx. These three residents encompassed

the 200, 300, and 400 units.

Surveyor reviewed Resident R10's eMAR and eTAR. Resident R10 was added to the facility line listing for GI s/sx on 1/5/25 and

a documented well date of 1/6/25. Resident R10 had orders for sennosides-docusate sodium tablet 8.6-50 mg. Give 2 tabs po BID for constipation. Torsemide tablet 10 mg (a diuretic.) Give 1 tablet (10 mg) with 20 mg tablet for total of 30 mg daily for edema. Torsemide tablet 20 mg. Give 1 tablet (20 mg) with 10 mg tablet for total of 30 mg daily for edema. During the period in which Resident R10 was experiencing s/sx of GI outbreak she continued to receive all doses of torsemide and sennosides-docusate sodium without fluid monitoring. Resident R10's eMAR and eTAR note that the facility was monitoring Resident R10's bowel movements but not the consistency or frequency. Resident R10 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/8/25 on NOC shift. Facility does not have time of well date for discontinuation of isolation precautions on 1/8/25; unable to determine from documentation and interviews if precautions discontinued appropriately.

Surveyor reviewed Resident R56's eMAR and eTAR. Resident R56 was added to the facility line listing for GI s/sx on 1/5/25 and

a documented well date of 1/6/25. Resident R56 had orders for Miralax 17 grams. Give 17 g PO daily for constipation. HOLD for loose stools. During the period in which Resident R56 was experiencing s/sx of GI outbreak she received Miralax as scheduled aside from 1/6/25 when medication was held. Resident R56's eMAR and eTAR notes that the facility was monitoring Resident R56's bowel movements but not the consistency or frequency. Resident R56's eMAR and eTAR include an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/5/25 AM shift and end date of 1/7/25 PM shift.

Surveyor reviewed Resident R239's eMAR and eTAR. Resident R239 was added to the facility line listing for GI s/sx on 1/5/25 and a documented well date of 1/6/25. Resident R239 had orders for Citrucel tablet 500 mg. Take 1 tab PO BID for constipation. Take with plenty of water. During the period in which Resident R239 was experiencing GI s/sx her Citrucel was held on only 2 occasions, 1/5/25 AM shift and 1/7/25 PM shift. Resident R239 received all other doses

during this time frame. Resident R239's eMAR and eTAR notes that the facility was monitoring Resident R239's bowel movements but not the consistency or frequency. Resident R239 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/5/25 on PM shift and ending 1/8/25 on PM shift.

On 1/6/25, Resident R5, Resident R9, Resident R16, Resident R21, Resident R22, Resident R51, Resident R54, Resident R67, Resident R80, and Resident R242 were noted to be experiencing GI s/sx.

These residents resided among all four units of the facility. There were also six staff (COTA (Certified Occupational Therapy Assistant) GG, AA (Activities Assistant) HH, PT (Physical Therapist) II, CNA JJ, CNA KK, CNA LL) that were experiencing GI s/sx.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 COTA GG was placed on the staff GI line list on 1/6/25 with symptoms of vomiting and diarrhea. COTA GG has no well date or return to work date listed. Level of Harm - Immediate jeopardy to resident health or AA HH was placed on the staff GI line list on 1/6/25 with symptoms of nausea, vomiting, and abdominal safety cramping. AA HH has no well date listed but returned to work on 1/13/25.

Residents Affected - Many PT II was placed on the staff GI outbreak line list on 1/6/25 with symptoms of nausea, vomiting, and diarrhea. PT II has no well date or return to work date listed.

CNA JJ was placed on the staff GI outbreak line list on 1/6/25 with symptoms of nausea, vomiting, and diarrhea. CNA JJ has no well date listed but returned to work on 1/9/25.

CNA KK was placed on the staff GI outbreak line list on 1/6/25 with symptoms of nausea, vomiting, and diarrhea. CNA KK has no well date listed but returned to work on 1/12/25.

CNA LL was placed on the GI outbreak line list on 1/6/25 with symptoms of nausea and vomiting. CNA LL has no well date listed but returned to work on 1/10/25.

On 1/6/25, DPH was notified of the facility GI outbreak by the DON (Director of Nursing). At this point the facility had 28 residents and eight staff with GI signs and symptoms.

