Wi Veterans Home-boland Hall

and no further follow up with neurosurgery was needed. R5 denied any pain or side effects of his

jeopardy to resident health or Surveyor noted that R6 remained at the hospital as of the time of the survey.On 9/15/25, at 1:06 PM, safety Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated DON-B expects staff on evenings and nights to call the on-call nurse, who will then call DON-B, regarding any new/worsening behaviors

(IDT) will meet to discuss resident triggers, behaviors and incident. DON-B indicated DON-B or NHA-A can initiate 1:1 supervision for residents. DON-B indicated DON-B should have been made aware of R6's escalating behaviors and found interventions to keep other residents safe.

The facility's failure to keep R7 and R5 free from abuse created a finding of immediate jeopardy that began on 7/17/25.

Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m.

The immediate jeopardy was removed on 9/18/25 when the facility completed the following: - Staff development / Designee will educate licensed nurses and direct care staff on: Member to member altercation, abuse education, and educating on managing behaviors.- The social worker will review members for appropriate placement.

All staff was educated member to member altercation policy, member behavior policy, care planning policy, mood assessment, and root cause analysis.- Social worker and clinical staff will review progress notes for resident's exhibiting aggressive behaviors or patterns of escalating behaviors and update care plans accordingly. IDT (interdisciplinary team) will review policy for member behaviors.

Staff to review care plan for member's exhibiting behaviors for appropriate interventions. - SDC/Designee provided education to all staff regarding elopement on their very first shift in their work unit.- SDC/Designee provided education on managing aggressive behaviors and providing intervention before there is member to member contact. (early detection of escalating behavior) on their first shift in their work unit.- Administrator/Designee will provide education to social services on responding to resident's psychosocial needs, behaviors and wishes to be discharged , developing a plan and updating the care plans.- Administrator/Designee will provide education to mangers on completing a RCA (root cause analysis) for falls, elopements, and escalated behaviors. - SW (social worker) to audit 5 x per week x 6 weeks progress notes for any residents increase behaviors.

Care plan & interventions to be updated based on Audit findings.

Findings to be presented to QAPI (quality assurance and performance improvement) committee for review and suggestions.

Findings discussed at IDT clinical daily stand-up meeting.No additional information was provided.

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was any documentation to show any follow up by the former NHA on the witness statements

concerning. R2 had a significant injury discovered on 6/14/25 and evidence the injury may have

be followed up to rule out abuse, neglect or another cause of R2's right shoulder pain.

Surveyor informed NHA-A the only documented pain for R2 during the Month of June 2025 prior to 6/14/25 was on 6/11/25, 6/13/25 and 6/14/25. NHA-A informed Surveyor NHA-A would look for more information but informed Surveyor she understood the Surveyor's concern, but felt there was unlikely any more documentation.

On 9/16/25, at 1:07 PM Surveyor interviewed STH-AA about R2's pain in the right upper arm on Friday 6/13/25. STH-AA informed Surveyor that R2 told STH-AA that R2's right arm hurts. STH-AA informed Surveyor that STH-AA informed the staff of the R2's pain complaint.

Surveyor asked STH-AA if anyone brought R2 any pain medication or came back to assess R2. STH-AA informed Surveyor not while STH-AA was there.

Surveyor asked STH-AA if anyone followed up with STH-AA on the witness statement STH-AA gave indicating R2 had right arm pain on 6/13/25 during R2's fracture investigation. STH-AA informed Surveyor no one followed up with STH-AA about STH-AA's statement indicating R2 had pain in the upper right arm on 6/13/25.

No additional information was provided on why R2's 6/14/25 right clavicle fracture of unknown origin investigation was not thoroughly investigated.

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the weekend due to R6 needing to be a 1:1, which the facility did not have the staff to accommodate

following the 30 day notice until placement was found, POA then informed DON-B to just discharge R6

Surveyor noted that on 8/27/25, R6 was sent to the hospital prescribed the following relevant medications: Risperidone 0.5mg two times per day and Duloxetine 60mg once per day.Surveyor reviewed the Hospital paperwork, dated 9/2/25, which documents R6's current active relevant medications are as follows: Duloxetine 60mg daily, Olanzapine Injection 5mg/0.5 vial as needed, risperidone 0.5mg twice per day as needed, risperidone 1mg every 12 hours, and Trazodone 50mg as needed twice per day.On 9/17/25, at 10:30 AM, Surveyor spoke with Hospital RN-EEE, who informed Surveyor that based on Hospital documentation, R6 was calm and cooperative on 9/3/25, has a history of being difficult to arouse, did not have a 1:1 in place, was not restrained, and did not receive any of R6's prescribed as needed medications (risperidone, olanzapine and trazodone) in the hospital until 9/10/25. RN-EEE explained that R6 was on a pureed diet due to a failed swallow study.

Surveyor noted that a change in R6's medications would not prevent R6 from returning to the facility. As of the time of the exit of the survey, R6 remained at the hospital and had been discharged from the facility.

