Wi Veterans Home-boland Hall

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

no documentation that Resident R11's vitals were taken after the elopement. The incident is blank for sections mental status, predisposing environmental factors, predisposing situation factors. Surveyor notes there is no documented registered nurse (RN) assessment. The facility has not provided any statements in regard to Resident R11's elopement from the facility. NHA-A stated the facility is still gathering statements. Surveyor shared the concern with NHA-A and Director of Nursing (DON-B) that Resident R11's physician has not been updated in regard to Resident R11's elopement from the facility. Surveyor shared based on documentation that MD-L completed a monthly compliance visit and does not document that MD-L was made aware of Resident R11's elopement from the facility. NHA-A acknowledged the concern and provided no further information at this time.

On 9/16/25, at 1:47 PM, Surveyor was provided documentation by the facility that the medical director was notified at 11:15 AM on 9/16/25 of Resident R11's elopement from the facility. A body check was completed on 9/16/25. Surveyor noted that these actions were completed six days after Resident R11's elopement.

No additional information was provided as to why Resident R11's physician was not notified of Resident R11's elopement, when Resident R11 eloped on 9/11/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

sent to the hospital for further evaluation.Surveyor reviewed the facility provided document titled After Visit Summary for Resident R5, dated 8/28/25. Surveyor noted Resident R5 was discharged from the hospital with diagnoses that include Traumatic Brain Injury (TBI)-subdural hematoma measuring 5mm, Small Traumatic Subarachnoid hemorrhage, and Acute left frontal ischemia, likely traumatic.On 9/10/25, at 10:14 AM, Surveyor interviewed Resident R5. Surveyor observed Resident R5 to have a healing bruise under Resident R5's left eye. Resident R5 explained to Surveyor that Resident R5 was working on bird houses in Resident R5's room. Resident R6 came into Resident R5's room, catching Resident R5 off guard and began hitting Resident R5 over the head with Resident R6's cane. Resident R5 indicated that Resident R5 has never experienced issues with Resident R6 in the past, but explained other people have. During our discussion, Resident R5 received a call for follow up regarding Resident R5's injuries sustained during the assault. Resident R5 indicated being ok with Surveyor listening to Resident R5's phone call with Neurosurgery. Surveyor noted the Neurosurgery Nurse Practitioner explained to Resident R5 the results of Resident R5's most recent diagnostic imaging, indicating Resident R5's brain bleed was getting smaller and no further follow up with neurosurgery was needed. Resident R5 denied any pain or side effects of his injuries. Resident R5 expressed feeling grateful and safe knowing Resident R6 would not be returning to the facility. Surveyor noted that Resident R6 remained at the hospital as of the time of the survey.On 9/15/25, at 1:06 PM, 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 or in the event of a member-to-member altercation. During daytime hours, the Intradisciplinary team (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 Resident R6's escalating behaviors and found interventions to keep other residents safe. The facility's failure to keep Resident R7 and Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

up by the former NHA on the witness statements documenting Resident R2's pain started on 6/11/25. Surveyor informed NHA-A the concern that a follow up on those witness statements was not done especially when a right shoulder fracture was discovered is concerning. Resident R2 had a significant injury discovered on 6/14/25 and evidence the injury may have started on 6/11/25 in the witness statements. Surveyor informed NHA-A these statements needed to be followed up to rule out abuse, neglect or another cause of Resident R2's right shoulder pain. Surveyor informed NHA-A the only documented pain for Resident 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 Resident R2's pain in the right upper arm on Friday 6/13/25. STH-AA informed Surveyor that Resident R2 told STH-AA that Resident R2's right arm hurts. STH-AA informed Surveyor that STH-AA informed the staff of the Resident R2's pain complaint. Surveyor asked STH-AA if anyone brought Resident R2 any pain medication or came back to assess Resident 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 Resident R2 had right arm pain on 6/13/25 during Resident R2's fracture investigation. STH-AA informed Surveyor no one followed up with STH-AA about STH-AA's statement indicating Resident R2 had pain in the upper right arm on 6/13/25.