Surveyor reviewed Resident R5's eMAR and eTAR. Resident R5 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. Resident R5 had orders for furosemide tablet 20 mg for accumulation of fluid resulting from CHF (congestive heart failure), edema. Miralax 17 gram/dose. Mix 17 grams in drink of choice PO every other day for constipation and Senokot-S tablet 8.6-50 mg. Give 1 tablet PO daily for constipation. During the period in which Resident R5 was experiencing s/sx of GI outbreak she continued to receive all doses of furosemide without fluid monitoring. Resident R5 also continued to receive all doses of Miralax and Senokot-S. Resident R5's eMAR and eTAR notes that the facility was monitoring Resident R5's bowel movements but not the consistency or frequency.

Surveyor reviewed Resident R9's eMAR and eTAR. Resident R9 was added to the facility line listing for GI s/sx on 1/6/25 and a documented well date of 1/7/25. Resident R9's eMAR and eTAR notes that the facility was monitoring Resident R9's bowel movements but not the consistency or frequency. Resident R9's eMAR and eTAR include an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/6/25 AM shift and end date of 1/8/25 NOC shift.

Surveyor reviewed Resident R16's eMAR and eTAR. Resident R16 was added to the facility line listing for GI s/sx on 1/6/25 and

a documented well date of 1/9/25. Resident R16 had orders for senna tablet 8.6 mg. Give 2 tablets by mouth daily for constipation. During the period in which Resident R16 was experiencing s/sx of GI outbreak she continued to receive all doses of senna without monitoring frequency or consistency of bowel movements. Resident R16 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/6/25 on PM shift and ending 1/9/25 on NOC shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 65 525209 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525209 B. Wing 04/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mulder Health Care Facility 713 Leonard St N West Salem, WI 54669

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed Resident R21's eMAR and eTAR. Resident R21 was added to the facility line listing for GI s/sx on 1/6/25 and

a documented well date of 1/7/25. Resident R21 had orders for furosemide 20 mg. Give 0.5 tablet (10 mg) PO daily for Level of Harm - Immediate chronic BLE (bilateral lower extremity) edema and Senna with Docusate Sodium tablet 8.6-50 mg. Give 2 jeopardy to resident health or tablets po BID for constipation. Hold for loose stools. During the period in which Resident R21 was experiencing s/sx safety of GI outbreak she continued to receive all doses of furosemide and Senna with Docusate Sodium without monitoring frequency or consistency of bowel movements or fluid hydration. Resident R21 had orders in the eMAR Residents Affected - Many and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/6/25 on PM shift and ending 1/9/25 on NOC shift.

Surveyor reviewed Resident R22's eMAR and eTAR. Resident R22 was added to the facility line listing for GI s/sx on 1/6/25 and

a documented well date of 1/7/25. Resident R22 had orders for Miralax 17 grams/dose. Give 17 grams PO in beverage of choice daily for constipation and psyllium husk powder. Give 3.4 grams in beverage of choice BID for constipation. During the period in which Resident R22 was experiencing s/sx of GI outbreak he continued to receive all doses of Miralax and psyllium husk powder without monitoring frequency or consistency of bowel movements.

Surveyor reviewed Resident R51's eMAR and eTAR. Resident R51 was added to the facility line listing for GI s/sx on 1/6/25 and

a documented well date of 1/7/25. Resident R51's eMAR and eTAR notes that the facility was monitoring Resident R51's bowel movements but not the consistency or frequency. Resident R51 had orders in the eMAR and eTAR to enter progress note every shift to include symptoms present/not present related to acute gastroenteritis: nausea, vomiting, diarrhea, abdominal cramping, fever, chills, start 1/6/25 on AM shift and ending 1/8/25 on NOC shift. Resident R51's eMAR and eTAR include an order for GI Symptoms: Monitor and chart for symptoms and temp Q shift x 72 hours, start date of 1/6 [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 65 525209

F-F880)

The facility did not utilize the QAPI process during or after the outbreak to gain feedback, collect data, and monitor the infection prevention and control process. There was no evidence the facility identified deficient practices during or after the GI outbreak or analyzed the data to implement a process improvement for infection control/GI outbreaks.

Example 2

Sufficient/competent Staff-Behavioral Health Needs

The facility has been cited at