No additional information was provided as to why the facility's physician did not document the specific needs for R6 that cannot be met at the facility, the facility's attempts to meet R6's needs, and the services available at the receiving facility to meet R6's needs for R6 to have an appropriate discharge.

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jeopardy to resident health or expressions. safety On [DATE], Activity Aide (AA)-FF documented R11 was waiting outside “for a ride to his

On [DATE], another elopement assessment was completed with a score of 16, indicating R11 is high risk for eloping.

Surveyor notes that an elopement care plan with a safety plan was not implemented until [DATE].

R11 had multiple previous verbalizations of wanting to leave the facility. On [DATE], 15-minute checks were implemented.

The only intervention on R11's care plan added on [DATE] was to monitor behaviors to determine: duration, frequency, intensity, and patterns.

Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or treatment of treatment program.

On [DATE], Nursing Supervisor (NS)-HH documentation states 15-minute checks discontinued, however, Surveyor notes that staff continued to document 15 minute checks were in place.

On [DATE], 15-minute checks were discontinued as documented by NS-HH.

On [DATE], RN-BB documents R11 is expressing that R11's kids are taking R11 to court and trying to take all R11's money and that R11's children were handing over their HCPOA to a guardian. R11 is upset and unreceptive to redirection.

Surveyor notes on [DATE] the coping trauma informed care plan was initiated.

On [DATE], at 7:45 AM, R11 initiated conversation with Surveyor who was observing two other Residents on the unit.

Surveyor notes R11 was very focused on leaving, the upcoming court hearing, and wanting to get to the bank so R11 can pay a lawyer for the upcoming court hearing.

On [DATE], at about 9:55 AM. R11 was found out of the facility, down at the 3 way stop sign.

Staff were alerted by a family membe

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WI Veterans Home-Boland Hall 21425 E Spring St Union Grove, WI 53182

process is reviewed upon admission. DSS-D states if a family member reports an issue to the nurse

that the TV was extremely loud and can be heard from several rooms away.

Surveyor asked R14 if the

been set to 100, which is the. volume setting the maximum the TV can be set to.Surveyor asked R14 if R14 has hearing aids, R14 stated yes and that the hearing aids were put at the front desk a long time ago. R14 stated R14 would wear the hearing aids if another pair was provided. R14 states R14 would be very happy to have hearing aids again and feels it would help R14 talk to others and hear R14's TV.Surveyor reviewed the facility's grievance log noted that on 9/6/2022, FM -K had reported the hearing aids missing for quite some time. It was found that a staff member had placed them in the medication room due to the hearing aids being broken.

The hearing aids went out for repair.Surveyor reviewed R14's Electronic medical record (EMR) and a progress note from 9/7/2022 at 11:32 AM written by Former Social Services-C documents the hearing aids were left at the front desk and the driver was notified.R14's progress note dated 9/23/2022 at 10:45 AM documents the return of the hearing aids and they are in place by Registered Nurse (RN)-G.R14's Audiologist ([NAME])-G note dated 1/24/25 documents R14's responsive capacity as confused and a limited evaluation from R14's lack of compliance with the test but suggests moderate hearing loss. [NAME]-G documents R14's clinical findings for degree of hearing loss as could not establish hearing loss. [NAME]-G recommends: Slow clear speech with Visual cues, No further testing required.R14's progress note dated 2/3/25 at 8:14 AM written by LPN-N documents: No hearing aids available.Surveyor noted that R14's physician order for hearing aids was discontinued on this date with no explanation.On 9/15/2025, at 10:48 AM Surveyor interviewed Director of nursing (DON)-B regarding the process for replacing or repairing assistive devices. DON-B informed Surveyor that the that the unit clerk that handled repair and/or replacement and scheduling appointments for audiology is no longer working at the facility and there is a new employee being trained currently.On 9/15/2025, at 10:55 AM, Surveyor interviewed Director of Activities (DA)-F. DA-F informed Surveyor that R14 participates in activities two to three times a week. DA-F stated DA-F can't recall R14 ever having hearing aids. DA-F states it would be helpful for R14 to have hearing aids as R14 does have difficulty hearing. DA-F states R14 will let others know if R14 cannot hear them or has trouble understanding.On 9/15/2025, at 11:08 AM, Surveyor interviewed Activity Aid (AA)-E. AA-E stated that AA-E has never seen any hearing aids or assistive devices for R14's hearing while employed at the facility. AA-E stated R14 is quiet and likes independent activities and is not sure if giving new hearing aids would improve quality of life but feels it should be attempted as it potentially could increase quality of life and improvement in socializing.On 9/15/2025, at 3:22 PM, Surveyor shared a concern with DON-B and Administrator-A that R14 is missing hearing aids.

The facility had no additional information to provide at this time.On 9/16/2025, at 9:42 AM, Surveyor interviewed Registered Nurse (RN)-O about R14's hearings aids to verify that R14's hearing aids are not in the building. RN-O stated RN-O has never seen R14 with hearings aids.

RN-O showed surveyor where hearing aids and other individual devices are stored. RN-O stated each resident has their own bin with their name on it. RN-O showed surveyor where the hearing aids are kept.

Surveyor observed multiple charging cases for hearing aids that are plugged into the power.

