Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Haven Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
The facility failed to maintain physician progress notes (PPN) for several residents, as observed during a survey. The primary physician kept PPNs in a separate electronic system inaccessible to the facility's staff, resulting in a lack of documentation in the residents' hybrid medical records. Despite regular visits by the physician, the absence of PPNs in the physical charts was confirmed by the RN/UM, and the facility's policy on maintaining these notes was not followed.
The facility failed to follow infection control practices in the laundry room, where clean clothes were found touching the floor. Additionally, the facility did not adhere to its Water Management Program policy, lacking records and a plan to prevent Legionella growth. The facility monitored chlorine and coliform levels but did not document monitoring for waterborne pathogens.
A facility failed to include anti-anxiety medication in a resident's care plan, despite the resident having a physician's order for Lorazepam due to increased shortness of breath. The resident, with severely impaired cognition, was administered the medication on two occasions, but this was not reflected in their care plan. Interviews with staff confirmed the oversight, and the facility's policy required such integration in the care plan.
A facility failed to ensure a CP identified and reported a medication administration irregularity for a resident with severe cognitive impairment. The resident, on an NPO diet and receiving medications via a g-tube, had a physician's order for Donepezil to be administered orally. The CP did not report this discrepancy, contrary to facility policy.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Deficiency in Maintaining Physician Progress Notes
Penalty
Summary
The facility failed to maintain physician progress notes (PPN) in accordance with accepted professional standards, as observed during a survey. This deficiency was identified for seven residents, where the surveyor could not find any PPN documentation in the hybrid medical records (HMR) for these residents. The residents involved had various medical conditions, including multiple sclerosis, type 2 diabetes, dementia, and heart failure, among others. Despite some residents being cognitively intact, they either could not recall their last visit with their primary physician or had no PPN documentation available. The surveyor's investigation revealed that the primary physician (PP) for all residents visited the facility regularly but maintained the PPNs in a separate electronic system inaccessible to the facility's staff. This lack of access meant that the nursing staff and other facility personnel could not review or utilize the PPNs for resident care management. The absence of PPNs in the residents' physical charts further compounded the issue, as confirmed by the Registered Nurse/Unit Manager (RN/UM). The facility's policy, as provided by the Director of Nursing (DON), stated that physician orders and progress notes should be maintained per OBRA regulations and facility policy. However, the surveyor found that this policy was not being followed, as evidenced by the lack of PPNs in the residents' records. The DON acknowledged awareness of the concern during a meeting with the survey team, but no additional information was provided to address the deficiency.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices in the laundry room, as observed by a surveyor and the facility's Infection Preventionist (IP). Clean clothes were found touching the laundry room floor, covered with a blanket, which the Housekeeping Manager (HM) confirmed were clean and intended for residents. The Director of Nursing (DON) acknowledged that these clothes were lost-and-found items and had been on the rack for 30 days. The facility's policy titled 'The Laundry Process' did not address the handling of clean clothes after washing, contributing to the deficiency. Additionally, the facility did not follow its Water Management Program policy to prevent the growth of Legionella. During the survey, the Licensed Nursing Home Administrator (LNHA) admitted that the facility lacked records for their water management and had no water management plan. Although the facility monitored chlorine and coliform levels, there was no documented evidence of monitoring for waterborne pathogens. The facility's policy, reviewed in November 2023, stated the need for water management plans to reduce the risk of legionellosis, but this was not implemented, leading to the deficiency.
Failure to Include Anti-Anxiety Medication in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was prescribed anti-anxiety medication. The deficiency was identified during a survey when it was observed that the resident's care plan did not include the use of Lorazepam, an anti-anxiety medication, despite the resident having a physician's order for it. The resident, who was admitted with unspecified dementia and had severely impaired cognition, was administered Lorazepam on two occasions due to increased shortness of breath, yet this was not reflected in their care plan. The surveyor's review of the resident's medical records, including the quarterly Minimum Data Set and hospice records, confirmed the absence of a care plan addressing the use of anti-anxiety medication. Interviews with facility staff, including an LPN and the hospice company's Clinical Director/RN, revealed that the care plan should have included the anti-anxiety medication. The facility's policy on hospice services also required that each resident's plan of care integrate hospice plans and describe services to maintain the resident's well-being, which was not adhered to in this case.
Failure to Identify and Report Medication Administration Irregularity
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in the medication administration for a resident with severe cognitive impairment. The resident, who was admitted with conditions including gastrostomy status, neurocognitive disorder with Lewy bodies, and dysphagia, had a physician's order for Donepezil to be administered orally. However, the resident was on an NPO diet and received medications via a gastrostomy tube. Despite this discrepancy, the CP's evaluation reports for November and December 2024 did not indicate any new medication recommendations or identify the administration route issue. During a review of the resident's physician's orders, the Registered Nurse/Unit Manager acknowledged the discrepancy in the administration route of Donepezil. The CP later confirmed that part of her review process included ensuring medications were administered via the correct route and admitted that the facility should have been notified about the discrepancy. The facility's policy required the CP to report such irregularities to the Director of Nursing and other relevant staff, but this was not done, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oxford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Manor Hcc | 7.5 mi | ★★★★★ | 0 | 0 |
| Heath Village | 7.6 mi | ★★★★★ | 8 | 0 |
| Little Brook Nursing And Convalescent Home | 8 mi | ★★★★★ | 0 | 0 |
| Clover Rest Home | 10 mi | ★★★★★ | 0 | 0 |
| Slate Belt Health & Rehabilitation Center | 12.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.