Mulder Health Care Facility

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated to move it for her. CNA G then responded, I'm not moving your belongings, you can, otherwise we can't help you. Resident R4 then told staff, That's fine you can leave. CNA D then stated that if she leaves, I can't help you; there's no other staff that feels comfortable to help you on tonight. Resident R4 asked who else could from other halls. CNA D stated she told her who, then CNA G stated, Do you want me to help?? and the resident said, That's fine. Staff pulled the covers down, and CNA G grabbed the resident's arm/wrist to turn her to her left side. Resident R4 tried to pull her arm away and said, You don't have to grab my arm. CNA G said, I'm trying to put you on the bed pan. Do you want my help or not? CNA G continued to hold onto Resident R4's arm to turn her to assist with putting resident on bed pan. Resident R4 continued to resist. CNA D stated I went to grab the nurse because the situation was not deescalating.On 09/16/25 at 10:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F, who stated she was in the hall when she was called to Resident R4's room. LPN F stated that when she entered the room Resident R4's eyes were watering, and she was visibly trembling. LPN F stated CNA G was speaking aggressively and was not appropriate. LPN F stated she asked CNA G to leave a couple of times before she did. LPN F stated that CNA G got really close to Resident R4's face and asked her if she wanted her to leave, and Resident R4 responded that, Yes she wanted her to leave. CNA G responded fine, and then left.

When asked if she noticed anything with Resident R4's wrist, LPN F stated the arm was slightly red, near the wrist.

When asked if Resident R4 was upset, while she continued with the cares, LPN F stated that Resident R4 calmed as soon as CNA G left the room. When asked if she felt CNA G was abusive to Resident R4, LPN G responded, Yes. LPN F stated she called the Director of Nursing (DON) right away to report the incident and began to gather statements for an investigation. LPN F stated she was surprised that CNA G was not removed from the building during the investigation. LPN F stated that CNA G continued to work the rest of the night shift on

the 100 hall.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she then explained no other staff were able to come assist, so CNA G came. CNA D stated that CNA G spoke to Resident R4 in a condescending manner. CNA D stated that CNA G grabbed Resident R4's wrist and did not let go when the resident asked. CNA D stated CNA G was scolding Resident R4 and described the situation as a power trip.Review of CNA D's witness statement dated 09/09/25 at 10:45 PM reveals the following information.

CNA D's statement states that CNA G told Resident R4 she needed to move her belongings. Resident R4 stated to move it for her. CNA G then responded, I'm not moving your belongings, you can, otherwise we can't help you. Resident R4 then told staff, That's fine you can leave. CNA D then stated that if she leaves, I can't help you; there's no other staff that feels comfortable to help you on tonight. Resident R4 asked who else could from other halls. CNA D stated

she told her who, then CNA G stated, Do you want me to help? and the resident said, That's fine. Staff pulled the covers down, and CNA G grabbed the resident's arm/wrist to turn her to her left side. Resident tried to pull her arm away and said, You don't have to grab my arm. CNA G said, I'm trying to put you on the bed pan. Do you want my help or not? CNA G continued to hold onto Resident R4's arm to turn her to assist with putting resident on bed pan. Resident continued to resist. CNA D stated I went to grab the nurse because

the situation was not deescalating.On 09/16/25 at 10:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F, who stated she was in the hall when she was called to Resident R4's room. LPN F stated that when

she entered the room Resident R4's eyes were watering, and she was visibly trembling. LPN F stated CNA G was speaking aggressively and was not appropriate. LPN F stated she asked CNA G to leave a couple of times

before she did. LPN F stated that CNA G got really close to Resident R4's face and asked her if she wanted her to leave, and Resident R4 responded that, Yes she wanted her to leave. CNA G responded fine, and then left. When asked if she noticed anything with Resident R4's wrist, LPN F stated the arm was slightly red, near the wrist. When asked if Resident R4 was upset, while she continued with the cares, LPN F stated that Resident R4 calmed as soon as CNA G left the room. When asked if she felt CNA G was abusive to Resident R4, LPN G responded, Yes. LPN F stated she called the Director of Nursing (DON) right away to report the incident and began to gather statements for an investigation. LPN F stated she was surprised that CNA G was not removed from the building during the investigation. LPN F stated that CNA G continued to work the rest of the night shift on the 100 hall.Review of LPN F's witness statement dated 09/09/25 states in part, Nurse called to resident room by CNA D stating, CNA G and Resident R4 were arguing. The nurse walked into CNA G demanding resident roll. Resident had

a look of fear and distress, so the nurse immediately asked CNA G to leave. CNA G told resident she's got it, and she will continue cares. The nurse said no I'll take over. To which CNA G responded no I got it. This nurse then said in a stern voice, You need to leave now. CNA G then turned to resident leaning in inches from her face and kept repeating, Do you want me to leave [Resident R4]? This nurse repeated herself for the third time asking CNA G to leave as well as resident stating again that she would like CNA to leave. This nurse then repeated to CNA to leave. CNA finally left and continued to talk aggressively to resident on her way out. Nurse reported incident to DON within 30 minutes of interaction. Review of the facility self-report indicates it was reported to the state on 09/12/2025. The self-report indicates the incident occurred on 09/09/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

