Wi Veterans Home-Boland Hall

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 67 of 67 residents residing in the facility. The facility did not accurately test parts per million (PPM) of the sanitizing solution or complete testing logs.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 67 members (M) residing in the facility. The facility's infection surveillance program did not include a system to monitor employee illness symptoms, resolution of symptoms, or return to work dates. M5 was on enhanced barrier precautions (EBP). Certified Nursing Assistant (CNA)-J transferred M5 without donning the appropriate personal protective equipment (PPE). Staff did not offer members hand hygiene before meals, including M51, M60, M20, and M28. Staff did not ensure M45's catheter bag was covered and not in contact with the floor.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Office of the State Long-Term Care Ombudsman was notified of transfers/discharges for 6 members (M) (M9, M7, M31, M11, M68, and M5) of 6 sampled members. M9 was transferred to the hospital on [DATE], 11/29/25, 12/25/25, and 2/26/26. Ombudsman (OMB)-H was not notified of the transfers. M7 was transferred to the hospital on 2/7/26, 2/26/26, and 3/11/26. OMB-H was not notified of the transfers. M31 was transferred to the hospital on 1/23/26 and 2/3/26. OMB-H was not notified of the transfers. M11 was transferred to the hospital on 1/6/26 and 1/30/26. OMB-H was not notified of the transfers. M68 was transferred to the hospital on 3/9/26 and did not return to the facility. OMB-H was not notified of the transfer/discharge. M5 was transferred to the hospital on 3/6/26. OMB-H was not notified of the transfer.

Inspectors wroteBased on staff interview and record review, the facility did not offer Prevnar 20 vaccines for 3 members (M) (M6, M7, and M31) of 5 sampled members. M6, M7, and M31 were eligible to receive the Prevnar 20 vaccine. M6, M7, and M31 were not offered the vaccine. The facility's Immunization Program, dated 4/17/25, indicates: All immunizations shall be offered and administered according to the most current guidance. Specific vaccines: Pneumococcal: 1. Licensed nursing reviews pneumococcal vaccine status on admission and at least annually and references the most current recommendations. 2. It is recommended that staff utilize the Centers for Disease Control and Prevention (CDC) PneumoRecs Vax Advisor to assist in determining the member's pneumococcal status and needs. 1. On 4/22/26, Surveyor reviewed M6's medical record. [...]

Inspectors wroteBased on interview and record review the facility did not identify resident concerns as grievances for 1 (R1) of 1 Residents reviewed for grievances. Social Worker-Q did not initiate grievances when R1's power of attorney voiced a concern R1 was being put to be too early and R1 did not receive an eye drop medication according to physician orders.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident's unaccounted for narcotic medication was reported to the local police. This was observed with 1 of 3 Facility Reported Incidents (FRI) reviewed. R2's narcotic medication was discovered unaccounted for and was not reported to the local police. The facility's policy and procedure titled Prohibition and Prevention of Member Abuse, Neglect, and Exploitation date 7/2/2024. The Policy documents: The Facility shall comply with Section 1150B [42 U.S.C. 1320b-25} Reporting to Law Enforcement of Crimes Occurring in Federally Funding Long-term Care Facilities. All incidents shall be investigated and reported to the appropriate agency as required by the agency.

Inspectors wroteBased on interview and record review the Facility did not ensure quality of care was provided for 1 (R1) of 6 Residents. R1's ophthalmology consult on 9/8/25 includes documentation under Blepharoconjunctivitis OS (left eye) to continue polymyxin- trimethoprim one drop four times a day to left eye. The facility did not continue this order and discontinued the eye drops on 9/8/25. R1 did not receive polymyxin- trimethoprim one drop four times a day to left eye according to physician orders.

