Healthcare Facility Inspection of the VA New Jersey Healthcare System in East Orange

VA Office of Inspector General · Report 25-00242-195 · September 25, 2026 · Office of Healthcare Inspections

What the OIG found

The OIG performed a focused inspection of the VA New Jersey Healthcare System in East Orange, evaluating culture, environment of care, patient safety, integrated veteran care, and the veteran-centered safety net. Issues requiring correction appeared in two domains, environment of care and patient safety, and produced the largest recommendation set in this group of inspections. The OIG made 11 recommendations, addressing safety and cleanliness, airflow testing in supply rooms, temperature and humidity monitoring, fire doors and fire safety inspections, sprinkler system testing, and prevention of repeat findings, as well as service-level workflows for communicating test results, follow-through on root cause analysis improvement actions, and handling of adverse events and institutional disclosures.

Who it concerns

VA New Jersey Healthcare System in East Orange, New Jersey

Why it matters to a family

This report touches two things families depend on: that the building itself is fire-safe, and that if something goes wrong in a veteran’s care, the facility follows through — including how adverse events are disclosed.

The official report

The OIG’s report page · Full report (PDF)

Summary ours; the report is the OIG’s. Read it at vaoig.gov →