to help? and the resident said, That's fine. Staff pulled the covers down, and CNA G grabbed the resident's arm/wrist to turn her to her left side. Resident tried to pull her arm away and said, You don't have to grab my arm. CNA G said, I'm trying to put you on the bed pan. Do you want my help or not? CNA G continued to hold onto Resident R4's arm to turn her to assist with putting resident on bed pan. Resident R4 continued to resist. CNA D stated I went to grab the nurse because the situation was not deescalating.On 09/16/25 at 10:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F who stated she was in the hall when she was called to Resident R4's room. LPN F stated that when she entered the room Resident R4's eyes were watering, and she was visibly trembling. LPN F stated CNA G was speaking aggressively and was not appropriate. LPN F stated

she asked CNA G to leave a couple of times before she did. LPN F stated that CNA G got really close to Resident R4's face and asked her if she wanted her to leave, and Resident R4 responded that, Yes she wanted her to leave.

CNA G responded, Fine, and then left. When asked if she noticed anything with Resident R4's wrist, LPN F stated

the arm was slightly red, near the wrist. When asked if Resident R4 was upset, while she continued with the cares, LPN F stated that Resident R4 calmed as soon as CNA G left the room. When asked if she felt CNA G was abusive to Resident R4, LPN G responded, Yes. LPN F stated she called the Director of Nursing (DON) right away to report

the incident and began to gather statements for an investigation. LPN F stated she was surprised that CNA G was not removed from the building during the investigation. LPN F stated that CNA G continued to work

the rest of the night shift on the 100 hall.Review of LPN F's witness statement dated 09/09/25 states in part, Nurse called to resident room by CNA D stating CNA G and Resident R4 were arguing. The nurse walked into CNA G demanding resident roll. Resident R4 had a look of fear and distress, so the nurse immediately asked CNA G to leave. CNA G told resident she's got it and she will continue cares. The nurse said no I'll take over. To which

the CNA G responded no I got it. This nurse then said in a stern voice, You need to leave now. CNA G then turned to resident, leaning in inches from her face, and kept repeating, Do you want me to leave [Resident R4]? This nurse repeated herself for the third time asking CNA G to leave as well as resident stating again that she would like CNA G to leave. This nurse then repeated to CNA to leave. CNA finally left and continued to talk aggressively to Resident R4 on her way out. Nurse reported incident to DON within 30 minutes of interaction.On 09/15/25 at 4:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated that following

the incident, CNA G continued to work the rest of her shift, until 6:30 AM on the 100 hall. NHA A later provided information which stated that CNA G worked on 09/11/25 from 6 AM - 2:30 PM and on 09/12/25 from 6 AM - 2:30 PM. While working CNA G primarily worked on one of the facility's 4 halls, but she had the potential to assist with any of the residents on any of the halls.Review of the facility's roster matrix provided

on 09/15/25 revealed that 16 residents resided on the 100 hall on 09/09/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on interview and record review, 1 of 8 sampled residents (Resident R1) was not provided with supervision to prevent accidents.Resident R1 was being transferred to the bathroom via EZ stand when her shoulder was bumped into the door frame; the CNA staff who were assisting the resident at the time did not report this incident to

the charge nurse.This is evidenced by: The facility policy, titled Resident Incident/Accident Reporting Protocol, dated reviewed 01/2025, states, All incidents and accidents (regardless of how minor they may present) must be reported to the Charge Nurse immediately upon discovery with a completed applicable event report and communicated to the oncoming shift.Resident R1 was admitted to the facility with diagnoses including, right sided hemiplegia, impaired mobility, hypertensive intracerebral hemorrhage, chronic pain, and osteoarthritis.Surveyor reviewed a witness statement written by Registered Nurse (RN) C on 08/23/25, which states in part: During AM medication pass, resident was complaining of 10/10 pain in right arm.

Resident stated last night (8/22) . was being transferred by EZ stand to bathroom, arm was hit on the door frame on accident. Resident R1 indicated the Certified Nursing Assistant (CNA) stated sorry after.After this incident was reported by the resident on 08/23/25, the facility gathered other statements including the ones below.Surveyor reviewed a witness statement written by CNA D on 08/23/25, which states in part: I assisted with putting resident on toilet, her right arm was brushed against the door due to easy stand barely fits and resident arm was hanging, Resident stated it hurt but it was fine. It occurred on 08/22/25, at approximately 9:15 PM.Surveyor reviewed a witness statement written by CNA E which states in part was using EZ stand with resident to use the bathroom and while pushing her in to the bathroom her right arm hit

the frame of the door. I apologized and repeatedly asked if she wanted an ice pack, and she said no. It occurred on 08/22/25, at approximately 9:30 PM.Surveyor reviewed Resident R1's medical record and could not locate any information related to the above incident in the medical record on 08/22/25, when the incident occurred.Interview with DON B on 09/15/25 at 3:40 PM confirmed that CNAs did not report the incident to

the nurse working with Resident R1 at the time of the incident, or the charge nurse, or to the oncoming shift, as the policy directs.

Event ID:

Facility ID:

If continuation sheet