Violations mount at Wis. veterans home
Union Grove facility has pattern of problems
Navy veteran Randy Krall was so dehydrated when he was rushed from a veterans nursing home to a hospital that doctors had trouble getting a urine sample to diagnose what was wrong.
Earlier that day in November 2020, Krall’s wife, Luane, got a call from a nursing aide at the veterans home in Union Grove, Wisconsin, where Randy lived. His chart showed he hadn’t had water for much of the day, the aide said.
Alarmed, Luane asked that Randy be taken immediately to the Veterans Administration hospital in Milwaukee.
Randy survived, but a few weeks later he returned to the Union Grove veterans home, and his condition declined.
On Dec. 19, 2020, there were signs that Randy, 69, was dying. His skin color was changing, and his breathing quickened, but no one contacted family, contrary to the facility’s policy. A nurse called Luane after Randy died.
Luane Krall filed a complaint, and an inspection followed. The veterans home received federal citations for failing to notify Luane about Randy’s deteriorating condition and making sure he was hydrated. The facility also was cited for not properly caring for his bedsores, according to records from the U.S. Centers for Medicare and Medicaid Services.
Failures in Randy’s care are part of a pattern of violations at the Union Grove home over the past five years, making the Wisconsin facility one of the most troubled state-run veterans homes in the nation, according to an analysis by the Milwaukee Journal Sentinel.
Union Grove ranked in the top five out of 117 CMS-certified state veterans facilities for having the most violations and fines, the analysis found. In the past five years, Union Grove was cited for 62 violations and fined $250,000.
Family members, residents and volunteers at the home described how a once-solid facility has tumbled into frequent disarray with sometimes dangerous conditions and a staff burned out from forced overtime and constant churn.
“Something is not right at that facility,” Luane Krall said. “It is unbelievable what Randy had to endure. It was horrible. No one should receive this kind of care. (Residents) really dedicated their lives to serve this country, and they are not served there.”
‘Still changing the culture’
Allen Hanson, 75, who lived at the home for nearly four years, said he moved to a facility in Milwaukee last fall because of poor care. Hanson described a litany of problems at the Union Grove nursing home: medication mistakes, residents falling, and trouble getting nursing aides to bring residents water.
Last year, he said, he saw a 95-yearold veteran who had fallen on the floor of his room. An aide told Hanson the man was “acting out” to get attention.
“I said, ‘He is on the fricking floor.’ She said: ‘Mind your own business. Don’t worry about it,’ and went and shut the door,” Hanson said.
In March, the Union Grove home was cited for failing to investigate reports of abuse to patients, not giving residents regular showers, infection control and unsanitary conditions, according to Wisconsin Department of Health Services records. Federal authorities are reviewing the violations, a spokeswoman with the Centers for Medicare and Medicaid Services said.
After each inspection, the Union Grove home issued plans to correct the problems, records show.
Mary Kolar, head of the Wisconsin Department of Veterans Affairs, which oversees state veterans homes, blamed the problems at Union Grove on a lack of staff and frequent changes in leadership – with five leaders in as many years. The department is taking steps to try to fix understaffing, a spokeswoman said.
“Union Grove is a challenge,” Kolar told the Journal Sentinel, part of the USA TODAY NETWORK. “We are still changing the culture.”
Feeling like a prisoner of war
Compared with all other nursing homes in Wisconsin, Union Grove’s violation record is among the worst. It ranked 27th out of 343 facilities, with three times more violations than the average Wisconsin nursing home, according to the Journal Sentinel analysis.
And while COVID-19 hit many nursing homes across the country hard, problems at Union Grove occurred before the pandemic and continue, records show.
The conditions, including the elimination of several activities for residents, led to a meeting in March among family, residents and volunteers. A Journal Sentinel reporter attended the meeting, which was open to the public.
A resident at the meeting told Kolar he sometimes feels like a prisoner of war at the home.
“No one is making you stay there,” Kolar told the resident.
“Please don’t call it a POW camp. You have choices.”
Republican State Sen. Van Wanggaard, who also attended the meeting, said veterans shouldn’t have to move: The state should fix the problems.
“This is a benefit they earned. This is a right these guys have,” he said.
Kenney Blue, a Vietnam War veteran who has lived in the home for eight years, said he can’t get out of bed by himself and is frustrated when he puts on his call light and no one comes, forcing him to the point where he urinates in his bed. He said he has been left in bed until noon some days.
“They come like 30, 45 minutes later and say, ‘Can I help you?’ I say: ‘It’s a little late now. I was calling to use the bathroom. What if I was having a heart attack or a stroke?”
A close call with opiates
The nation’s first veterans homes date to the Civil War era, when President Abraham Lincoln vowed to care for those scarred by battle. Today, there are 160 facilities across the U.S., at least one in every state, providing rehabilitation stays, assisted living and nursing home care for veterans and their spouses.
The homes are owned and operated by the states but largely funded by the federal government at roughly $1 billion last year. One hundred seventeen state veterans homes receive federal insurance and therefore are subject to annual inspections as well as inspections triggered by complaints to state departments of health and the Centers for Medicare and Medicaid Services.
Starting in 2017, violations began to mount at Union Grove. Problems have included making medication errors, neglecting wound care, failing to alert family to changes in patients’ conditions, unnecessarily restraining residents and serving poor food.
One of the most serious violations against Union Grove was issued in August 2020 for failing to follow COVID-19 protocols, resulting in a $93,314 fine. Three months later inspectors were back, and again the facility was cited for poor infection control, records show.
Among the violations recorded last year: giving a resident too many opiates. A nurse found the resident unresponsive and he was rushed to the hospital, where he was revived, the report said.
“I was in bad shape. I was very close to dying,” the resident told the inspector, according to the report. “My wife thought she was going to lose me.”
U.S. Rep. Bryan Steil, R-Wis., whose district includes the home, said he has received reports of problems at the home for years, but he didn’t understand the scope until the Journal Sentinel shared its analysis with him.
“It makes your stomach just churn that our veterans did not receive the care that they deserve.”