DVA Mismanagement Of Union Grove Veterans Home

Years of contacts by concerned elected officials, a call for a federal VA investigation, increasingly desperate pleas from family and residents, alarm bells sounded by staff, rejection of federal assistance, and DVA still has no plan.

5 Things to Know About DVA Mismanagement of Union Grove:

  1. Evers’ appointees have been unable to develop a plan in response to increasingly urgent alarm bells about staffing and care crises
  2. Alarming personal stories demonstrate the safety of staff and veterans has been jeopardized by poor management
  3. DVA relies on agency temp staff – paying $95 an hour for an aide – to fill vacancies, but still forces overtime on their workers
  4. Veterans have fled the home; the census at Union Grove is half what it was in 2018
  5. DVA wants to use ARPA funds earmarked for Wisconsin Veterans in state homes to demolish buildings


Union Grove Veterans home has seen a staff exodus, a sharp decline in residency, and increasingly urgent pleas for staffing reforms and improved care throughout the Evers Administration.

There is no doubt that the pandemic impacted long-term care facilities, making it more difficult for nursing homes to do the already-difficult job of providing quality care to our most vulnerable citizens.  And through changing guidance, new requirements, and workforce challenges, most homes stepped up and did their best.

Wisconsin’s Department of Veterans Affairs didn’t step up, and the residents and staff at Union Grove suffered because of mismanagement by Evers’ hand-picked agency leadership.

We’ve seen news stories in recent years featuring patients and families raising serious concerns about Union Grove .  We learned about increasing citations over the past several years.  We saw elected officials call for an investigation into Union Grove, and question the DVA on the declining care, and the lack of an improvement plan.  We’ve seen Evers admit that his administration has been “unable to fulfill our duties to these great veterans, by having adequate staff, and adequately trained staff.”

What we haven’t seen is the inside view of what the Evers appointees charged with fulfilling those duties to our great veterans were saying, doing, or planning to achieve that goal.

Documents of internal agency communications reveal leadership appointed more for their political background than knowledge of how to effectively run an institution as specialized and complex as a nursing home for veterans. Good intentions cannot substitute for expertise, or the willingness to seek and accept help to solve problems – problems that can mean life or death for vulnerable patients.


Homes Background

Wisconsin operates three Veterans Homes, located at King in Waupaca County, Chippewa Falls, and Union Grove, with a cumulative total of 751 licensed skilled nursing beds for veterans and spouses; Union Grove has 158 of those beds.  The homes are funded through a combination of Medicaid, private pay, USDVA per diem and disability payments, and Medicare. In some years, the homes generate a surplus, and in others, a deficit.  According to the Legislative Fiscal Bureau’s most recent informational paper, in 2019-20, the homes generated a surplus of nearly $5 million.


Evers Appointees Lacked Expertise

When Evers took office, state Veterans Homes faced similar challenges to other nursing homes across the country, but his top leadership appointees did not grasp those difficulties even at a basic level. Soon after their appointments in March 2019, DVA Secretary Mary Kolar and Deputy Secretary James Bond claimed the following provisions in Evers’ just-introduced 2019-21 budget would address staffing problems at the homes:

  • Restoring prevailing wage laws
  • Creating a task force to study a $15 minimum wage
  • A phased-in, common-sense approach to raising wages for working people (?)

That the top leadership of this agency believed these actions would impact veterans home staffing problems demonstrates how little the leadership team understood about the jobs they had been given.

Five months into her tenure, Kolar was attributing staff shortages to young and foreign-born workers, the most willing to work for low wages in jobs requiring low education levels, “who often lack the basic skills necessary to perform this highly personal, regulated work” but are nonetheless highly sought after by other local employers.

As time went on, Kolar became more savvy at explaining away Union Grove’s failures as staffing troubles in long-term care, the pandemic, and a competitive employment market, while the staffing crisis grew well beyond the COVID shield she used to hide a problem she clearly was not equipped to solve.

