Hollidaysburg Veterans Home

In the surveyor’s words

From the most serious findings on record at Hollidaysburg Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF689May 26, 2026

  Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of six residents reviewed (Resident 3) resulting in a fall with fracture. This deficiency is being cited as past non-compliance.Findings include: A facility policy regarding resident falls dated January 1, 2026, that all unwitnessed falls or a known strike to the head or neck required the neurological evaluation process. A significant change minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated May 1, 2026, revealed that the resident was cognitively impaired, was occasionally incontinent of urine, and required substantial assistance with toileting hygiene. […]

• Actual harm, isolatedF600Feb 11, 2026

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of seven residents reviewed (Resident 3), resulting in a fall and fracture for the resident. This deficiency was cited as Past Non-Compliance.Findings include: The facility's policy regarding resident abuse, dated January 5, 2026, revealed that the facility will provide protections for health, safety, welfare, and rights of each resident residing in the nursing home by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident… […]

• Actual harm, isolatedF689Feb 11, 2026

  Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as care planned and ordered for one of seven residents reviewed (Resident R2) who fell and suffered a fracture and failed to ensure that the residents' environment remained free of accident hazards for one of seven residents reviewed (Resident 3), who fell and suffered a fracture. […]

• Actual harm, isolatedF743Sep 23, 2021

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident did not display decreased social interaction, and/or withdrawn, angry or depressive behaviors, unless unavoidable, for one of 50 residents reviewed (Resident 49), resulting in physical and mental decline and hospitalization for the resident. Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated July 15, 2021, indicated that the resident was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF804Jun 11, 2026

  Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures. Findings include:The facility's policy regarding food temperatures, dated January 1, 2026, indicated that all hot foods were to be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F).Interview with a group of residents on June 10, 2026 at 2:00 p.m. revealed that the hot food is served warm or cold and that asking staff to reheat it in the microwave takes too much time. […]