Yearly inspection of Wisconsin veterans home at Union Grove finds repeat violations for not reporting abuse, preventing falls
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The state-run veterans home at Union Grove was cited for six violations in its latest yearly inspection − including several repeats of recurring issues − adding to a laundry list of violations leveled against the facility in the last five years.
A Milwaukee Journal Sentinel investigation in May found the Union Grove home was one of the most troubled state veterans homes in the nation, according to an analysis of data from the U.S. Centers for Medicare and Medicaid Services. The Union Grove home ranked in the top five out of 117 CMS-certified veterans homes for having the most violations and fines, the Journal Sentinel analysis found.
Past violations include failing to keep residents hydrated, not investigating patient abuse, infection control issues, medication mistakes, poor food and not doing enough to keep residents from falling. Residents and family members said care has declined as leadership frequently changed and the home struggles with chronic understaffing.
The Journal Sentinel's reporting prompted calls by federal lawmakers from both political parties for more oversight of the veterans home − which is run by the state, but funded by federal dollars.
State officials have blamed the problems at Union Grove on a lack of staff, especially during the pandemic when nursing homes across the nation faced staffing shortages. Officials have increased pay for some employees in an effort to recruit and retain staff and have relied on contracted workers and − at times − temporary help from other agencies, such as the Wisconsin National Guard, to supplement staff.
However, in a written reply to lawmaker inquiries, it was revealed Wisconsin had failed to apply for federal dollars specifically for veterans homes that could have helped with staffing.
State lawmakers have been exploring the possibility of an audit of the veterans home since June. The problems at the state-run home have also been highlighted in the run-up to Election Day by Republican candidates up and down the ballot.
More:'No one should receive this kind of care': Lack of water. Medication mistakes. Abuse allegations.
The latest inspection, which was conducted over a week in August, brings the total number of violations issued against Union Grove since 2017 to 76. The inspection report was made public in October.
In it, inspectors found instances where the facility did not thoroughly investigate an allegation of abuse or report it to state regulators, did not do enough to prevent a couple of residents from falling and did not properly train two nursing aides. The facility was also cited for giving residents potentially unnecessary medications, including antipsychotics − which have long been the focus of scrutiny for their misuse in nursing homes as a chemical restraint to subdue residents with behavioral issues.
The facility has been cited in the past for some of the same violations, including for not reporting allegations of abuse or exploitation in a timely manner three other times in the last five years. The home has also been cited on three previous occasions for giving residents anti-anxiety medication without a documented reason for doing so. Failures to protect residents from falling have also prompted previous citations.
Most of the latest violations were classified as low-level infractions. None of them were found to have resulted in "actual harm" to residents.
Colleen Flaherty, a spokeswoman for the Wisconsin Department of Veterans Affairs, said the latest citations were related "primarily to clerical and reporting duties" and that the veterans home had already taken steps to correct the issues identified in the report.
"The leadership at Union Grove are continually working to improve the quality of care they provide to residents," she wrote in an email.
Flaherty also noted that none of the latest violations had to do with dehydration. The state was sued earlier this year in the death of Navy veteran Randy Krall, whose widow said he suffered from a litany of problems in care. Krall died because the staff failed to ensure he was getting enough water, the lawsuit says.
Flaherty did not give any information about a separate inspection conducted by the federal Department of Veterans Affairs in July, saying those results are not yet available to the public.
Union Grove and other veterans homes like it are subject to inspections not only by CMS and the state agencies that work on its behalf, but also by the federal VA.
Wisconsin had never applied for a federal grant to improve staffing retention
In May, U.S. Sen. Tammy Baldwin, D-Wis., and U.S. Rep. Bryan Steil, R-Wis., separately sent letters to Denis McDonough, secretary of the VA, voicing concern about conditions at Union Grove. In her letter, Baldwin called on federal officials to step up oversight and to identify any resources that could be leveraged to improve conditions.
It turned out Wisconsin had never taken advantage of a federal grant program that could have helped shore up low staffing levels blamed for many of the issues at the Union Grove home, according to the VA's response in August.
Other states have used the program to offer sign-on bonuses, retention bonuses, tuition assistance programs, student loan repayment programs and other financial incentives to help attract and retain nurses and nursing aides at state veterans homes.
In the August letter, an assistant secretary of the VA encouraged Wisconsin officials to apply for the grant, which is available to all states.
Wisconsin officials have since submitted a pair of applications to the program − their first − for about $670,000 in all, to help address "significant staffing shortages" at the veterans homes at Union Grove and at King, in central Wisconsin.
