Map showing the location of WI VETERANS HOME-BOLAND HALL in UNION GROVE, Wisconsin
21425 E SPRING ST, UNION GROVE, WI, 53182

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinLowest tier among peers321 rated homes · average 3.0★
  • Racine CountyLowest tier among peers6 rated homes · average 1.8★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs WI avg
  • StaffingCan add or remove a star4★+0.3 vs WI avg
  • Quality measuresCan add or remove a star1★−2.1 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 35% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.35hrsTop 8%WI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.77hrsTop 3%WI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better58%Above only 25% of peersWI avg48%RN turnover49%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$125,470Above only 12% of peersWI avg$41,875Fines · denials2 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
46citations
9inspection dates
3actual harm (G–I)
6immediate jeopardy (J–L)
Dec 3, 2025most recent

Citations by monthAug 2022 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 3, 20255 citationsCycle 1worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Dec 30, 2025
  2. F585Honor 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.Resident RightsD · isolatedCorrected Dec 30, 2025
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 30, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 30, 2025
  5. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Dec 30, 2025
Oct 1, 202510 citationsCycle 1worst K · immediate jeopardy
  1. F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareK · patternCorrected Nov 18, 2025
  2. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Nov 18, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Nov 18, 2025
  4. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareJ · isolatedCorrected Nov 18, 2025
  5. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationF · widespreadCorrected Nov 18, 2025
  6. F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Resident RightsD · isolatedCorrected Nov 18, 2025
  7. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationF · widespreadCorrected Nov 18, 2025
  8. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Nov 18, 2025
  9. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Nov 18, 2025
  10. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Nov 18, 2025
Jun 12, 20252 citationsCycle 1worst J · immediate jeopardy
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Jul 2, 2025
  2. F742Provide 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.Quality of Life and CareG · isolatedCorrected Nov 18, 2025
May 13, 20251 citationCycle 1worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected May 21, 2025
Mar 26, 20257 citationsCycle 1worst J · immediate jeopardy$112,600, payment denial
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 16, 2025
  2. F585Honor 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.Resident RightsD · isolatedCorrected Apr 16, 2025
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 16, 2025
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 18, 2025
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected May 21, 2025
  6. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Apr 16, 2025
  7. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareG · isolatedCorrected May 15, 2025
Jan 9, 20257 citationsCycle 1worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 5, 2025
  2. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Mar 3, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Feb 26, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 10, 2025
  5. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jan 10, 2025
  6. F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationC · widespreadCorrected Jan 14, 2025
  7. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 15, 2025
Aug 8, 20243 citationsCycle 2worst E · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 8, 2024
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 8, 2024
  3. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 30, 2024
Oct 16, 20235 citationsCycle 2worst G · actual harm$12,870
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Nov 3, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 3, 2023
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 3, 2023
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 3, 2023
  5. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Nov 3, 2023
Aug 23, 20226 citationsCycle 3worst F · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 9, 2022
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 9, 2022
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 16, 2022
  4. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Sep 16, 2022
  5. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Sep 16, 2022
  6. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Oct 1, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.35hrsTop 8%+1.16 vs WI avg
  • Registered nursesRN hours only1.77hrsTop 3%+0.81 vs WI avg
  • Licensed practical nursesLPN hours0.21hrs
  • Nurse aidesCNA hours3.37hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.85hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better58%Above only 25% of peersWI avg 48%
  • RN turnoverRegistered nurses only49%Not ranked by CMS
  • Administrators who leftIn the past year4Leadership changed
  • Occupancy158 certified beds · ~71 residents a day45%Above only 5% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $125,470In fines
  • 2Fines
  • 1Payment denial
  • $41,875WI avg in fines
Above only 12% of peersFewer fines than 12% of rated homes in Wisconsin

Actions on record

  1. Mar 26, 2025Civil money penalty$112,600
  2. Mar 26, 2025Denial of payment for new admissionsfrom Apr 24, 2025
  3. Oct 16, 2023Civil money penalty$12,870

Ownership

As filed with CMS

Structure

Ownership type
Government - State
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • State of Wisconsin
Operational or managerial control
  • State of Wisconsin
  • Lauren Beaumont
  • James Parker
  • Tammy Servatius
  • Sarfraz Sidhu

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525688 · 21425 E SPRING ST, UNION GROVE, WI, 53182.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Racine County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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