Hollidaysburg Veterans Home: CPAP Delay Left Vet Without Device - PA
The veteran, identified in inspection records only as Resident 2, has chronic obstructive pulmonary disease, a progressive lung condition that permanently narrows the airways. He relied on the CPAP machine every night to push pressurized air through a mask and keep his airway open while he slept. Without it, he used supplemental oxygen instead. He told inspectors it was not the same thing, and that going without his machine bothered him very much. He could not sleep well.
He went without it for nine nights.
The machine had been taken by the facility's adaptive and maintenance department to replace filters and fix a broken magnet on the mask strap. According to the RN supervisor who later investigated the situation, maintenance told a licensed practical nurse that they were removing the machine. That information went nowhere. The LPN did not pass it to the supervising registered nurse. No one contacted the physician.
There were problems getting the right filters. The magnet repair took longer than expected. Days passed.
On May 18, five days after the machine was removed, a computer system flagged an alert about the missing device. That is how the RN supervisor said she first learned what had happened. She notified the physician that day. By then, the veteran had already spent five nights without his CPAP.
He would spend four more before the machine was returned to his room, around May 22.
When inspectors interviewed the veteran on May 26, he told them that at home, when his CPAP needed cleaning or repair, the medical supply company gave him a loaner until his own machine was fixed. He had a system. The facility had no equivalent.
The RN supervisor acknowledged to inspectors that if the correct staff had been notified when the machine was first removed, the physician could have weighed in and a replacement might have been arranged. The Director of Nursing confirmed on the same day that there was no documented evidence the physician had been told anything on May 13, and said he should have been.
The facility's own policy, dated January 1, 2026, required staff to notify the covering registered nurse of any change in a resident's condition, who would then update the supervisor, the physician, and the family. The chain broke at the first link. The LPN who received the information from maintenance never passed it up.
Inspectors cited the facility under Pennsylvania nursing services regulations for failing to ensure the physician was notified in a timely way about a change in condition. The violation was rated as causing minimal harm or potential for actual harm, and affected one of six residents whose records were reviewed during the complaint inspection, which was completed May 26.
The veteran's CPAP machine was back in his room and working by the time inspectors arrived. The nine nights it was gone are not recoverable.
For a man with COPD sleeping without his CPAP, using oxygen as a substitute and lying awake in the process, the gap between what the facility's policy promised and what actually happened was not a paperwork problem. It was nine nights of interrupted sleep and an airway without the support it needed, because a maintenance worker told a nurse something, and the nurse said nothing to anyone else.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hollidaysburg Veterans Home from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 14, 2026 · Our methodology
HOLLIDAYSBURG VETERANS HOME in HOLLIDAYSBURG, PA was cited for violations during a health inspection on May 26, 2026.
He relied on the CPAP machine every night to push pressurized air through a mask and keep his airway open while he slept.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.