WI Veterans Home-Boland Hall: Elopement Unreported - WI
The veteran, identified in inspection records only as Resident 11, eloped from the facility on that date. When a state surveyor reviewed the incident documentation, the elopement report was incomplete in ways that raised immediate questions about what the facility had actually done in response. The sections designated for mental status, predisposing environmental factors, and predisposing situational factors were all blank. There was no documented registered nurse assessment. No vitals had been recorded after the elopement. The facility had collected no staff statements.
When the surveyor asked about the missing statements, Nursing Home Administrator A said the facility was still gathering them.
Still gathering them. The elopement had already occurred.
The surveyor raised a more pressing concern: Resident 11's own physician had not been told that the resident had walked out of the building. The medical director had completed a monthly compliance visit after the elopement, and nothing in that visit's documentation indicated the doctor had been informed. When the surveyor flagged this directly to Administrator A and Director of Nursing B, the administrator acknowledged the concern and offered nothing further.
On September 16, five days after the surveyor raised the issue and six days after the elopement itself, the facility notified the medical director. A body check was completed the same day.
Six days.
The inspection report notes the timeline without elaboration. No explanation was ever provided to the surveyor for why Resident 11's physician was not contacted on September 11, the day the resident left the building.
What a physician notification in those first hours might have meant for Resident 11 is not documented. What the body check on September 16 found is not documented. Whether Resident 11 had been located immediately or had spent time outside the facility before being returned, the record does not say. The incident report, stripped of its required fields, leaves those questions open.
What the record does show is a facility that, confronted by a surveyor with the gaps in its own paperwork, was still in the process of assembling basic facts about an incident that had already happened. Staff statements that should have been collected in the immediate aftermath of an elopement were still pending. A nurse assessment that should have been completed when Resident 11 returned had not been documented. The vitals that would establish a baseline for whether the resident had been harmed by the experience were not recorded anywhere the surveyor could find.
WI Veterans Home-Boland Hall serves veterans at its Union Grove campus. Resident 11 is one of them.
The deficiency was cited at a level of minimal harm or potential for actual harm. Whether that framing accounts for what might have happened in the six days between the elopement and the physician's notification, the inspection report does not address. The physician's monthly compliance visit came and went in that window. The doctor examined whatever records were in front of them and, based on the documentation available, never learned that the resident they were reviewing had recently walked out the door.
No further information was provided to the surveyor as to why that call wasn't made on September 11.
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 veteran, identified in inspection records only as Resident 11, eloped from the facility on that date.
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.