Hollidaysburg Veterans Home
HOLLIDAYSBURG VETERANS HOME in HOLLIDAYSBURG, PA — inspection on May 26, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
the facility failed to ensure that the physician was notified timely about a change in condition for one
January 1, 2026, indicated that when there was a change in the resident's condition, staff would notify the covering Registered Nurse who would then update the supervisor, physician, and family.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 29, 2026, revealed that the resident was cognitively intact, had diagnoses that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow, making it difficult to breath, and used a CPAP (a Continuous Positive Airway Pressure) machine to provide pressured oxygen through a mask to keep his airway open.A progress note for Resident 2, dated May 18, 2026, at 1:19 a.m. indicated that the CPAP machine was observed to be unavailable.Interview with Resident 2, on May 26, 2026, at 11:51 a.m. indicated that when he was at home and the CPAP machine needed fixed/cleaned, the medical supply company gave him a replacement until his was repaired. He further indicted that it bothered him very much to not have his machine and that he could not sleep well. He indicated that he used his oxygen at night but that was not the same as his CPAP machine. At the time of the investigation the CPAP machine was in his room and functioning.
Interview with Registered Nurse (RN) Supervisor 4 on May 26, 2026, at 12:25 p.m. indicated that she investigated the concern regarding Resident 2's CPAP machine being unavailable.
She indicated that On May 13, 2026, the machine was taken by adaptive/maintenance to change the filters and fix a broken magnet on the strap of the appliance.
Maintenance told Licensed Practical Nurse 5 that they were taking the residents CPAP machine to make repairs.
There was no communication between the LPN and the RN regarding the removal of the CPAP machine from the residents room.
She went on to say that there was some difficulty acquiring the correct filters and with adequately fixing the magnet on the strap.
Therefore, the resident was without his CPAP machine from May 13, 2026, until approximately May 22, 2026. RN Supervisor 4 indicated that on May 18, 2026, the computer flagged a notice regarding the machine and that is how she became aware of the situation. At that time she made the physician aware of the situation.
She indicated that if the appropriate staff would have been notified as per the procedure, then the provider may have made recommendations and/or a replacement CPAP machine may have been provided.There was no documented evidence that the physician was notified on May 13, 2026, regarding the resident's CPAP machine needing repairs and consequently becoming unavailable to Resident 2 for sleep.Interview with the Director of Nursing on May 26, 2026, at 3:00 p.m. confirmed that there was no documented evidence that the physician was notified timely when Resident 2's CPAP machine was unavailable for him to use, and he should have been.28 Pa.
Code 211.12(d)(3) Nursing services. 28 Pa.
Code 211.12(d)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
39A437 05/26/2026
Hollidaysburg Veterans Home 500 Municipal Dr Hollidaysburg, PA 16648
During completion of audit, any identified concerns will result in corrective action, with the concern documented and monitored through completion.
These audits will continue for a period of 6 months, and the results will be reviewed during the Quality Assurance Committee Meeting to determine whether additional interventions and monitoring is necessary.
Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F-F689 on May 20, 2026. 28 Pa.
Code 211.12(d)(5) Nursing services.
39A437 05/26/2026
Hollidaysburg Veterans Home 500 Municipal Dr Hollidaysburg, PA 16648
that he was on break when Resident 3 fell and was sent to the hospital. A witness statement by RN 1
vitals when the resident came back from the hospital. RN 1 couldn't find a neurological sheet so he
check sheet with the other time increments so another staff could have filled them in. RN1 started with the 1:30 a.m. slot noting he came back from the hospital. I only filled out that 1:30 a.m. time slot. Resident 4 was good, alert and talking, acting like his normal self.
Now when he fell on May 4,2026, at 4:40 a.m.
Registered Nurse Supervisor (RNS) 3 started a new neurological check sheet, entering the one set, then Resident 3 was sent out to the hospital.A witness statement with Nurse Aide 2 on May 4, 2026 at 4:30 a.m., revealed while doing 15 minute rounds at approximately on May 4, 2026, 4:15 a.m. Resident 3 was heard moaning and was found on the floor. A witness statement with Nurse Aide 2 on May 7, 2026, not timed, indicated that she assisted the resident to the bathroom at 3:30 a.m. on May 4, 2026, at 4:15 p.m. the Resident 3 was sleeping, and then at 4:30 a.m. the resident was found on the floor.A witness statement by RNS 3 on May 6, 2026, at 2:58 p.m. revealed that frequent checks (15 minute checks) were started when he returned from the hospital at 1:40 a.m. on May 4, 2026. RNS 3 was no informed to add any interventions to Resident 3's plan of care when he returned. RNS 3 completed a neurological check at 4:30 a.m. after the second fall.
The resident was not wearing an incontinent brief at the time and was only wearing pants, and he was not incontinent at the time of the fall. Resident 3 was confused and could not express what happened. A review of toileting documentation revealed that staff did not document every two hours as care planned, Some staff document when they toilet Resident 3 and others will only document once per shift.
Interview with the Director of Nursing on May 26, 2026, at 4:55 p.m. confirmed that there was no documented evidence that Resident 3's was toileted every two hours as a fall intervention.
This has been a problem and multiple educations have been sent out to staff with instructions on how to document toileting and care.28 Pa.
Code 211.12(d)(3)(5) Nursing services.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.