Map showing the location of MULDER HEALTH CARE FACILITY in WEST SALEM, Wisconsin
713 LEONARD ST N, WEST SALEM, WI, 54669

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinLowest tier among peers321 rated homes · average 3.0★
  • La Crosse CountyLowest tier among peers7 rated homes · average 3.7★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs WI avg
  • StaffingCan add or remove a star4★+0.3 vs WI avg
  • Quality measuresCan add or remove a star4★+0.9 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 35% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 58% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.49hrsAbove only 18% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.85hrsAbove only 39% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better37%Above 76% of peersWI avg48%RN turnover21%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$292,588Above only 2% of peersWI avg$41,875Fines · denials2 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
55citations
11inspection dates
2actual harm (G–I)
3immediate jeopardy (J–L)
Sep 16, 2025most recent

Citations by monthDec 2022 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 16, 20254 citationsCycle 1worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 16, 2025
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 16, 2025
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 16, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 16, 2025
Apr 14, 202520 citationsCycle 1worst L · immediate jeopardy$278,155
  1. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 9, 2025
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 9, 2025
  3. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected May 9, 2025
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 9, 2025
  5. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected May 9, 2025
  6. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected May 9, 2025
  7. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected May 9, 2025
  8. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 9, 2025
  9. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected May 9, 2025
  10. F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareE · patternCorrected May 9, 2025
  11. F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareJ · isolatedCorrected May 9, 2025
  12. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected May 9, 2025
  13. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected May 9, 2025
  14. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected May 9, 2025
  15. F838Conduct 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.AdministrationF · widespreadCorrected May 9, 2025
  16. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected May 9, 2025
  17. F880Provide and implement an infection prevention and control program.Infection ControlL · widespreadCorrected May 9, 2025
  18. F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected May 9, 2025
  19. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 9, 2025
  20. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected May 9, 2025
Dec 16, 20241 citationCycle 2worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Dec 31, 2024
Nov 4, 20241 citationCycle 2worst J · immediate jeopardy$14,433
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Nov 20, 2024
Jul 24, 20241 citationCycle 2worst D · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 14, 2024
Feb 22, 20249 citationsCycle 2worst F · no actual harm
  1. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Mar 21, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Mar 21, 2024
  3. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2024
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2024
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2024
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 21, 2024
  7. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Mar 21, 2024
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 21, 2024
  9. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 21, 2024
Dec 15, 20232 citationsCycle 3worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jan 17, 2024
  2. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlF · widespreadCorrected Jan 17, 2024
Oct 18, 20232 citationsCycle 3worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 9, 2023
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 9, 2023
Apr 10, 20233 citationsCycle 3worst E · no actual harm
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected May 12, 2023
  2. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected May 12, 2023
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 12, 2023
Mar 14, 20234 citationsCycle 3worst F · no actual harm
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected May 12, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 11, 2023
  3. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Apr 11, 2023
  4. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 12, 2023
Dec 30, 20228 citationsCycle 3worst G · actual harm
  1. F572Give residents a notice of rights, rules, services and charges.Resident RightsD · isolatedCorrected Jan 27, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 27, 2023
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 27, 2023
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jan 27, 2023
  5. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Jan 27, 2023
  6. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Jan 27, 2023
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 27, 2023
  8. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jan 27, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.49hrsAbove only 18% of peers−0.70 vs WI avg
  • Registered nursesRN hours only0.85hrsAbove only 39% of peers−0.11 vs WI avg
  • Licensed practical nursesLPN hours0.56hrs
  • Nurse aidesCNA hours2.08hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.05hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better37%Above 76% of peersWI avg 48%
  • RN turnoverRegistered nurses only21%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy87 certified beds · ~77 residents a day88%Above 81% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $292,588In fines
  • 2Fines
  • 0Payment denials
  • $41,875WI avg in fines
Above only 2% of peersFewer fines than 2% of rated homes in Wisconsin

Actions on record

  1. Apr 14, 2025Civil money penalty$278,155
  2. Nov 4, 2024Civil money penalty$14,433

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Atrium Centers26 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Orion Operating Services LLC
Indirect owners (5%+)
  • Atrium Centers, INC.
  • Essel Bailey
  • Donald Finney
Operational or managerial control
  • Susan Albright Ross
Corporate officers
  • Susan Albright Ross
  • Essel Bailey
  • Donald Finney
Managing employees
  • Susan Albright Ross

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525209 · 713 LEONARD ST N, WEST SALEM, WI, 54669.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and La Crosse County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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