“In more than 20 years, I’ve never seen this many citations and this much in fines leveled against one nursing home in the state,” said Kevin Martin, an attorney representing a family filing a lawsuit seeking to hold Union Grove responsible for the death of resident Randy Krall.

The Wisconsin Veterans Homes at King and Union Grove have been making headlines for years with allegations of poor quality of care. As much as a quarter of a million dollars in fines from deficiencies have been cited in federal inspections.

The concerns were, to say the least, sad as to what was happening there — the treatment that he was receiving and ultimately what happened to him because of the treatment that he received at Union Grove,” said Martin.

“This all came to a head in late 2020 when he suffered from profound dehydration, when he started suffering from some bedsores. And ultimately he needed to be hospitalized for those conditions and was never able to recover,” Martin explained.

“The worst of these things happened after he was discharged from the hospital and returned to Union Grove. Randy only had a few days left to live because of his injuries and the day that Randy started showing changes that he was in the dying process, Union Grove staff were supposed to call his wife and let him know that Randy is experiencing these changes. He’s very close to death, so that she could go and be with him, be at his side and hold his hands. They never called, and told her that they didn’t call her until after he had died, and they robbed her of the right to be at her husband’s side as he passed away.”

Kevin Martin is the attorney representing the family of Randy Krall, a deceased resident of the Wisconsin Veterans Home at Union Grove in Racine County, in their lawsuit against the state. Martin alleges conditions at the home were factors in the death of Krall in late 2020. (Credit: PBS Wisconsin)

These events are supported in a federal inspection report — and documents showed more problems.

“Medication errors. Water being left out of Randy’s reach. Dead bugs that were found in the room. His call light going unanswered for more than 45 minutes. Unfilled doctor’s orders for a Holter monitor to monitor his heart for physical therapy. Ants crawling around in his room. Uncooked food, cold food, food that was swimming in liquid. Expired milk that was being served. Urine and feces that was found around the toilet, not cleaned up. Injuries of unknown origin,” listed Martin.

The Wisconsin Department of Veterans Affairs said they can’t comment on matters involving any specific individual, due to HIPAA and other privacy laws.

An April hearing of the Senate Committee on Labor, Regulatory Reform, Veterans and Military Affairs heard testimony on the conditions of the Wisconsin Veterans Homes.

“We have invited speakers here today to give us an update and their perspectives as it relates to the conditions at the Veterans Home, primarily at King and Union Grove,” explained state Sen. Patrick Testin, R-Stevens Point, at the start of the hearing.

In a WisconsinEye video still image, the Wisconsin Senate Committee on Labor, Regulatory Reform, Veterans and Military Affairs holds an information hearing about the state’s veterans homes on April 6, 2023. Volunteers and staff invited to testify shared their observations and experiences about conditions at the homes. (Credit: Courtesy of WisconsinEye)

Testimony painted a grim picture inside Union Grove and King.

Some worked 16 hour shifts for three days in a row. We spoke with a nurse who had worked 32 days in a row,” stated Ellen Jante, who has been a volunteer and whose husband was a resident, about the conditions for staff.

“He has wet himself in the bed. Several mornings in the past few years, because no one comes to help when he puts his call button on,” stated Union Grove volunteer Laurie Miller about conditions for residents. “Now he says he doesn’t want to go outside because he knows he won’t want to go back in.”

Hearing participants pointed to leadership as the problem.

“With a change of oversight and change of management coming out of Madison and at the local location, things started to deteriorate,” stated Doug Womack, a former executive director at the King home.

In a WisconsinEye video still image, Laurie Miller testifies to the Wisconsin Senate Committee on Labor, Regulatory Reform, Veterans and Military Affairs on April 6, 2023. Miller has been a volunteer at the Wisconsin Veterans Home at Union Grove in Racine County, and shared a story about the difficult experiences of a resident. (Credit: Courtesy of WisconsinEye)

But these ordeals are contrary to the results of a satisfaction survey conducted by the Wisconsin Department of Veterans Affairs in 2023. Results show residents at King and Union Grove rate the facilities’ care at an average of 8.1 out of 10, and nearly 75% of respondents said they were “never unhappy with care.”

“I wanted to hear first-hand from the members on the ground, the members and the staff in the facilities. And so that was a good start, said Wisconsin Department of Veterans Affairs Secretary-designee James Bond in an August interview. “So I’m going to put together a work group that’s going to analyze the results, come up with some recommendations, and that will help us put together a path for moving forward.”

Bond, who was appointed by Gov. Tony Evers in January, pushed back against claims saying the homes are in crisis.

“When there’s any kind of allegation with respect to our homes, those are things that we investigate. We follow up. We make sure that we correct whatever it is that needs to be corrected, Bond said.

“I also want to say to those members that I want to hear directly from you. If you have concerns that you feel are not being addressed, you know, reach out to me.”

Wisconsin Department of Veterans Affairs Secretary-designee James Bond says the agency will be examining the results of a customer satisfaction survey about the Wisconsin Veterans Homes and urges staff and residents to reach out to him with their concerns. (Credit: PBS Wisconsin)

The agency notes competition from private facilities, a declining veteran population and staffing as key challenges.

“So if their stressors are the same across the industry, why is Union Grove ranked in the bottom five in this country? That’s illogical,” Martin said.

The 2023-25 state budget approved funding for a study into all three Wisconsin Veterans Homes, and lawmakers are hoping more can be done.

“I would hope that one of the biggest takeaways in all of this is that I think every member on the committee is all in agreement that we want an audit,” said Testin in April.

“If the Legislature decides that they want to have an audit so they can take a better look at our operations or our financial situation and offer suggestions on how we might be able to improve, I think that would be a good thing,” said Bond.