Alarm Bells

There has been media coverage of the problems at Union Grove; but there has not been a view behind the scenes into the agency itself. While emails only show what officials put in writing, they paint a picture of a rapidly growing crisis, with staff, families, patients, and elected officials ringing alarm bells with DVA leadership at an increasing pace. Everyone who could possibly have told DVA urgent solutions were needed, did.


Elected Officials

These records show contacts from multiple elected officials on behalf of constituents who had concerns, complaints, and often deep fears about the care veterans were receiving at Union Grove and the turnover and pressures on the staff.

No elected official was more engaged with DVA on issues from patient care to volunteer activities and from staffing concerns to family worries than Speaker Robin Vos, who represents Union Grove. His staff emailed frequently and set up repeated meetings and calls with the Secretary, DVA staff, families, volunteers, and staff at the home. His work behind the scenes underlies the frustration found in the letters he and Senator Wanggaard sent to Evers regarding the early termination of National Guard staffing assistance at the home in May.

Congressman Steil’s office also regularly contacted DVA about member concerns, and in August 2020, his concerns about the rising number of COVID cases at Union Grove led him to ask the USDVA to assist in and investigate the situation. Their response raised more concerns; the federal VA had offered staffing assistance to Union Grove on May 27, 2020.  Evers’ DVA refused the help from the Trump Administration, much like they went on to refuse offered federal assistance during the Kenosha riots that summer. Months later, after the outbreak in the homes, Union Grove did ask for federal staffing assistance, which they received nearly immediately. They received more assistance in 2021.

If the information in these records is a guide, Steil’s concerns were more than warranted. Kolar’s COVID concerns didn’t put the most vulnerable people her agency serves first.  DVA administration was already telecommuting by March 23, 2020 for their safety, but it wasn’t until April 3 – the day her boss Evers moved to shut down the Spring election because it was far too dangerous to vote even with masks, distancing, and plexiglass barriers – that she required staff at the homes to mask up.

In August of 2022, two years after Steil’s request, Senator Baldwin’s office sent a letter to the USDVA, also asking them to identify federal resources that could assist at Union Grove.  The USDA response to Baldwin revealed, as had their response to Steil, another failure of the Wisconsin DVA: they had not applied for a VA grant available to all states to assist in the recruitment and retention of nurses. The application deadline this year was September 30, but it is unknown whether Kolar and her team applied.

USDVA also indicated that their Infection Preventionists had provided consultation and assistance to Union Grove on three separate occasions, providing training, corrective action plans, and assistance in mass testing.


Families and Staff

These records reveal the deep respect, concern, and affection families, residents, and staff have for one another.

Emails to DVA leadership with concerns about staffing levels and turnover, forced overtime, and patient care came from patients, family and staff. Families wrote with concern about staff being overworked and unable to do justice to their jobs or their families. Patients wrote worried about staff turnover and the loss of trusted caregivers. Staff wrote expressing anxiety that there was not adequate staff to give the veterans the care they needed.

The emotion in these letters is, at times, heartbreaking.


December 14, 2019

“I can tell you the nurses and CNA’s told me yesterday they have never seen staffing this bad…a CNA on (my husband’s) floor was
on her 4th 16-hour day in a row yesterday.  Even the most dedicated people are reaching the end of their rope.
And someone working 16 hours a day is not even safe to be doing their jobs.”

February 18, 2020

“How would you feel if your loved one was a resident here and they called you on the phone and pleaded with you to come quickly because there is no one to take care of them? My husband did that this past weekend.  Only 1 CNA on the floor! When are you going to fix this?”
(DVA indicated staffing was ‘adequate’ on this day.)

August 10, 2020

“My husband has been confined to his bed because there is insufficient staff to use the Hoyer lift for him to be up in his wheelchair.”

