U.S. Sen. Tammy Baldwin is calling on the Trump administration to immediately investigate claims from Tomah VA Medical Center employees who say the facility suffered serious failures in patient care, including inadequate hospice coverage and delayed medications for seriously ill veterans. The demand comes after a former hospice nurse at the facility was charged with patient abuse in connection with the alleged intentional withholding of oxygen from a veteran who later died.
Baldwin's office says employees reported that inadequate staffing at the western Wisconsin facility contributed to falls, pressure injuries, choking incidents while eating, missed patient checks, and other adverse outcomes, according to the senator's press release published by Urban Milwaukee. The senator, who represents Wisconsin in the U.S. Senate, requested that the VA Office of Inspector General conduct an independent investigation into the employees' allegations and also called on VA Secretary Doug Collins to immediately investigate the claims of failures to care for veterans and unacceptable conditions at the medical center.
Criminal Case Against Former Hospice Nurse
The case driving the renewed scrutiny centers on Beth Marie Holtz, a 53-year-old former Tomah VA hospice nurse. Monroe County law enforcement charged Holtz with felony patient abuse on September 9 in connection with an August 17, 2025, incident in which she allegedly intentionally removed prescribed oxygen from a 75-year-old hospice patient suffering from pulmonary fibrosis, according to Law & Crime.
Court filings from Monroe County prosecutors, as detailed by the same outlet, allege Holtz told a staff colleague that “it's easier to do death paperwork than falls paperwork” and instructed staff to keep the patient's oxygen off for roughly 90 minutes after finding him on a bathroom floor. After another nurse intervened and reconnected the oxygen, the patient's skin color and breathing temporarily improved, the criminal complaint records indicate, though the veteran ultimately died six days later, on August 23, 2025. The outlet notes that Holtz could face up to 15 years in prison if convicted.
Baldwin's List of Demands
Baldwin's office says Tomah VA employees contacted her directly with patient-care concerns, and she requested a full review of staffing levels, provider coverage, medication delays, hospice care, and patient safety at the facility. Among the specific questions she wants answered: whether current staffing levels and provider coverage are adequate for safe and appropriate care, whether management and leadership practices contribute to unsafe conditions, and how recent provider departures and vacancies have affected patient care.
She also wants the VA to assess the adequacy of hospice care, provider coverage, and timely access to end-of-life medications, and to examine how facility leadership responded to patient safety concerns raised by frontline employees. Baldwin is asking the department to identify immediate actions needed to address patient safety risks and to name the officials responsible for implementing and sustaining any corrective actions.
Questions About the Response to the Nurse's Alleged Abuse
Beyond the broader staffing review, Baldwin requested specific information about how VA and Tomah leadership responded to the nurse's alleged abuse incident, including the date leadership first became aware of it and details of any administrative, clinical, patient safety, and management reviews conducted afterward. She also asked the VA to determine whether the actions taken after the August 2025 incident were sufficient to protect veterans from similar harm, and to detail what deficiencies were identified and what corrective actions were required.
Baldwin said employees who raise concerns must receive zero-tolerance protection against retaliation or reprisal, and her office stated it will not provide the identities of employees who contacted it without their express authorization. She requested a written response detailing the VA's immediate actions at Tomah and the protections in place for employees who raise concerns, and asked that Veterans Health Administration and Veterans Integrated Service Network leadership communicate protected reporting channels directly to Tomah employees.
A Facility With a Troubled History
Tomah VA Medical Center sits on a 173-acre campus in rural Wisconsin and serves roughly 26,000 veterans across an 18-county catchment area spanning western Wisconsin and southeastern Minnesota, according to the VA's own facility information. The current allegations arrive against the backdrop of a facility that has faced serious scrutiny before. In 2015, Tomah drew national attention over an over-prescription scandal in which veterans dubbed the facility “Candy Land” and its former chief of staff the “Candy Man” for the excessive distribution of addictive narcotic painkillers, as reported by the Wisconsin State Journal.
A May 2016 investigation by the U.S. Senate Homeland Security and Governmental Affairs Committee documented systemic failures and a widespread culture of fear and whistleblower retaliation at Tomah, following the August 2014 fatal drug overdose of 35-year-old Marine veteran Jason Simcakoski, according to the committee's report archived on GovInfo. Baldwin herself faced political criticism during her 2018 re-election campaign over how her office initially handled a 2014 internal inspector general report on Tomah's over-prescriptions before the scandal became public, according to PolitiFact.
Federal Oversight Now Falls to Secretary Collins
The request for accountability now lands with Doug Collins, who was confirmed by the U.S. Senate in a 77-23 vote in February 2025 to serve as the 12th U.S. Secretary of Veterans Affairs under President Donald Trump, per Ballotpedia. The Department of Veterans Affairs oversees Tomah VA Medical Center as part of its broader Veterans Health Administration network, and it remains to be seen whether Collins' administration will grant Baldwin's requested independent investigation.
The facility has seen some recent investment even as these safety concerns persist. In March 2024, Tomah opened a newly remodeled 3,790-square-foot urgent care clinic operating seven days a week to expand triage and exam capacity for regional veterans. Baldwin's latest demand follows her ongoing pattern of pressing federal officials on veterans' healthcare access, including her push on ACA tax credit expiry and her separate questioning of a Milwaukee-area health system's staffing and outsourcing practices.