Inspectors wroteBased on interview and record review the facility did not ensure each resident received adequate supervision to ensure each resident's environment remains free of accidents and hazards for 1 (R10) of 3 residents. On 10/18/25 during a body check R1 was identified with a skin tear over purple senile purpura to the right side of R1's clavicle. There is no evidence staff were interviewed to inquire how R1 may have received this skin tear and did any staff observe R1 picking his clavicle. On 10/21/25 R1 sustained a skin tear due to the arm of a shower chair having a sharp area. The facility removed the chair but there is no preventative measures documented to prevent this from occurring in the future. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure pharmacy procedures were followed to identify an unaccounted for narcotic medication. This was observed with 1 (R2) of 4 resident medication reviews. R2 was missing a narcotic medication on 8/16/25 that was not discovered until 9/5/25.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide 5 residents (R4, R7, R11, R12 and R15) of 11 residents reviewed with the necessary cares and services to promote quality of life and assist residents to maintain their highest practicable level of physical, mental, and psychosocial well-being. *The facility did not provide R7 with the sense of safety within the Facility from R6. R7 indicated being in fear of R6, a resident who displayed escalating aggressive behaviors. R7 was assaulted by R6 and was assessed as experiencing Post-Traumatic Stress Syndrome (PTSD) as a result. R6 went on to assault R5 a few weeks later. The facility did not have a plan to effectively monitor R6. * The facility failed to provide R4 a sense of satisfaction with oneself, the environment, and the care received. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 6 (R2, R11, R4, R3, R8, and R10) of 7 residents received adequate supervision to prevent accidents from falls and elopements * R2 has had 15 falls since 1/9/25. On 1/17/25 R2 fell. A fall risk assessment on 1/17/25 indicates R2 is at low risk for falls. On 3/5/25 the facility completed another fall risk assessment and was assessed to be high risk for falls. R2 fell on 4/1/25, 4/3/25, & 4/7/25. R2's fall risk assessment dated [DATE] assesses R2 as low risk for falls. R2's fall risk assessment dated [DATE] and subsequent fall risk assessments assess R2 as high risk for falls. On 4/3/25 R2 was transferred to the hospital and diagnosed with a traumatic hematoma of the forehead. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free from abuse affecting 2 of 11 residents (R7 and R5) reviewed for abuse concerns. On 7/17/25, R6 punched R7 in the head and mouth, resulting in R7 having a bloody lip. R6 was placed on 1 on 1 supervision for a short period of time. The facility indicated they did not have the staffing to keep a person on 1 on 1 supervision long term. R6 was then put on 15-minute checks. R6 continued to demonstrate aggressive behaviors where staff needed to intervene before the behaviors escalated. On 8/27/25, R6 hit R5 multiple times over the head with a cane. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 15 residents reviewed (R6, R14, R15, R12 and R11) received medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. * R6 has had 13 episodes of aggressive behaviors toward staff and other residents since 7/26/24, On 7/17/25, R6 punched another resident in the mouth. On 8/25/25, R6 hit R5 on the head with R6's cane, resulting in a traumatic brain injury for R5. The facility did not identify and seek ways to support R6's psychosocial and behavioral needs by reevaluating and assessing R6's behaviors. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure all allegations involving potential abuse and/or neglect, and injury of unknown origin were thoroughly investigated for 4 (R10, R8, R14, R3 and R2) of 10 facility reported incidents reviewed involving residents. *On 7/14/25, R14 and R10 were involved in a member-to-member altercation that was not thoroughly investigated, and the facility did not conduct interviews of other members. *On 8/27/25, R8 and R14 were involved in a member-to-member altercation that was not thoroughly investigated. *On 7/10/25, allegation of abuse was submitted to the State Survey Agency involving R3. The facility did not conduct interviews of other members. *A thorough investigation was not completed for R2's injury of unknown injury. Findings Include: [...]

Inspectors wroteBased on interview and record review the facility did not ensure a resident's physician was notified for 2 (R1 & R11) of 11 residents reviewed. R1's physician was not notified when R1 was screaming out in pain with minimal movement on 8/22/25. The incident report dated 8/22/25 documents the provider notification to be done the next day. R11's physician was not notified when R11 eloped on 9/11/25.