October 18, 2020 

“Are you aware that there is a mass exodus of long-term employees at the veterans home in Union Grove?  Does anyone care that really good nurses are leaving because nobody is listening or doing anything about the staffing shortage.  Do you even care?”

January 25, 2021

”The veterans here need staff who are not physically and mentally exhausted caring for them. Yesterday…a second shift LPN called in and said she would be late…she drove her car into a ditch because she fell asleep 5 minutes away…The LPN just worked the pm shift…and was forced to work the night shift preceding. She left in the morning and was returning…she had three hours of sleep.”

January 28, 2021

“I am sorry to be emailing you, but I don’t know who else to turn to.  I have worked her for 14 years, since the place opened… I love and care for these members and it is awful to see what is happening here. I continue to work here because I think who will take care of my guys…Staff are being forced to work non-stop double shifts.  Today is yet another nurses’ last day. She is heartbroken, she loves her guys, but she can’t do it anymore.”

January 31, 2021

“With all due respect, the nursing shortage at Boland Hall is not due to a “national crisis.” We have lost sixteen if not more nurses…in just the past few months. It has nothing to do with the shortage, it is due to forcing and management.”

February 1, 2021

“Yesterday…there was 1 aide, and 1 nurse per unit (20 members). The poor aide was running around trying to get 20 people up and fed for breakfast.  The aide said to me that she was so disgusted getting members up and cleaning them as most had a dark brown ring on their sheets from dried urine they had been laying in.  If I’m not mistaken, I thought I heard one of the aides was here fore 20 hours.  We have a guy eating breakfast at 10:15. Breakfast is at 8. Its one thing to exhaust the staff but the members, our vets, deserve better care. We need help now. Please tell me we have some sort of plan in the works…”

By July 2021, the situation was bad enough that DHS staff suggested the private company that manages the
Chippewa Falls Veterans Home could temporarily take over Union Grove.

August 6, 2021

“We are actually imploding here. I can’t believe this is the state of Wisconsin and this is how we are taking care of our veterans. One CNA per floor again. One person to take care of forty veterans for eight hours again. This is an impossible task.
We are being dishonest to the veterans and their family’s if we tell them we can provide good care to them.
No one is supervising this facility. We continue to lose staff as this is now dangerous and unsafe for staff and our veterans.”

September 17, 2021

“Today I saw an aide incoherent and lethargic.  Unable to move or speak passed out on the couch as we called 911. A wonderful aide who is here almost every am and pm taking great care of our vets. Completely just exhausted on a gurney and the facility is worried about getting her to sign a force refusal paper as she is on her way to the hospital. As she left there was no staff to cover Gates Hall it was 1300 and no one had eaten lunch… My heart is breaking for our veterans who deserve better care and for my co-workers who continue to do the best they can every day overworked and exhausted.” 


September 2021, DVA paused admissions to the homes deciding it was easier not to have so many veterans to take care of than to solve staffing problems.

Throughout these years, at only one point did Kolar show any urgency in these email records.  When the inability of the department to fill the Medical Director position for the homes spurred her to email the DOA secretary asking for help finding a physician, she expressed her concern about fines from CMS and USDVA that would result from a vacancy.

She didn’t mention any concern about potential harm to patient care if the homes were without a physician as Medical Director.


Loss of Staff and Members

Nearly 4 years into the Evers Administration, the situation at Union Grove is this:

  • Occupancy is down from 157 to 79
  • Their staff vacancy rate is – on paper – about 54%
  • About $4 million in pandemic funds have gone to Union Grove
    • One portion of that needed to be earmarked by the department by Sept 30, 2022
    • It’s not clear how much has been spent and on what
    • According to the DVA 2019-21 biennial report, DVA received almost $20 million in stimulus funds

All those federal funds, multiple months of staffing assistance from the USDVA, and almost 4 years later they still have not developed a staffing plan to stabilize the workforce at Union Grove.


