Hollidaysburg Veterans Home: Fall Care Failures - PA
The first fall happened on May 3, 2026. The resident, identified in inspection records only as Resident 3, was sent to the hospital. He came back in the early hours of May 4, at 1:30 a.m. The nurse on duty, identified as RN 1, had started a neurological check sheet after the first fall, filling in the 10:30 p.m. time slot, then left the remaining time increments blank for other staff to complete. When Resident 3 returned from the hospital, RN 1 filled in only the 1:30 a.m. slot. The sheet sat there. Nobody added the 15-minute safety checks that should have followed a fall of that nature. Nobody updated his care plan.
He fell again.
The second fall happened later that same morning. A charge nurse, identified as RNS 3, completed a neurological check at 4:30 a.m., after the second fall had already occurred. At that point, Resident 3 was confused and could not explain what had happened to him. He was found wearing only pants, no incontinence brief, and was not incontinent at the time. He had not been wearing the brief because, a witness statement later confirmed, no one had been told to add any new interventions to his care plan when he returned from the hospital.
The Quality Assurance Registered Nurse confirmed during an interview on May 26, 2026, that there was no documented evidence of neurological checks completed in the gap between his hospital return and the second fall, and no documented evidence that 15-minute checks had been initiated as a fall intervention at any point after he came back.
The inspection, a complaint survey completed May 26, 2026, cited the facility for failing to ensure that an effective root cause analysis was conducted after the first fall, and for failing to put appropriate interventions in place before the second fall occurred. The deficiency was cited at the level of actual harm.
The facility's own corrective action summary acknowledged the failure directly. "On May 3rd and May 4, 2026 the resident experienced two falls in a short period of time," the document reads. "After the first fall an effective root cause analysis was not identified, and appropriate interventions were not put into place which put the resident at an increased risk to experience the second fall."
In the weeks that followed, the facility moved through a corrective action plan. Education sessions ran from May 8 through May 20, covering the incident and accident policy, post-fall assessments, witness statement requirements, and care plan updates. Ninety percent of registered nurses received the training by May 20. The remaining two were to be educated before their next scheduled shift.
The Director of Nursing was assigned to audit every resident fall going forward, checking that a root cause analysis was completed and that corresponding interventions were implemented. Those audits were set to continue for six months, with results reviewed by the Quality Assurance Committee.
Inspectors reviewed the corrective actions and concluded the facility had returned to compliance with the relevant federal standard by May 20, 2026.
What the records do not resolve is the period between 1:30 a.m. and the second fall, when Resident 3 was back in the building, confused, and without the safety net that his first fall should have triggered. The nurse who left the neurological check sheet partially filled. The charge nurse who was not told to update the care plan. The gap in documentation that the Quality Assurance nurse confirmed on the day of the inspection.
Resident 3 was described by RN 1 as alert and talking after returning from the hospital, acting like his normal self. Then he fell again in the dark, confused, unable to say what had happened.
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.
The first fall happened on May 3, 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.