Mulder Health Care Facility

Penalties

• Apr 14, 2025 — Fine ($186,261)
• Nov 4, 2024 — Fine ($14,433)

Inspection findings

1. Jan 22, 2026 Health · 4 findings
   • Not serious Scope/severity E Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Feb 16, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Feb 16, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Feb 16, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 16, 2026 · CMS health inspection

2. Sep 16, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Oct 16, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Oct 16, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 16, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Oct 16, 2025 · CMS health inspection

3. Apr 14, 2025 Fire Safety · 30 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0622 Resident Rights Deficiencies

     Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0624 Resident Rights Deficiencies

     Prepare residents for a safe transfer or discharge from the nursing home.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0625 Resident Rights Deficiencies

     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.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0626 Resident Rights Deficiencies

     Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

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

     Corrected May 9, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0700 Quality of Life and Care Deficiencies

     Try 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.

     Corrected May 9, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0741 Quality of Life and Care Deficiencies

     Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0745 Quality of Life and Care Deficiencies

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

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0838 Administration Deficiencies

     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.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected May 9, 2025 · CMS health inspection

   • Serious Scope/severity L

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jun 16, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 9, 2025 · CMS fire safety

4. Dec 16, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 31, 2024 · CMS health inspection

5. Nov 4, 2024 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Nov 20, 2024 · CMS health inspection

6. Jul 24, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 14, 2024 · CMS health inspection

7. Feb 22, 2024 Health · 9 findings
   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 21, 2024 · CMS health inspection

8. Dec 15, 2023 Health · 2 findings
   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 17, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0887 Infection Control Deficiencies

     Educate 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.

     Corrected Jan 17, 2024 · CMS health inspection

9. Oct 18, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Nov 9, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 9, 2023 · CMS health inspection

10. Dec 30, 2022 Health · 11 findings
    • Not serious Scope/severity D

      F0572 Resident Rights Deficiencies

      Give residents a notice of rights, rules, services and charges.

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Jan 27, 2023 · CMS health inspection

    • Serious Scope/severity G

      F0689 Quality of Life and Care Deficiencies

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

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0756 Pharmacy Service Deficiencies

      Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      Implement 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.

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jan 27, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Jan 20, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0311 Smoke Deficiencies

      Have an enclosure around a vertical opening shaft.

      Corrected Jan 20, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0911 Gas, Vacuum, and Electrical Systems Deficiencies

      Meet requirements for the installation and maintenance of electrical systems.

      Corrected Jan 20, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ALBRIGHT ROSS, SUSAN — corporate officer, NOT APPLICABLE, since 12/09/2019
• ALBRIGHT ROSS, SUSAN — adp of the snf, NOT APPLICABLE, since 01/02/2018
• ALBRIGHT ROSS, SUSAN — operational/managerial control, NOT APPLICABLE, since 01/02/2018
• ANDERSON, CURT — adp of the snf, NOT APPLICABLE, since 08/01/2025
• ANDERSON, CURT — operational/managerial control, NOT APPLICABLE, since 08/01/2025
• BAILEY, ESSEL — corporate officer, NOT APPLICABLE, since 12/09/2019
• BAILEY, ESSEL — 5% or greater indirect ownership interest, 74%, since 12/09/2019
• CHERRY, JILL — operational/managerial control, NOT APPLICABLE, since 06/01/2025
• CHERRY, JILL — adp of the snf, NOT APPLICABLE, since 06/01/2025
• COGBILL, ELIZABETH — adp of the snf, NOT APPLICABLE, since 05/01/2025
• COGBILL, ELIZABETH — operational/managerial control, NOT APPLICABLE, since 05/01/2025
• FINNEY, DONALD — corporate officer, NOT APPLICABLE, since 12/09/2019
• FINNEY, DONALD — 5% or greater indirect ownership interest, 25%, since 12/09/2019
• HAFNER, PAIGE — operational/managerial control, NOT APPLICABLE, since 01/16/2025
• HAFNER, PAIGE — adp of the snf, NOT APPLICABLE, since 01/16/2025
• JOHNSON, CINDY — adp of the snf, NOT APPLICABLE, since 09/18/2024
• JOHNSON, CINDY — operational/managerial control, NOT APPLICABLE, since 09/18/2024
• PAREDES, MIGUEL — adp of the snf, NOT APPLICABLE, since 08/18/2021
• SHEAR, NICK — operational/managerial control, NOT APPLICABLE, since 11/04/2024
• SHEAR, NICK — adp of the snf, NOT APPLICABLE, since 11/04/2024
• SIDIE, ASHLEY — adp of the snf, NOT APPLICABLE, since 11/24/2025
• SIDIE, ASHLEY — operational/managerial control, NOT APPLICABLE, since 11/24/2025
• STEWART, BRENDA — managing control - governing body, NOT APPLICABLE, since 09/18/2024
• STEWART, BRENDA — adp of the snf, NOT APPLICABLE, since 09/18/2024
• STEWART, BRENDA — operational/managerial control, NOT APPLICABLE, since 09/18/2024
• AMICUS CAPITAL HOLDINGS INC — operational/managerial control, NOT APPLICABLE, since 08/18/2021
• AMICUS CAPITAL HOLDINGS, INC. EMPLOYEE STOCK OWNERSHIP TRUST — adp of the snf, NOT APPLICABLE, since 08/18/2021
• AMICUS PROPERTIES LLC — adp of the snf, NOT APPLICABLE, since 01/01/2021
• ATRIUM CENTERS MANAGEMENT LLC — adp of the snf, NOT APPLICABLE, since 09/18/2024
• ATRIUM CENTERS MANAGEMENT LLC — operational/managerial control, NOT APPLICABLE, since 09/18/2024
• ATRIUM CENTERS, LLC — operational/managerial control, NOT APPLICABLE, since 08/20/2019
• BROAD RIVER REHABILITATION — adp of the snf, NOT APPLICABLE, since 09/01/2021
• FIFTH THIRD BANK — 5% or greater mortgage interest, NOT APPLICABLE, since 05/19/2022
• FIFTH THIRD BANK — operational/managerial control, NOT APPLICABLE, since 05/19/2022
• FORVIS MAZARS LLP — adp of the snf, NOT APPLICABLE, since 06/01/2023
• GALESVILLE LTC PHARMAY LLC — adp of the snf, NOT APPLICABLE, since 01/01/2025
• LEADERSTAT LTD — adp of the snf, NOT APPLICABLE, since 01/01/2025
• OCS REAL ESTATE HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 01/01/2021
• ORION OPERATING SERVICES LLC — 5% or greater direct ownership interest, 100%, since 12/09/2019
• ORION OPERATING SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 08/20/2019
• ORION PROPERTIES NINETEEN LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 01/01/2025