"The Wisconsin Veterans Homes at Union Grove and at King have experienced caregiver staffing concerns going back to 2016," says a joint letter from Baldwin and Gov. Tony Evers in support of the state's application. "The situation was exacerbated and became much more critical during the pandemic. Veterans homes ... are dealing with record high vacancy rates in all direct care classifications."
Under the program rules, the state would provide a 50% match, if awarded to the grant.
This is the first time Wisconsin has applied to the program, which has been in existence since before Evers' tenure, Flaherty confirmed. She did not respond to a question asking why the Evers administration had not applied for the funding before.
Republicans running for state and Congressional offices have seized on problems at the veterans homes in their overtures to voters. Tim Michels, the Republican businessman running against Evers for governor, blamed Evers for a lack of leadership and pledged to change the culture of the state Department of Veterans Affairs if elected.
"What happens in organizations that are failing or broken? People don't like to work there, and that all starts at the top," Michels said last week from outside the veterans home in Racine County. "People don't quit their job; they quit their boss. I think right now the shortage of staff here is because the staff is quitting the governor of Wisconsin."
He did not offer any more specific steps for how he would change the work environment or improve staffing levels.
Britt Cudaback, a spokesperson for Evers, said states across the country are experiencing severe shortages of health care workers and that Wisconsin is no exception.
"The governor's priority continues to be ensuring our veteran homes have the necessary staffing and support to provide our veterans the best services and care anyone can offer while also working to find long-term solutions to our state's workforce challenges," she said in an email.
She pointed to the Evers' administration's efforts to recruit and retain workers across the health care sector by contracting with staffing agencies, directing federal pandemic aid to workforce development initiatives and training National Guard members as nursing aides, among other initiatives.
Lawmakers on the Joint Legislative Audit Committee, led by two Republicans, have submitted several inquiries to the state Department of Veterans Affairs since June, asking for information on citations, complaints and staffing levels at the Union Grove home.
No audit has been opened, but committee members are still evaluating the potential for one, said Jason Mugnaini, chief of staff for the committee's co-chair, state Sen. Robert Cowles, R-Green Bay.
What the latest inspection report found
In the latest inspection, the veterans home at Union Grove was cited for not doing a thorough investigation of an August incident in which a resident accused a nursing aide of abusing him while changing his brief.
The inspection report says the resident repeatedly told the aide she was hurting him and told her to stop. After she didn't, he tried to move her hands away by slapping or pushing her hands away, the report says.
The resident had a video and audio recording of the incident, but a copy of the recording was not included in the investigation file. Nor did the investigation include a statement from the resident or from other residents who had been cared for by the aide in question, according to the report. Inspectors couldn't find any evidence the aide was removed from caring for residents while facility officials further investigated the incident.
Officials with the facility did not report the incident to state regulators when it occurred, as they are required to do. The Division of Quality Assurance, part of the state's Department of Health Services, is in charge of investigating incidents of alleged abuse, neglect or exploitation of nursing home residents.
Inspectors also found a resident who was on two antipsychotic medications, but did not have proper diagnoses for those medications. A pharmacist first raised questions about the use of antipsychotics in the resident, who had dementia.
The diagnosis used to prescribe the medications was "delirium." The pharmacist noted that, "Since delirium is considered to be an emergency, short-term diagnosis, it is not considered to be appropriate for long-term use of psychotropic agents."
Another resident was on anti-anxiety medication, even though there was no documented reason for his continued use of the medication.
The facility was also cited for not taking steps to prevent two residents with difficulty walking from falling down. One of the residents fell twice within a two-week time period last year and was found on the floor near their bed, the report says. Inspectors faulted the facility for not properly investigating what caused the resident to fall down and how to prevent future falls.
The final violation was for two nursing aides who had worked at the veterans home for more than a year and had not completed any in-service training, including in dementia management or resident abuse prevention.
No fines have been imposed for the latest violations, according to a CMS spokesperson. The Union Grove home was also cited for violations stemming from inspections in March and June, though it is unclear whether those resulted in any fines.
The facility has incurred nearly $252,000 in fines from violations between 2017 and 2021, according to the CMS spokesperson.
Reporter John Diedrich, of the Milwaukee Journal Sentinel staff, contributed to this report.
This article originally appeared on Milwaukee Journal Sentinel: Inspection of troubled Wisconsin veterans home finds repeat violations
