WI Veterans Home-Boland Hall: Elopement Jeopardy - WI
The resident, identified in inspection records as R11, had been assessed as high-risk for elopement with a score of 16. He had told staff multiple times he wanted to leave.
The 15-minute safety checks were put in place after those warnings. Then they were discontinued. Then, according to the inspection report, a nursing supervisor documented they had been discontinued a second time, even though floor staff kept recording them as active. Nobody had sorted out which version was true.
R11 wasn't found by staff. A family member spotted him and alerted the facility.
Federal inspectors, who were already on the unit that morning observing other residents, spoke with R11 at 7:45 a.m. He told them he needed to get to the bank to pay a lawyer. He was focused on an upcoming court hearing, worried that his children were trying to take his money and hand over his healthcare power of attorney to a guardian. He was upset. He was not redirected successfully.
Two hours and ten minutes later, he was outside, down at the stop sign.
The Centers for Medicare and Medicaid Services cited the facility for an immediate jeopardy violation, the most serious level of harm in the federal inspection system, meaning inspectors concluded the failure had placed residents at risk of serious injury or death.
The inspection report traces a sequence of missed steps that stretched back months. An elopement care plan with an actual safety component wasn't put in place until well after R11 had already been flagged as high-risk and had already been expressing that he wanted to leave. The first intervention added to his care plan was to monitor his behaviors and note their duration, frequency, and intensity. That was it. Watch and document.
When 15-minute checks were finally implemented, the documentation around them fell apart. A nursing supervisor recorded that the checks had been discontinued. Staff kept charting them anyway. A later note confirmed the checks were discontinued again. Whether anyone was actually checking on R11 during the period when the records contradicted each other is not clear from the report.
What is clear is that on the morning of October 1, inspectors watched R11 pace and talk about leaving, and that roughly two hours later he was outside the facility grounds, alone, at an intersection.
The inspection was a complaint survey. Someone had reported concerns before inspectors arrived.
R11's situation had grown more acute in the weeks before he walked out. A registered nurse documented that he was upset about the legal proceedings involving his children, that he felt his family was moving against him, and that he was unreceptive to redirection. A trauma-informed coping care plan was started after that note. The elopement safety plan had come earlier. The 15-minute checks had come and gone.
Veterans homes operate under the same federal oversight framework as other nursing facilities that accept Medicare and Medicaid funding. An immediate jeopardy citation requires the facility to demonstrate it has corrected the problem before inspectors will lower the deficiency level.
The report does not describe what R11 encountered at the intersection, how long he was outside, or what condition he was in when staff reached him. It ends where the family member's call ends, with staff alerted and R11 somewhere down the road from the place that was supposed to be keeping him safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wi Veterans Home-boland Hall from 2025-10-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
WI VETERANS HOME-BOLAND HALL in UNION GROVE, WI was cited for violations during a health inspection on October 1, 2025.
The resident, identified in inspection records as R11, had been assessed as high-risk for elopement with a score of 16.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.