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The Wisconsin Veterans Home at King.

A U.S. Department of Veterans Affairs inspection found three instances in which the Wisconsin Veterans Home at King failed to meet federal standards, including one where a resident fell from a bed and suffered a skull fracture and brain injuries.

According to a report from a federal inspection of the King veterans home in January, the home did not meet three of 158 standards that the U.S. Department of Veterans Affairs requires of state veterans nursing homes. VA inspectors found that King did not meet its standard for protecting residents from abuse in the case of one resident there who fell from a bed. It also found that the home failed to meet an additional standard when it did not update that resident's care plan following the fall. In the third instance, the home could not provide documentation of elevator safety inspections, another VA standard.

The facility met the other 155 federal standards outlined in the report.

The report is the result of a January request from Sen. Tammy Baldwin for the federal VA to conduct a "for cause survey" at King. Baldwin made the request after the Centers for Medicare and Medicaid Services, a federal agency that regulates nursing homes, confirmed that staff at the King veterans home mishandled liquid oxygen there in May 2016. CMS also issued the home seven more federal citations in December after following up on complaints there, and dropped the ratings of two residence halls on the King campus. 

A "for cause survey" is an unannounced federal review to investigate any incidents, complaints or deficiencies that might jeopardize the health or safety of residents at a veterans home, according to the agency.

“Our veterans and their families have made incredible sacrifices for our country and they deserve the highest quality of care. This survey shows that veterans are not receiving the proper care they have earned and that all actions available must be taken to improve safety and care for our veterans at King,” Baldwin said in a statement Monday.

Wisconsin Department of Veterans Affairs spokeswoman Carla Vigue said in an email Monday night that the agency strives to provide veterans living at King with the highest level of care.

"As always, we take very seriously any issues that might arise in our facilities. These issues are important for us to address and we put a plan of correction in place," she said. "We use each of these surveys as an opportunity to improve our service to veterans.”

Though the Wisconsin Veterans Home at King is a state-run home, it receives hundreds of thousands of dollars in federal per diem payments to cover living expenses for the veterans housed there. It is surveyed annually by the VA each year. The home received no citations when the VA completed its last annual survey in June 2016.

The for-cause survey was conducted Jan. 10-13 at the Wisconsin Veterans Home at King.

Tim Latimer, a VA inspector based in Madison who participated in the review, said in an interview in January that the reviews incorporate interviews with staff members and residents to ensure it is comprehensive. The inspection is also done in coordination with an outside contractor that does external care reviews. 

"It’s a thorough review of numerous areas that include policies and procedures, incident reports, infection control, per diem payments (and) nursing services," Latimer said.

In the case of the veteran who fell, inspectors determined that the home and staff neglected to provide necessary care and services to prevent a quadriplegic resident from falling out of a bed during morning care. Staff then failed to update that resident's care plan to prevent falls. That instance violated the VA's standard for abuse, which also encompasses neglect.

The federal VA defines "neglect" as "any impaired quality of life for an individual because of the absence of minimal services or resources to meet basic needs." Inspectors found that nursing staff at King were negligent in their care of the resident who fell, according to the report. 

During an interview with inspectors, the resident stated that he/she had complained to nursing management before saying that nurse aides were inattentive, according to the report. The nurse aides said the resident fell because of a seizure or a muscle spasm, but the resident maintained he/she did not have a seizure or a spasm. The incident was reported to the state as possible neglect, according to the report.

Vigue said that the agency immediately self-reported this isolated incident to the State Office of Quality Assurance and the Federal VA when it occurred in October. 

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The King home was also found to have not met federal fire safety standards. The facility failed to provide inspectors with documentation showing they completed monthly fire service tests on its elevators.

In addition to three standards that were not met, federal inspectors found that King only "partially met" standards for two instances where the wrong cough medicine was given to a resident and another resident's care plan was not updated to prevent aspirational pneumonia.

Baldwin's January request for the VA inspection was the second one Baldwin sent to the agency following concerns over resident care and spending there. She also sent a letter last April asking for a review, but was denied after the federal agency said King has scored well on previous annual reviews. 

Since then, several high-level officials have left the agency, including former WDVA Sec. John Scocos. Scocos announced his resignation in November and left the job in January. His assistant deputy secretary Dan Buttery followed him out a few weeks later.

Gov. Scott Walker appointed Daniel Zimmerman as secretary in February. Last week, Zimmerman announced he was reassigning the top official at King, Commandant Jim Knight. Knight is set to become the agency's fiscal compliance auditor, where he will craft the strategic veterans homes plan, according to a letter from Zimmerman.

Walker has also asked for money for improvements at King, including $13 million for water, food and electrical improvements at the home in his capital budget for 2017-19, following Cap Times reporting showing yellow water there in August. Lead has also been found in the water at King, though at levels safe enough to consume, according to state officials.

The home is also under audit by the Legislature. Their report is set to be released this spring.