Inspectors wroteThe facility did not provide adequate evidence of a proper discharge for 1 of 3 residents (R6) reviewed for discharge and transfers.*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.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure a resident (R14) with hearing impairment received proper treatment and assistive devices for 1 (R14) of 1 residents reviewed for assistive devices.

Inspectors wroteBased on observation, record review, and staff interviews, the facility did not ensure that 1 out of 4 residents (R2) reviewed remained free from sexual abuse. R2, a female resident with a significant history of PTSD (post-traumatic stress disorder) and a history of sexual assault was inappropriately sexually touched by R1. The facility's failure to keep R2 safe from and free from sexual abuse created a finding of immediate jeopardy that began on 5/6/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 5/29/25 at 3:50 p.m. The immediate jeopardy was removed on 5/30/25, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), received appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for one (R2) of 4 residents reviewed. *R2's social history documents R2 experiencing trauma as an adult including sexual assault and having war related trauma resulting in a diagnosis of Post Traumatic Stress Disorder(PTSD). R2's Life Events Checklist for DSM-5(LEC-5) indicates R2 has a history of trauma and R2's comprehensive care plan was not individualized with known triggers, person-centered interventions, and/or goals related to R2's past history of trauma. [...]

Inspectors wrote8) M2's care plan indicates that M2 requires total assist by two staff with sit to stand lift for transfers. Staff to buckle legs with strap and secure belt prior to transfer. The resident is non-weight bearing. M2's Kardex report documents, Transfer: the resident requires total assist by two staff with sit to stand lift for transfers. Staff to buckle legs with strap and secure belt prior to transfer. Neither document include the size sling that staff are to use while transferring M2. On 5/13/25, at 10:40 AM, Surveyor observed, CNA-P remove sit to stand mechanical lift from M2's room with a blue sling draped on top. When CNA-P was asked how she knows what sling size to use for M2, CNA-P stated she did not know what sling size M2 uses. [...]

Inspectors wroteThe facility's policy and procedure titled, Member Rounds, with a last revision date of January 7, 2025, documents: Rounding shall be defined as nursing staff accounting for all members assigned to their unit frequently using the 4 Ps of rounding and purpose. It should be understood rounding is not every 2 hours as that is merely an absolute minimum: rounding is a continual event. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R2) of 6 residents reviewed received medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. * R2 eloped from the facility during a hospital appointment. R2 eloped from the hospital and was found at a hotel room approximately seven hours later. R2 had voiced and made it known to facility staff that R2 wanted to leave the facility and R2 was not provided with discharge/placement services.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R6) of 1 resident's resident representative was notified when there was a need to alter medical treatment. R6's POA (Power of Attorney) was not notified when R6 started Physical Therapy (PT) to work on R6's balance.

Inspectors wrote2.) R6 was admitted to the facility on [DATE] with diagnosis that include Alzheimer's disease, Dementia with mood disturbance, Cancer and difficulty walking. R6's Quarterly Minimum Data Set assessment dated [DATE] documents that R6 has long and short-term memory problems, is unable to recall faces, names, location, and season, and has severely impaired cognition with making decisions. R6 wears glasses. R6 requires supervision with walking and transfers. R6 has an activated healthcare Power of Attorney (POA)-U.R6's [Activities of Daily Living] care plan initiated on 9/26/23 documents the following intervention: AM routine: Encourage R6 to wear glasses full time for distance and reading. Clean glasses when dirty (date initiated 9/18/24). On 3/25/25 at 8:51 AM, Surveyor interviewed R6's POA. POA-U stated that R6 has not has his correct eyeglasses for over a month. [...]

