WI Veterans Home Moses Hall

In the surveyor’s words

From the most serious findings on record at WI Veterans Home Moses Hall, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 20, 2026

  Based on staff interview and record review, the facility did not provide the necessary care and services during a choking incident for 1 member (M) (M1) of 1 sampled member. M1 had diagnoses including anoxic brain damage and dysphagia (difficulty swallowing) and was noted to be impulsive with lack of judgement. M1 and M1's family requested that M1 receive a regular texture diet for pleasure and were aware of the risks and benefits. On 2/4/26, M1 put half of a peanut butter sandwich in M1's mouth when Certified Nursing Assistant (CNA)-I stepped away to retrieve a towel. Staff noted M1 was choking but did not call 911 due to M1's Do Not Resuscitate (DNR) code status. […]

• Immediate jeopardy, isolatedF684Feb 7, 2022

  Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practicable well being for 1 Resident (R) (R1) of 1 resident when a diabetic medication was started and when a change in a surgical wound occurred. R1 was admitted to the facility for aftercare following surgery and had previously well controlled diabetes. While in the hospital, R1 received sliding scale insulin for higher than usual blood glucose levels. R1's discharge orders contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The insulin order was not transcribed on R1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Jun 17, 2026

  Based on interview and record review, the facility did not ensure the member environment was as free of accident hazards as possible when staff did not follow an intervention to prevent/reduce the impact of a fall for 1 member (M) (M121) of 6 sampled members. M121 had a history of falls. On 5/15/26, staff did not follow an intervention in M121's care plan to prevent recurrence when they did not lock M121's bed height adjustment with the bed in the lowest position. M121 fell out of bed, landed on their face, and required sutures in the left eyebrow. […]

• Actual harm, isolatedF689Apr 20, 2026

  Based on observation, staff and member interview, and record review, the facility did not ensure adaptive eating/drinking equipment was used during meal time to prevent burns for 2 Members (M2 and M6) of 3 sampled members. M2 did not receive coffee in a covered mug during supper on 3/1/26. M2 attempted to transfer the coffee from the uncovered mug to an insulated mug with a cover. The coffee spilled in M2's lap and resulted in burns to M2's bilateral thighs. (This example is being cited at a level G.)M6 did not receive coffee in a covered mug during lunch on 4/8/26.Findings include:The facility's Adaptive Equipment policy, dated May 2023, indicates: Adaptive equipment shall be available to assist members in maintaining or achieving their highest level of independent functioning possible. […]

• Actual harm, isolatedF760Mar 19, 2025

  Based on staff interview and record review, the facility was not free of significant medication errors for 2 residents (R) (R54 and R170) of 11 sampled residents. R54 received five extra doses of baclofen (a medication used to treat muscle spasms) on 1/15/25 and 1/16/25 due to a transcription error. R54 experienced overdose symptoms that required emergency transport and admission to the hospital on 1/17/25. R170 was administered double the ordered dose of long-acting insulin on 3/1/25 and 3/2/25. Findings include: The facility's Medication Administration policy, revised 2/6/25, indicates: .All medications shall be administered following the seven rights of administration. […]