The High Cost of Temp Agency Staff and Overtime

One dirty little secret about their staffing is the use of “agency” staff. In these arrangements, the department contracts with a health care temp staffing agency for personnel to fill in gaps.  These workers aren’t counted in the vacancy reports, but they cost a bundle.

While the wage for a CNA employed by Union Grove might be $19/hour, the agency charges DVA $90 per hour for a CNA.  A Union Grove employed LPN might make an average of $23/hour. The agency rate is $100/hour; for RNs, they charge $195/hour.

According to these records, the current agency is NuWest, and used by DVA and DHS.  (Good luck finding them in OpenBook.) A conservative estimate is that Union Grove paid well over $4 million to staffing agencies during the Evers Administration.

In February of 2022, with the census under 100, there were still 21 agency staff (12 CNAs and 9 nurses).  Keep in mind that these agency contracts are on top of the overtime paid to staff which these records make obvious is excessive.


Failing the Veterans at Union Grove

That level of agency staff was in addition to the 16 National Guard assisting at that time.  Yet in April of 2022, regular employees of the home were still being asked to work 16 hours, and with only 8 hours off, to return for another 8-, 12-, or 16-hour shift.

It’s hard to understand how this can still be happening with the low census and all the external help.  It’s not hard to understand why this level of forced overtime over a span of years is bad for recruitment, retention, and quality of care. And bad for the workers.

There is no question that staffing is a challenge in healthcare, and additional constraints inherent in our civil service system raise the bar a little more. The pandemic presented additional difficulties, and while Union Grove may be the poster child for how not to manage a healthcare facility, the problems of paying exorbitant rates for agency temp staffing, forcing overtime, and paying high rates for overtime work are not unique to the Veterans Homes, or other state agencies including DHS and DOC.

There is a strong policy argument to be made that paying $95 per hour for a worker that you could employ for a third of the cost, including benefits and a pay bump, is wasteful. It also creates tension among the staff (one staffer mentioned she had been an LPN for 28 years and made less than an agency CNA she worked with) and does nothing to prevent turnover and all the costs associated with it. And in health care, it contributes to lower quality of care.

Continuity of care in health care means more than robust collaboration and sharing of information. It also means a stable care team who are familiar with the patients and their needs and norms.  For those in nursing homes, this consistency can be especially important, particularly for those who cannot communicate with their caretakers.

The constant churn of staff at Union Grove undermines the quality of care the veterans receive. The average tenure of the commandants at Union Grove during the Evers Administration is less than a year, and many direct care staff don’t make it even that long. Add the cycling-in of desperately-needed but temporary assistance from the National Guard, the USDVA, and temp agencies, and it’s no surprise that the most knowledgeable people about what is happening at Union Grove are the veterans, their families, and the few long-term staff who remain.


DVA Wants to Use ARPA Veterans Home Funds as a Wrecking Ball

The Evers’ “COVID Dashboard” doesn’t really allow a view into how agencies are spending their pandemic stimulus funds. DVA’s plan for a quarter of their $20 million demonstrates clearly why that is not good government.

These records show that DVA leadership was working with DOA in 2021 and 2022 on a plan to use $5 million of ARPA funding to demolish 4 buildings owned by DVA, three at Union Grove.  Deputy Secretary Bond was working with top agency budget staff as well as DOA’s Director of Facilities Development to use funds specifically set aside for state Veterans Homes (and allocated to them based on the number of residents) to demolish old buildings on the campus.

Secretary Kolar personally met with the Governor’s office staff on the demolition plan this year. These records do not reveal their final decisions on the allocation of this $7.5 million pot of ARPA funds, but bids closed on the demolition projects in July, so the work is moving ahead.

The most urgent problem at Union Grove is not a few old cottages on the grounds, it is the care of veterans in the home. The fact that Evers’ hand-picked leaders at DVA can’t see that, even after nearly 4 years, tells us everything we need to know about his leadership, and theirs.