Inspectors wroteBased on interview and record review the Facility did not report 2 of 4 allegations of abuse or neglect to the Nursing Home Administrator (NHA) or State Survey Agency during the required timeframe. * R4 reported potential abuse to the charge nurse which was delayed in being reported to the Nursing Home Administrator (NHA) and the state agency. * Double briefing of residents was discovered and there was a delay in the issue being reported to the Nursing Home Administrator (NHA) and the state agency.

Inspectors wroteBased on interview and record review, the Facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated, staff member removed to prevent further incidence, or all staff education provided for 2 (R4 and R3) of 4 allegations of abuse or neglect reviewed.* R4 made an allegation of abuse that was not acted on by the staff member being removed from contact with residents or all staff education provided to prevent further abuse. *R3 had an injury of unknown origin that was not thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility did not complete a performance review at least once every 12 months for 1 Certified Nursing Assistant (CNA) reviewed. This deficient practice has the potential to affect all 62 residents who reside in the facility. CNA-M last had a performance review completed 11/14/23 for the performance period of 11/1/2022 to 10/31/2023.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R25 and R38) of 2 injuries of unknown origin investigations that were reviewed were reported to the state agency. * On 11/8/24, R25 was discovered with a 15 cm by 6 cm bruise to left posterior axilla. The facility assumed it was from transferring R25 without a gait belt. This injury was not reported to the state agency. * On 10/15/24, R38 was discovered with a 7.5 cm by 4.4 cm bruise to the right upper arm. The facility assumed it was from R38 ambulating about the unit and hitting a walls and doorways. This injury was not reported to the state agency.

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 (R25, R38 and R43) of 7 facility investigations involving potential abuse thoroughly investigated. * R25 was discovered with a 15 cm by 6 cm bruise to left posterior axilla. The facility assumed it was from transferring R25 without a gait belt. A thorough investigation into the bruise and its origin was not completed. * R38 was discovered with a 7.5 cm by 4.4 cm bruise to the right upper arm. The facility assumed it was from R38 ambulating about the unit and hitting a walls and doorways. A thorough investigation into the bruise and its origin was not completed. * On 12-30-24 the facility investigated an allegation of potential neglect of R43 by Certified Nursing Assistant (CNA)-I. The facility failed to conduct a thorough investigation of the reported incident.

Inspectors wroteBased on interview and record review, the facility did not refer all PASRR (Preadmission Screening and Resident Review) Level I residents with a possible serious mental disorder on admission or with a significant change in status assessment to the referring agency to complete the PASRR Level II for 1 (R17) of 1 residents reviewed for PASRR completion. * R17 had a change in condition level 1 PASRR screen, which indicated R17 has a major mental disorder, which would trigger a level 2 PASRR to be completed. A level 2 PASRR was not completed for R17.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R10 and R40) of 3 residents reviewed for pressure injuries. * R10 was found to have MASD (Moisture Associated Skin Damage) on 8/18/24 by an LPN (Licensed Practical Nurse) and there is no documentation that an RN (Registered Nurse) assessment was completed until 8/21/2024. No skin evaluation documentation was available for R10 between 8/18/24 and 8/21/24. * R40 had a care plan intervention in place to wear gripper socks due to a pressure injury to R40's heel. R40 was observed during the survey wearing shoes.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R7) of 9 residents reviewed received adequate supervision, interventions to prevent accident hazards. * R7 did not have a Registered Nurse assessment status post a fall that caused a fracture of R7's left arm. Findings Include: The Facility's policy titled, [name of facility] Member Falls, with a last review date of 06/2021, documents in part, . After a Fall: 1) The Member is examined head to toe by an RN (Registered Nurse) before being moved, unless the Member is uncooperative, or needs to be moved because of danger in the environment. 1.) R7 was admitted to the facility on [DATE] and has diagnoses that includes dementia. R7's Significant change Minimum Date Set (MDS), dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 09, indicating R7 has moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R17) of 1 residents reviewed for weight loss. R17 sustained a 4.8% weight loss over a period of 7 days. The Physician was not consulted with, no assessment or evaluations were conducted.

