New Jersey Veterans Memorial Vineland

In the surveyor’s words

From the most serious findings on record at New Jersey Veterans Memorial Vineland, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Dec 18, 2025

  Incident 2684633Based on interviews, review of the medical records, and review of other pertinent facility documentation, it was determined that the facility failed to properly administer tube feeding as ordered, and to monitor a severely cognitively impaired resident (Resident #2) on tube feeding; which caused the resident to receive 800 milliliters (ml) of tube feeding in 4 hours instead of the physician ordered 60ml per hour (which should be 240 ml in 4 hours). Nursing staff found Resident #2 with symptoms of respiratory distress on [DATE] at approximately 10:30 PM., and their oxygen saturation (the amount of oxygen circulating in the blood) reading at 63% (healthy levels 95 - 100%) on room air. At that time, the facility called 911 emergency to transport Resident #2 to the hospital. […]

• No harm, potential for more than minimal, widespreadF812Aug 30, 2024

  Based on observation, interview, and document review, it was determined that the facility failed to consistently handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/19/2024 from 9:21 to 10:21 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following during the initial kitchen tour: 1. In the dry storage area, on the canned food rack, there was a dented 6-pound 10 oz can of tomato puree and a dented 46 fluid oz can of pineapple juice. There was a bin labeled dented cans in front of the canned food racks. The FSD stated that the expectation was that staff should have observed that cans were dented before putting it on the shelf. […]

• No harm, potential for more than minimal, patternF657Jan 7, 2023

  Based on record review, interviews, and facility policy review, the facility failed to ensure: 1. one resident (Residents (R) R82) and/or their representative out of a survey sample of 34 was invited to participate in their quarterly care plan meetings; and 2. the care plan policy included inviting residents/representatives to quarterly care plan meetings. This failure would affect all residents and/or representatives who are scheduled for quarterly care plan meetings. Findings include: Review of a document provided by the facility titled Resident Face Sheet, indicated R82 was admitted to the facility on [DATE] with a diagnosis of dementia. […]

• No harm, potential for more than minimal, patternF803Jan 7, 2023

  Based on resident council interview, staff interview, and record review, the facility failed to obtain food preferences and provide menus for meal selection for five residents (Resident (R)185, R113, R68, R8, and R101) out of nine residents reviewed for food preferences in a total sample of 34 residents. These deficient practices resulted in the residents who prefer to eat in their rooms instead of the dining room not having the opportunity to choose foods from the menu but instead received the main course. Findings include: On 01/03/23 at 10:43 AM, R185 stated he has mentioned to the dietary department during food committee meetings that residents who prefer to eat in their rooms instead of the dining room do not choose other menu options. […]

• No harm, potential for more than minimal, patternF883Jan 7, 2023

  Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one (Resident (R) 82) of five residents (and/or their representatives) reviewed for flu/pneumonia vaccinations in a total sample of 34 residents, the opportunity to be vaccinated with the Prevnar (PVC20) in accordance with nationally recognized standards. The facility failed to update their most current policies to reflect current standards on pneumococcal vaccinations. This practice had the potential to increase the risk for residents over [AGE] years of age and/or with immunocompromising conditions who had not been vaccinated per CDC guidelines to contract pneumonia. […]