Wi Veterans Home-Boland Hall
21425 E Spring St, Union Grove, WI 53182 · Racine County · 158 certified beds · avg 61 residents/day · certified since Dec 1, 2006
Abuse citation flag (CMS)SFF Candidate
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Oct 1, 2025 · F-0675 · triggered by a complaint
The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care.
Why it matters: Ignoring who a resident is as a person diminishes their dignity and quality of life.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 1, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 1, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 1, 2025 · F-0745 · triggered by a complaint
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 12, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Mar 26, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 21, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 12, 2025 · F-0742 · triggered by a complaint
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 26, 2025 · F-0745 · triggered by a complaint
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 15, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 16, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 3, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (44)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 22, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 22, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 22, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 22, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Oct 1, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. · from a complaint |
| Oct 1, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 1, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 1, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Oct 1, 2025 | F · Potential for harm, facility-wide | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. · from a complaint |
| Oct 1, 2025 | F · Potential for harm, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint |
| Oct 1, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 1, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 1, 2025 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Oct 1, 2025 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · from a complaint |
| Jun 12, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 12, 2025 | ▲ G · Actual harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| May 13, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 26, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 26, 2025 | ▲ G · Actual harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 9, 2025 | C · Minimal risk, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Aug 8, 2024 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 8, 2024 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 8, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 16, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 16, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 16, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 16, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 16, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 1 | G ▲ |
| 2024 | 3 | 0 | E |
| 2025 | 32 | 8 | K ▲ |
| 2026 | 4 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
6 fines totaling $281,174, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Jun 12, 2025 | Fine | $10,358 |
| Jun 12, 2025 | Fine | $10,358 |
| Jun 12, 2025 | Fine | $17,345 |
| Jun 12, 2025 | Fine | $157,053 |
| Jun 12, 2025 | Payment Denial | 144 days from Jun 27, 2025 |
| Mar 26, 2025 | Fine | $73,190 |
| Mar 26, 2025 | Payment Denial | 27 days from Apr 24, 2025 |
| Oct 16, 2023 | Fine | $12,870 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 7.34 | 4.29 | 3.95 | top 2% in Wisconsin; top 1% in the U.S. |
| Registered Nurse hours | 2.38 | 1.01 | 0.69 | top 1% in Wisconsin; top 1% in the U.S. |
| Weekend total nurse staffing | 6.77 | 3.84 | 3.50 | top 2% in Wisconsin; top 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.67 | 0.68 | 0.48 | top 1% in Wisconsin; top 1% in the U.S. |
| Total nursing staff turnover (%) | 51.4 | 46.9 | 45.8 | bottom 36% in Wisconsin; bottom 33% in the U.S. |
| RN turnover (%) | 39.4 | 39.7 | 42.9 | bottom 48% in Wisconsin; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 6.03, RN 1.96, weekend 5.56. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Government - State
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| State of Wisconsin | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/27/2006 |
| Beaumont, Lauren | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/22/2025 |
| Beaumont, Lauren | Individual | ADP of the SNF | NOT APPLICABLE | 09/22/2025 |
| Parker, James | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/22/2012 |
| Parker, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/22/2012 |
| Parker, James | Individual | ADP of the SNF | NOT APPLICABLE | 04/22/2012 |
| Servatius, Tammy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/14/2025 |
| Servatius, Tammy | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/14/2025 |
| Servatius, Tammy | Individual | ADP of the SNF | NOT APPLICABLE | 10/14/2025 |
| Sidhu, Sarfraz | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/21/2022 |
| Sidhu, Sarfraz | Individual | ADP of the SNF | NOT APPLICABLE | 05/21/2022 |
| State of Wisconsin | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/27/2006 |
| State of Wisconsin | Organization | ADP of the SNF | NOT APPLICABLE | 03/27/2006 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you learn each resident's personal preferences and make sure staff actually follow them?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Who provides social services here, and how would they support my family member's emotional and social needs?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Oak Ridge Care Center | 1.2 mi | Union Grove, WI | ★★★☆☆ | 2/5 | |
| Burlington Health and Rehabilitation Center | 9.5 mi | Burlington, WI | ★☆☆☆☆ | 1/5 | |
| Lincoln Park Nursing and Rehab LLC | 11.6 mi | Racine, WI | ★☆☆☆☆ | 1/5 | |
| Complete Care at Ridgewood LLC | 11.7 mi | Racine, WI | ★★★☆☆ | 3/5 | |
| Complete Care at Grande Prairie | 12.0 mi | Pleasant Prairie, WI | ★★☆☆☆ | 2/5 | |
| Brookside Care Center | 13.1 mi | Kenosha, WI | ★★★★★ | 4/5 | |
| Avina of Kenosha | 13.3 mi | Kenosha, WI | ★★☆☆☆ | 2/5 | |
| Tudor Oaks Health Center | 13.6 mi | Muskego, WI | ★★☆☆☆ | 2/5 | |
| Muskego Health and Rehabilitation Center | 13.6 mi | Muskego, WI | ★★☆☆☆ | 2/5 | |
| Waters Edge Health and Rehabilitation Center | 14.3 mi | Kenosha, WI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Medical Suites at Oak Creek (the) | 14.7 mi | Oak Creek, WI | —/5 | SFF | |
| Clairidge House | 15.0 mi | Kenosha, WI | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 525688.