Wi Veterans Home-Boland Hall

In the surveyor’s words

From the most serious findings on record at Wi Veterans Home-Boland Hall, in the surveyor’s own words.

• Immediate jeopardy, patternF675Oct 1, 2025

  Based 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. […]

• Immediate jeopardy, patternF689Oct 1, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Oct 1, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF745Oct 1, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Jun 12, 2025

  Based 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. […]