Hollidaysburg Veterans Home: Fall Care Failures - PA
That is what inspectors found at Hollidaysburg Veterans Home following a complaint investigation concluded May 26, 2026.
Resident 3, a man described as confused and unable to explain what had happened to him, was first found on the floor at approximately 4:15 a.m. on May 4. A nurse aide doing 15-minute rounds heard him moaning. She had helped him to the bathroom at 3:30 a.m. By 4:15 he was sleeping. By 4:30 he was on the floor.
He was sent to the hospital.
He came back at 1:40 a.m. That is when the monitoring was supposed to begin in earnest, with neurological checks at regular intervals to catch any sign that the fall had done damage that wasn't immediately visible. The registered nurse on duty, identified in the report as RN 1, said he completed one set of neurological checks and vitals when the resident returned. Then he ran into a problem: he couldn't find the neurological check sheet. So he started a new one, entering the 1:30 a.m. time slot, and left the remaining time increments blank.
His explanation, in his own words from a witness statement: "I left the neurological check sheet with the other time increments so another staff could have filled them in."
Nobody had.
At 4:15 a.m., still on the same night, Resident 3 fell again.
The registered nurse supervisor on duty, RNS 3, started yet another neurological check sheet after the second fall, entering one set of checks before the resident was sent back to the hospital. RNS 3 told inspectors he had not been informed to add any new interventions to the resident's care plan after the first hospital return. The 15-minute checks, he said, were started when the resident came back at 1:40 a.m. They did not prevent a second fall less than two hours later.
Resident 3 was not wearing an incontinence brief at the time of the second fall, only pants. He was not incontinent at the time. He was confused and could not say what had happened or why he had gotten up.
The inspection report does not say whether anyone ever completed the blank time slots RN 1 left behind.
What inspectors did find, when they reviewed the toileting records, was a pattern of incomplete documentation going back further than one bad night. Resident 3 had a care plan that called for toileting every two hours, specifically listed as a fall intervention. Some staff documented when they took him to the bathroom. Others documented only once per shift. The gaps in the record were not occasional lapses. They were routine.
The Director of Nursing, interviewed on May 26 at 4:55 p.m., confirmed it directly. There was no documented evidence that Resident 3 had been toileted every two hours as his care plan required. She acknowledged the problem was not new. Multiple rounds of staff education had already been sent out, with instructions on how to document toileting correctly. The education had not fixed it.
What the Director of Nursing did not say, and what the inspection report does not address, is whether anyone reviewed the toileting gaps before the first fall, or whether the two-hour schedule was being followed in practice even when it wasn't being written down.
The facility is cited under Pennsylvania nursing services regulations for the failures in monitoring and documentation.
Resident 3 fell twice before dawn. He was confused both times, unable to tell anyone what he needed or what had gone wrong. The monitoring sheet meant to track his condition after the first fall sat with blank time slots, waiting for a staff member who never came. The toileting schedule meant to keep him from getting up alone in the dark had been inconsistently followed for long enough that the Director of Nursing described it as an ongoing problem, one that education had not solved.
He fell anyway. Twice. In the same night.
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.
That is what inspectors found at Hollidaysburg Veterans Home following a complaint investigation concluded May 26, 2026.
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.