WI Veterans Home-Boland Hall: Training Gaps Found - WI
The staff members included four certified nursing assistants, two licensed practical nurses, and a food service assistant. Together, they represented seven of the eight employees whose records the surveyor pulled. All 71 residents living at Boland Hall had the potential to receive care from staff who had never been trained on the program.
The surveyor flagged the missing records at 12:35 in the afternoon on September 30. By 1:09 p.m., she had formally requested the documentation from Nursing Home Administrator A. The administrator and the Director of Nursing told her they needed to contact human resources and the facility's education company to try to locate the files.
They couldn't find them.
By 1:54 p.m., the Director of Nursing told the surveyor the facility was still searching and would have an answer by the following morning. Less than two hours later, the administrator stopped searching for an alternative explanation.
At 3:02 p.m., Nursing Home Administrator A confirmed to the surveyor that the seven employees had simply never received the training. The administrator said the facility was now working to provide the program to all staff because, as she put it, the Effective Communication training had never been included in the facility's training process at all.
Not misplaced. Not delayed. Never built into the system in the first place.
The inspection report, filed by the Centers for Medicare and Medicaid Services, rated the level of harm as minimal, with potential for actual harm. The violation was triggered by a complaint. Inspectors did not specify in the narrative how long the gap had existed, how many total staff had gone without the training, or what specific elements of the communication program staff had missed.
What the record does show is that when the surveyor asked for documentation, the facility's two top administrators had to call outside the building to look for it, came up empty, and then acknowledged the training program had a structural hole that nobody had closed.
For a facility serving veterans, many of whom may have complex medical needs, communication between staff and residents is not a clerical formality. Nursing assistants, nurses, and food service workers interact with residents throughout every shift. The Effective Communication program, as described in the inspection record, was designed to inform staff of its elements and goals, the building blocks of how staff are expected to talk with and understand the people in their care.
No additional information was provided in the inspection record explaining why the training had never been incorporated into the facility's onboarding or annual education process.
The facility is located at 21425 East Spring Street in Union Grove, a small city about 35 miles south of Milwaukee. Boland Hall is one of the state-run veterans homes operated in Wisconsin.
The surveyor completed the inspection on October 1, 2025. The inspection report was printed August 8, 2026. No plan of correction was included in the published record; CMS directed anyone seeking that information to contact the facility or the state survey agency directly.
Seven staff members went through an unknown number of shifts caring for veterans without the training the facility's own program required. The administrator confirmed it the same afternoon she was asked. What she could not explain was how long it had been that way, or how many other employees had worked through the same gap without anyone noticing.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 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 staff members included four certified nursing assistants, two licensed practical nurses, and a food service assistant.
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.