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

regimens, but quickly becomes agitated with any changes to his regimen. At this time 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.#Dementia, c/b behavioral issuesPer family, Pt is known to be violent at times but is generally cooperative when on a stable regimen. Followed geriatric outpatient for medical management. See above for details.PLAN:PTA risperidonePTA memantinePTA duloxetinePRN olanzapine 5mg POPRN olanzapine 5mg IMPRN trazadone 50mg [NAME] 9/16/25, at 12:24 PM, Surveyor interviewed DON-B. DON-B indicated DON-B went to visit Resident R6 at the hospital on 9/3/25 and Resident R6 was so heavily medicated, started on trazodone, indicating Resident R6 could not eat and was changed to a pureed diet. DON-B indicated Resident R6 needed to be off the new medications before allowing Resident R6 back to the facility. DON-B included the Medical Director informed DON-B the facility could not take Resident R6 back over the weekend due to Resident R6 needing to be a 1:1, which

the facility did not have the staff to accommodate that need. DON-B indicated the plan was to call back to

the hospital on Monday and reassess Resident R6. DON-B indicated, DON-B informed Resident R6's family member, Resident R6 would not be discharged from the facility following the 30 day notice until placement was found, POA then informed DON-B to just discharge Resident R6 from the facility. The facility provided Surveyor with a document titled Order Summary Report for Resident R6. Surveyor noted that on 8/27/25, Resident 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 Resident 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, Resident 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 Resident R6's prescribed as needed medications (risperidone, olanzapine and trazodone) in the hospital until 9/10/25.

RN-EEE explained that Resident R6 was on a pureed diet due to a failed swallow study. Surveyor noted that a change in Resident R6's medications would not prevent Resident R6 from returning to the facility. As of the time of the exit of

the survey, Resident 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 Resident R6 that cannot be met at the facility, the facility's attempts to meet Resident R6's needs, and the services available at the receiving facility to meet Resident R6's needs for Resident R6 to have an appropriate discharge.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0675 Level of Harm - Immediate jeopardy to resident health or safety

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

Surveyor notes that an elopement care plan with a safety plan was not implemented until [DATE REDACTED]. Resident R11 had multiple previous verbalizations of wanting to leave the facility. On [DATE REDACTED], 15-minute checks were implemented.

Residents Affected - Some

The only intervention on Resident R11's care plan added on [DATE REDACTED] 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 REDACTED], 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 REDACTED], 15-minute checks were discontinued as documented by NS-HH.

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

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

On [DATE REDACTED], at 7:45 AM, Resident R11 initiated conversation with Surveyor who was observing two other Residents

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

On [DATE REDACTED], at about 9:55 AM. Resident R11 was found out of the facility, down at the 3 way stop sign. Staff were alerted by a family membe

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Level of Harm - Minimal harm or potential for actual harm

plugged into the power. Surveyor observed that each hearing aid box has resident names, medical record number, and room number on them. Resident 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 Resident R14's hearing aids. DSS-D stated that DSS-D sent a message to the in-house audiology group to schedule an appointment for Resident R14 and is awaiting response back from audiology.No additional information was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

floor with her brief and pants down to her knees. She had toilet paper in her hand and turned to her 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 Resident R2, when was she toileted, were prior interventions in place and did not determine a root cause to help prevent further falls.

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745

Initiated 9/9/25

Level of Harm - Immediate jeopardy to resident health or safety

Interventions:

Residents Affected - Few

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

-Administer medications as ordered. Monitor/document for side effects and effectiveness. 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 -Resident R11 has deep breathing techniques to use when Resident R11's breathing is bothering Resident R11. Resident R11 also enjoys socializing and being around family and friends. Initiated 9/9/25 -Discuss feelings around change and loss, facilitate Resident R11's expression of these feelings. Initiated 9/9/25 -Encourage Resident R11 to talk about how Resident R11 is feeling to family, friends, or staff; remind Resident R11 to utilize Resident R11's support system if Resident R11 is feeling down. Initiated 9/9/25 -Please watch Resident R11 for the signs and symptoms which may indicate Resident 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]

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Based on interview and record review, the facility did not ensure that all facility staff received required Effective Communication program training for 7 of 8 facility staff that was reviewed. This has the potential to affect the 71 Residents who reside at the 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 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

WI Veterans Home-Boland Hall

21425 E Spring St Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Based on interview and record review, the facility did not ensure that all facility staff received required Quality Assessment and Performance Improvement (QAPI) program training for 7 of 8 facility staff that were reviewed. This has the potential to affect the 71 Residents who reside at the 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.

Event ID:

Facility ID:

If continuation sheet