Inspectors wroteBased on record review and interview, the facility did not ensure there was a QAPI (Quality Assurance Performance Improvement) meeting held at least quarterly with the required committee members in order to identify issues through the committee. This deficient practice had the potential to affect all 64 residents currently in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 4 (R1, R8, R2, R7, and R6) of 7 facility reported incidents reviewed were reported to the State Agency or local law enforcement agency as required. -R1 and R8 had a resident to resident physical altercation on 2/22/2024. The facility did not report the incident to local law enforcement. -R1 and R2 has a resident to resident physical altercation on 7/14/2024. The facility did not report the incident to local law enforcement. -R7 did not have a 24 hour report submitted to the State Agency for an allegation of neglect on 2/21/2024. -R6 did not have a 24 hour report submitted to the State Agency for an allegation of suicidal/homicidal ideation on 3/20/2024.

Inspectors wroteBased in interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 4 (R1, R8, R5, R6, and R7) of 7 Facility Reported Incidents (FRI's) reviewed. -R1 and R8 had a resident to resident physical altercation on [DATE]. The altercation was not thoroughly investigated. -On [DATE], R5 was verbally abused by a certified nursing assistant (CNA). The CNA continued to have access to vulnerable residents after the accusation and was not removed from resident care. -R6 had suicidal/ homicidal ideations of [DATE] that were not thoroughly investigated. -R7 had an accusation of neglect on [DATE] that was not thoroughly investigated.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that food was palatable and served at a safe and appetizing temperature on 4 of 4 units. This has the potential to affect 66 of the 67 residents residing in the facility. *R10 informed Surveyor that food is ok but can be dry and cold at times. *One of one test trays had vegetables that were unpalatable. *Staff did not always complete and log food temperatures in the unit kitchens prior to serving food.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with pressure injuries or at risk for pressure injuries received appropriate care and treatment to prevent the development of pressure injuries and to promote healing for 1 of 5 residents (R18) reviewed for pressure injuries. *R18 was noted to have multiple facility acquired open areas to their bilateral buttocks on 8/30/23 that were not assessed upon discovery. At this time, the physician was not consulted with, the care plan was not revised with interventions, and a treatment was not initiated based upon an assessment of the wounds. The pressure injuries were not assessed until 9/13/23. At that time the resident was noted to have 2 stage 3 pressure injuries. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an injury of unknown source for 1 (R68) of 2 residents reviewed was reported to the State Agency within the required 24 hours. *R68 was found to have a bruise on the coccyx and upper right shoulder on 9/28/23. The facility did not report this injury of unknown source to the State Agency.

Inspectors wroteBased on record review and staff interview, the facility did not ensure incidents involving potential abuse or potential misappropriation were thoroughly investigated for 2 Residents (R371 and R68) of 9 Residents reviewed for potential abuse, neglect or misappropriation. *R371 reported their cell phone was missing. The facility self-reported this incident to the State Agency, however, the facility did not complete a thorough investigation. Staff that may have had access to R371's room were not interviewed. *R68 presented with bruises to the back and coccyx. The facility did not thoroughly investigate how these bruises occurred.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure resident's environment was free of accident hazards for 1 of 8 resident reviewed for falls. R67 has a history of falls and care planned fall prevention interventions (i.e. gripper socks) were not observed in place. Findings Include: The facility policy, entitled Member Falls, dated 6/2021, states, Purpose/Overview: to ensure that each Member is provided a safe environment .The MDS (Minimum Data Set) contains the questions usually found on fall risk assessment tools. Research has shown that all people over the age of 65 are at risk for falls. Being in a new environment, people with compromised health are at high risk for falls. Procedure: #4. During the Care Plan review, assess the success or failure of the intervention to limit the risk of falling for the Member if Member is at high risk. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R20) of 1 residents reviewed received appropriate treatment and services related to catheter care. * R20 did not consistently receive catheter flushes in accordance with physician orders.