WI Veterans Home-Boland Hall: Improper Discharge - WI
The case involves a resident identified in inspection records only as R6, a man with dementia complicated by behavioral issues and a medication regimen his own physician described as one that could not be safely changed. The psychiatrist who evaluated him wrote that R6 "quickly becomes agitated with any changes to his regimen" and that "there is substantial medical reasoning based on patterns of behavior, not to mention safety concerns, that I can recommend that no medication weans should be attempted on this Pt, except as determined by his primary geriatrician."
R6 was sent to the hospital on August 27, 2025, prescribed risperidone and duloxetine. What happened over the following weeks became the center of a complaint inspection that concluded October 1.
The facility's Director of Nursing, identified in records as DON-B, visited R6 at the hospital on September 3. DON-B told the surveyor that R6 appeared heavily sedated, had been started on trazodone, could not eat, and had been placed on a pureed diet. DON-B concluded R6 needed to be off the new medications before the facility would accept him back. The Medical Director, DON-B said, told her the facility could not take R6 back over the weekend because he would require one-to-one staffing, and the facility did not have staff to cover that.
The plan, according to DON-B, was to call the hospital Monday and reassess.
Hospital records told a different story. The surveyor reviewed paperwork dated September 2 showing R6's active medications at that point included duloxetine, risperidone twice daily, and as-needed doses of olanzapine and trazodone. Then the surveyor spoke directly with a hospital registered nurse, identified as RN-EEE, on September 17.
RN-EEE said R6 was calm and cooperative on September 3, the same day DON-B visited and concluded he was too heavily medicated to return. R6 had a history of being difficult to arouse, the nurse said, but he had no one-to-one in place at the hospital and was not restrained. He had not received any of his as-needed medications, including the risperidone, olanzapine, or trazodone, until September 10. The pureed diet, RN-EEE explained, was the result of a failed swallow study, not his medications.
The surveyor's conclusion was direct: a change in R6's medications would not have prevented him from returning to the facility.
At some point during this period, the facility issued R6 a 30-day discharge notice. DON-B told the surveyor she had informed R6's family member that he would not actually be discharged until a placement was found. R6's power of attorney responded by telling DON-B to simply discharge him from the facility.
He was discharged. As of the survey's exit date, R6 remained at the hospital.
The inspection finding, cited at the federal F0627 level with a harm level of minimal harm or potential for actual harm, centers on what the facility's physician never did: document the specific needs R6 had that the facility could not meet, document what attempts the facility made to meet those needs, and document what services were available at the receiving facility to address those needs. None of that documentation existed in the record.
No explanation was provided to the surveyor as to why it didn't.
R6, a veteran whose psychiatric history required careful medication management and whose own care team warned against any changes to his regimen, ended the process without a documented discharge plan, without a facility, and still occupying a hospital bed weeks after he was first sent there.
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.
What happened over the following weeks became the center of a complaint inspection that concluded October 1.
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.