WI Veterans Home-Boland Hall: Fall Investigation Failures - WI
That was the fifth time she had fallen at WI Veterans Home-Boland Hall.
The woman, identified in inspection records only as Resident 2, had dementia. She had fallen four times before that day. After this fall, on April 9, 2025, she was transferred to the hospital. Doctors found a subdural hematoma, a subarachnoid hemorrhage, an intracranial bleed, and a fracture of the T12 vertebra in her spine.
Her hospital discharge summary described her as a woman with dementia, power of attorney activation, and a history of frequent falls "who comes in with a fall consequence of subdural hematoma and intracranial bleed." A CT scan was performed to monitor whether the bleeding worsened.
Federal inspectors who reviewed the case found that the facility had never conducted a thorough investigation into any of the four falls that came before.
Nobody had determined who last saw her before she fell. Nobody had documented when she was last toileted. Nobody had identified what interventions, if any, were in place. Nobody had established a root cause that might have changed what happened next.
The inspection, completed October 1, 2025, cited the deficiency at the most serious level the federal government assigns: Immediate Jeopardy to resident health or safety.
The gap between what the records showed and what the situation required was not subtle. Four falls. No investigation. No root cause analysis. Then a brain bleed and a broken spine.
Inspectors noted that the facility's failure to investigate the four prior falls was directly connected to the failure to prevent the fifth. Without a root cause, there was no basis for new interventions. Without new interventions, nothing changed between fall four and fall five.
The image inspectors documented is a specific one: an elderly woman with dementia, alone, on the floor, pants around her knees, trying to reach behind herself with toilet paper. Whatever happened in the minutes or hours before that moment, the facility could not account for. There was no record of who had last checked on her. There was no record of what her care plan had anticipated.
WI Veterans Home-Boland Hall sits on East Spring Street in Union Grove, a small city about 35 miles south of Milwaukee. It operates under the Wisconsin Department of Veterans Affairs and serves veterans and their spouses. Resident 2 was described in her hospital records as a female with dementia with behavioral disturbance and some delirium, along with essential hypertension and a urinary tract infection that was present when she arrived at the hospital.
The Immediate Jeopardy designation means inspectors concluded that the facility's failures had placed residents at risk of serious injury, serious harm, serious impairment, or death. It is not a finding that inspectors apply routinely. It is reserved for situations where the breakdown in care is severe enough that harm has already occurred or is likely to occur without immediate correction.
What the inspection record does not contain is any account of how Resident 2 fared after hospitalization, whether she returned to the facility, or what her condition was by the time inspectors completed their review in October. The hospital discharge summary noted that CT imaging did not show worsening of the bleed. What came after that is not in the record.
What is in the record is the fall itself. The floor. The toilet paper. The four falls before it that no one had fully examined. And a woman with dementia and a fractured spine who had been trying, alone, to take care of herself.
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: July 2, 2026 · Our methodology
WI VETERANS HOME-BOLAND HALL in UNION GROVE, WI was cited for violations during a health inspection on October 1, 2025.
That was the fifth time she had fallen at WI Veterans Home-Boland Hall.
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.