Surveyor observed that each hearing aid box has resident names, medical record number, and room number on them. R14's name was not amongst the hearing aid charging cases.On 9/16/2025, at 9:53 AM, DSS-D shared additional information regarding R14's hearing aids. DSS-D stated that DSS-D sent a message to the in-house audiology group to schedule an appointment for R14 and is awaiting response back from audiology.No additional information was provided.

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an incident audit report dated 4/9/25 at 07:45 (7:45 a.m.) and one staff statement by CNA-VV which

jeopardy to resident health or floor with her brief and pants down to her knees.

She had toilet paper in her hand and turned to her safety left side almost in a seated fetal position trying to wipe her bottom.

Surveyor noted the facility did not conduct a thorough investigation as there is no evidence as to who last saw R2, when was she

falls.

Surveyor noted the facility did not conduct a thorough investigation and did not determine the root cause of R2's four falls prior to R2's fall on 4/9/25. R2 transfer to the hospital and R2 was diagnosed with a Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, & T12 fracture.

R2's hospital Discharge summary dated [DATE] under diagnosis documents Traumatic subdural with intracranial bleed.

Dementia with behavioral disturbance with some delirium.

Essential hypertension.

Urinary tract infection present on admission.

Frequent falls.

Under Hospital Course documents Patient is a [AGE] year-old female with dementia with power of attorney activation with frequent falls who comes in with a fall consequence of subdural hematoma and intracranial bleed. patient was monitored CT did not show worsening bleeding.

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breathing bothers R11, R11 can feel triggered.

jeopardy to resident health or Initiated 9/9/25 safety Interventions:

-Administer medications as ordered.

Monitor/document for side effects and effectiveness.

Initiated 9/9/25 -Arrange for psych consult, follow up as indicated. R11 referred to in-house psychologist 6/10/25.

Initiated 9/9/25 -Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5.

Initiated 9/9/25 -R11 has deep breathing techniques to use when R11's breathing is bothering R11. R11 also enjoys socializing and being around family and friends.

Initiated 9/9/25 -Discuss feelings around change and loss, facilitate R11's expression of these feelings.

Initiated 9/9/25 -Encourage R11 to talk about how R11 is feeling to family, friends, or staff; remind R11 to utilize R11's support system if R11 is feeling down.

Initiated 9/9/25 -Please watch R11 for the signs and symptoms which may indicate R11 feeling sad or depressed such as somnolence, social isolation, increased sadness, frequent weeping, anger, refusal of cares, decreased appetite, weight loss/gain.

Initiated 9/9/25 Starting 3/26/25, the facility completed an [NAME]

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WI Veterans Home-Boland Hall 21425 E Spring St Union Grove, WI 53182

communications for direct care staff members.

required Effective Communication program training for 7 of 8 facility staff that was reviewed.

This

receive care from Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN) and Food Service Assistants (FSA).

Findings Include:On 09/30/24, at 12:35 AM, Surveyor reviewed CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ completed trainings for the past year and noted there was no documentation that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received training on the facility's effective communication program which outlined and informed staff of the elements and goals of the facility's Effective Communication program. On 9/30/24, at 1:09 PM, Surveyor requested missing training of the facility's Effective Communication program which outlined and informed staff of the elements and goals of the facility's Effective Communication program from NHA (Nursing Home Administrator)-A for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZSurveyor was informed by NHA-A and Director of Nursing (DON)-R they had to call human resources and the education company to try to locate these missing education documentation for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ. On 09/30/25, at 01:54 PM, DON-R informed Surveyor that the facility is still attempting to locate the missing documentation for the above employees by 10/1/25 in the morning for Surveyor.On 09/30/25, at 03:02 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ with the mandatory Effective Communication training.

NHA-A informed Surveyor the facility was working on providing Effective Communication training to all staff because the Effective Communication training had never been included in the facility's training process.No additional information was provided as to why the facility did not ensure that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received the required Effective Communication program training.

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WI Veterans Home-Boland Hall 21425 E Spring St Union Grove, WI 53182

Improvement Program.

required Quality Assessment and Performance Improvement (QAPI) program training for 7 of 8 facility

and have the potential to receive care from Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN) and Food Service Assistants (FSA).Findings Include:On 09/30/24, at 12:35 AM, Surveyor reviewed CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ completed trainings for the past year and noted there was no documentation that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received training on the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. On 9/30/24, at 1:09 PM, Surveyor requested training of the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program from NHA (Nursing Home Administrator)-A for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZSurveyor was informed by NHA-A and Director of Nursing (DON)-R they had to call human resources and the education company to try to locate missing education documentation for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ. On 09/30/25, at 01:54 PM, DON-R informed Surveyor that the facility is still trying to have the missing documentation by 10/1/25 in the morning for Surveyor.On 09/30/25, at 03:02 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ with the mandatory QAPI training. NHA-A informed Surveyor the facility was working on providing QAPI training to all staff because the QAPI training was never included in the facility's training process.No additional information was provided as to why the facility did not ensure that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received the required Quality Assessment and Performance Improvement program training.