Sen. Baldwin Calls For Tomah VA Investigation After Nurse Arrested

Tomah VA Medical Center. Photo by Maureen McCollum/WPR.

Democratic U.S. Sen. Tammy Baldwin is calling for an investigation into care at the Tomah VA Medical Center after a former hospice nurse was arrested last week on charges of patient abuse.

Baldwin sent a letter on Friday to U.S. Department of Veterans Affairs Secretary Doug Collins, asking the department to immediately review staffing levels and the quality of care at the facility. Baldwin also requested the VA Office of Inspector General investigate the allegations.

Baldwin said in the letter that employees at the Tomah VA contacted her office to report “severe lapses in patient care” as a result of “poor management and inadequate staffing.”

These issues contributed to inadequate patient checks, food choking incidents and patient falls, according to the letter.

Baldwin said the employee reports “raise particularly troubling concerns” about the care of hospice patients, including allegations of delays in veterans receiving medications and inadequate provider coverage.

“Veterans receiving hospice care are among the most vulnerable patients in the VA system, and they and their families should be able to trust that they will receive safe and compassionate care and be treated with dignity during the final days of their lives,” Baldwin wrote.

The letter comes the same week former VA nurse Beth Holtz was arrested on felony patient abuse charges for withholding oxygen from a hospice patient while working at the facility in August 2025.

According to the criminal complaint from the Monroe County district attorney, the 75-year-old patient had pulmonary fibrosis and required a continuous supply of oxygen.

Holtz told VA police at the time of the incident that she removed the patient’s oxygen because he was agitated by the mask, and she thought he was close to dying, according to the complaint.

But investigators reported that another staff member claimed Holtz said she hoped the patient would pass during her shift because recording his death in medical records would be easier than recording a fall he had earlier that day.

The complaint states that the patient was without oxygen for approximately an hour and a half on Aug. 17, 2025 and died six days later. The district attorney has accused Holtz of trying to hasten the patient’s death.

Baldwin said in the letter that the charges “raise serious questions” about the care of hospice patients and the VA’s response to the incident last year. The senator called for the VA to provide “a full accounting” of the department’s actions, including immediate steps taken to protect other patients and any reviews conducted after the incident.

Baldwin pointed out that inadequate care leading to patient harm has previously been discovered at the Tomah VA Medical Center.

Marine Corps veteran Jason Simcakoski died in 2014 after being overprescribed medications while receiving psychiatric treatment at the Tomah VA. His death revealed a culture of VA providers prescribing high levels of opioids and creating a culture of fear among facility staff.

“The Tomah VA and the veterans it serves have spent years working to rectify and recover from the serious failures uncovered at the facility more than a decade ago,” Baldwin wrote. “VA employees, veterans and the surrounding community worked hard to improve care, strengthen accountability and rebuild trust. We cannot allow serious patient safety or management problems to take root again or allow that hard earned trust to erode.”

The Tomah VA Medical Center did not immediately respond to WPR’s request for comment.

In early 2025, the Trump administration announced it was on track to reduce VA staff by 30,000 positions nationally. In a May visit to Wisconsin, Collins said facilities were not under a hiring freeze for needed positions.

Baldwin calls for investigation into Tomah VA after hospice nurse faces patient abuse charges was originally published by Wisconsin Public Radio.