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WI Veterans Home-Boland Hall: Fall Investigation Failures - WI
That was the fifth time she had fallen at WI Veterans Home-Boland Hall....
Latest reports, citations, and penalties from CMS data
That was the fifth time she had fallen at WI Veterans Home-Boland Hall....
It was the afternoon of Sunday, September 21, 2025....
The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents....
The toilet was broken off its seal in the floor....
The wound was already growing MRSA....
The citation, recorded as F0609, was tied to a specific intake complaint, number 2636500....
The harm level was classified as minimal harm or potential for actual harm, and the number of residents affected was listed as few....
The resident, identified in inspection records only as R1, was living with a Left Ventricular Assist Device, known as an LVAD....
LVAD patients require specialized monitoring....
The facility's fall and winter menu had spelled out the distinction clearly....
The deficiency affected many residents, inspectors noted, though they classified the level of harm as minimal or potential....
Thirteen minutes later, a state inspector found the resident sitting in the common area and asked him about his dressing....
The finding came out of a complaint inspection completed October 9, 2025....
The fall happened on October 3, 2025....
The episode happened on the evening of July 12, 2025....
The finding was documented during a complaint inspection completed October 14, 2025....
What they found was rated as causing actual harm to residents....
No instructions for staff on what to watch for....
The resident, identified in inspection records only as R3, had already fallen four times between July and September of this year....
The arrangement worked like this: the day receptionist handled resident funds Monday through Friday, roughly 9 a.m....