Wi Veterans Home-Boland Hall

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 158 beds and averages 61.4 residents a day — about 39% occupied, or roughly 97 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.56 hrs/resident/day on weekends vs 6.22 on weekdays — 11% thinner on weekends. RN hours go from 2.07 to 1.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

44 citations, most serious first. The 19 most serious are shown; the remaining 25 are one tap away and print in full.

• Immediate jeopardy · K2025-10-01 · tag F0675 — failed to support quality of life — pattern
  Honor each resident's preferences, choices, values and beliefs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. 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. R4 has continually expressed dissatisfaction with the living at the facility. R4's dissatisfaction with the facility has caused R4's behavior of planning unsafe ways of leaving the facility. R4's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-10-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The facility did not thoroughly investigate R2's falls on 4/1/25, 4/3/25, & 4/7/25, did not determine if prior interventions were in place and did not determine a root cause of these falls to prevent further falls. On 4/9/25 R2 fell. R2 was transferred to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-10-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R5 was sent to the hospital where R5 was diagnosed with a Traumatic Brain Injury (TBI) - subdural hematoma (a collection of blood between the brain's outer covering and the surface of the brain,) small traumatic subarachnoid hemorrhage (a bleeding that occurs in the space between the brain and the arachnoid mater, one of the membranes covering of the brain,) and acute (sudden onset of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-10-01 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The facility did not identify and promote non-pharmacological approaches to care that met the mental and psychosocial needs of R6 and did not assess and identify possible transition of care services for R6 The facility's failure to provide R6 with necessary medically related social services, created a finding of immediate jeopardy that began on 7/17/25.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-06-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. 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. Findings include: The facility's policy last revised on July 2, 2024 and titled, Prohibition and Prevention of Member (Resident) Abuse, Neglect, and Exploitation documents: *All staff shall be expected to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. One round should flow into the next round, this is how rounding reduces fall, skin breakdown, and other accidents and injuries.- Walking rounds shall occur at AM (morning) into PM (afternoon) and PM into NOC (night) shift change with CNA (Certified Nursing Assistant) staff from oncoming and outgoing shifts.- A walking round shall be considered when staff physically walk the unit to observe each member and their status, any noted change of the member shall be promptly reported to the on-duty nurse.2.) R1 was admitted on [DATE] with diagnoses that include repeated falls, dependence on other enabling machines and devices, unspecified…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-06-12 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Based on R2's history of trauma, R2 is vulnerable and on 5/6/25, the facility did not protect R2 from unwanted sexual contact from R1. Findings Include: Surveyor noted…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-26 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnoses that includes COPD, Dementia with Mood Disturbance, Dementia with Moderate Anxiety, PTSD and mild cognitive impairment. R2's Annual MDS dated [DATE] does not documents that R2 has short and long term memory problems. The MDS documents a PHQ-9 mood assessment score of 6, indicating that R2 has mild depression. Section GG documents that R2 has no impairment to R2's upper or lower extremities and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The assessment on 9/13/23 states the wound bed is 100% subcutaneous tissue (this is bottom layer of skin in your body that consists of loose connective tissue, larger blood vessels and is the major fat storage layer) without additional description of necrotic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-04-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: On 4/20/26 at 10:16 AM, Surveyor and Dietary Services Director (DSD)-C began an initial tour of the kitchen. DSD-C stated the facility follows the Federal Food and Drug Administration (FDA) Food Code. The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions. The 2022 FDA Food Code documents at 4-501.116 Warewashing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-04-22 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include; The facility's Infection Tracking and Surveillance policy, dated 4/17/25, indicates: The facility's Infection Preventionist designee shall be responsible for conducting…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-22 · tag F0628 — pattern
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: The facility's Notice of Transfer policy, dated January 2023, indicates: A designated employee sends a list of members…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. M6 was admitted to the facility on [DATE] and had diagnosis including diabetes, atrial fibrillation, and pneumonia. M6's Minimum Data Set (MDS) assessment, dated 3/4/26, had a Brief Interview for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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.Findings include:The facility's policy titled, Grievances and Complaints and last reviewed January 31, 2023, under Purpose documents To provide members and their representatives with a process to assist in writing concerns or complaints regarding the environment, missing items, or care and treatment provided by WVH (Wisconsin Veterans Homes). Under policy documents *A grievance shall be considered any circumstance thought to be unjust and grounds for a complaint and meets at least one of the following criteria: Pertains to the environment or care and treatment provided by the Homes, including missing property. Has reference to state or federal regulations, facility policies, or Member Rights and Responsibilities. Requires facility management…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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.Findings include:Surveyor reviewed a Facility Reported Incident (FRI) regarding R2's missing narcotic medication. The FRI investigation documents there was a missing tablet of Hydrocodone 5/325 milligrams. This was discovered missing on 9/5/2025 through an audit. The medication was missing on 8/16/2025. The FRI investigation does not indicate the local police were…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:R1's diagnoses include Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline), dementia (loss of cognitive function that interferes with a person's daily life and activities), central corneal ulcer (open sore on the cornea caused by an infection or other condition), left eye and conjunctivitis (inflammation of the eye's conjunctiva most caused by viruses, bacteria or allergies).R1's nurses note dated 9/4/25, at 8:30 a.m., and written by Licensed Practical Nurse (LPN)-J documents…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. On 12/2/25 & 12/3/25 there are multiple observations of R1's plan of care not being followed for non-slip material (Dycem) on the wheelchair and padding of the lower portion of the front bars on R1's wheelchair.Findings include: The facility's policy titled, Member Incidents and with an effective date of November 1,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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.Findings include:The facility's policy and procedure titled Controlled Substances dated 7/1/2004. This documents under Procedures: 4.) At time of administration, the licensed nurse compares the last recorded remaining medication count in the Electronic Health Record (HER) with the bubble pack/ medication package and enters the new remaining count value after the ordered dose(s) is prepared for administration/application. The number being administered is also recorded in the appropriate column of the Controlled Substance Perpetual Inventory sheet.Surveyor reviewed a Facility Reported Incident (FRI) involving R2's medication. The FRI document on 9/5/25, during an audit, 1 tablet of Hydrocodone 5/325 milligrams was missing. The FRI investigation determined the 1 tablet was missing from…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-10-01 · tag F0941 — widespread
  Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$281,174 in federal fines across 6 penalties. 2 Medicare payment denials on record.

• $10,358 — penalty dated 2025-06-12
• $10,358 — penalty dated 2025-06-12
• $17,345 — penalty dated 2025-06-12
• $157,053 — penalty dated 2025-06-12
• $73,190 — penalty dated 2025-03-26
• $12,870 — penalty dated 2023-10-16
• Medicare payment denial — starting 2025-06-27 for 144 days
• Medicare payment denial — starting 2025-04-24 for 27 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 13 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI