Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 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.
Meals were served below the required hot-food temperature on one unit when the surveyor observed lunch delivery and measured tray items after service. The garlic chicken, sweet potato, and broccoli were all below the 135 F threshold in the facility’s food temperature policy, and the FSD agreed they were not in range for serving temperature.
Missing Annual CNA Performance Evaluations: The facility failed to complete annual performance evaluations for all 5 CNAs whose personnel files were reviewed. The LNHA and DON confirmed the missing evaluations, and the DON stated that annual evaluations are used to identify strengths, weaknesses, and whether additional education or training is needed. The facility policy required formal written evaluations annually and forwarding the original tools to HR for filing.
Physician progress notes were not readily available in the resident charts for multiple residents. Surveyors found that only APN notes were present in the HMRs, while the attending physician’s PPN were kept in a different system and had not been sent to the facility in a timely manner. Residents interviewed could not consistently recall seeing the physician, and records showed a mix of diagnoses and cognitive levels, including dementia, COPD, CKD, and respiratory failure.
CNA in-service records showed that five CNAs each had less than the required 12 hours of annual training, and none of the files included dementia training. The LNHA and DON both confirmed the missing training, and the facility policy required at least 12 hours of annual in-service education, including dementia management and care of the cognitively impaired.
Surveyors observed a strong urine odor in one resident room on the West Unit and a heavily soiled toilet and bathroom floor with a strong urine odor in one resident room on the Secured Unit. The HK on the West Unit acknowledged the odor and said the room always smells like that, while the DHK confirmed the room had not been cleaned properly and did not provide a clean, homelike environment. In the Secured Unit room, the HK said, "Maybe I just gave it a quick clean," and the DHK confirmed the bathroom had not been adequately cleaned.
A facility failed to include comprehensive care plan interventions for two residents receiving ongoing treatments. One resident reported constant back pain and was ordered a Lidocaine patch for pain, but no pain care plan was documented. Another resident was receiving O2 via NC at 2 L/min for respiratory failure, but no oxygen care plan was documented. Facility policy stated that pain management and oxygen therapy interventions were to be incorporated into the care plan.
A resident with Alzheimer’s disease and DM was observed lying on a specialty air mattress set to 260 lbs, while the resident’s documented weight was 179 lbs. The record also showed no care plan or MD order for the low-air-loss mattress. An LPN acknowledged the setting was incorrect, and the RN supervisor confirmed the mattress gauge should be set to the resident’s weight and that an MD order should be in place.
A resident with a left chest CVC, severe cognitive impairment, and psoas/renal abscesses had empty IV antibiotic tubing left undated, uncapped, and open to air on repeated observations. The IP and an LPN acknowledged the tubing should have been dated and capped. Record review also showed the IPCP was not updated for the resident’s new diagnosis, ongoing IV antibiotic treatment, repeated readmissions, or the CVC infusion site, despite orders and notes documenting continued IV therapy.
An LPN and an AA were observed failing to follow hand hygiene procedures during meal service, including not lathering soap before rinsing, turning off the faucet with bare hands, touching a surgical mask and other surfaces, and assisting residents with meals without performing hand hygiene between tasks. The facility’s policy required hands to be lathered outside running water, rubbed vigorously, dried with a disposable towel, and the faucet turned off with a towel.
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.
Meals Served Below Required Temperature
Penalty
Summary
The facility failed to ensure meals were served at a palatable temperature on 1 of 2 units reviewed for food temperatures. During observation on 5/7/26, the surveyor calibrated a state-issued digital thermometer to 32 degrees Fahrenheit using the ice bath method in the presence of the Food Service Director (FSD). The surveyor and FSD then observed the food truck arrive on the 1st floor unit and saw the first lunch tray served at 11:36 AM. A test tray of regular diet and pureed consistency was identified and removed from the food truck by the FSD and placed on top of the food cart. After the last meal tray was delivered, the surveyor took temperatures of items on the tray in the presence of the FSD. The garlic chicken measured 131.3 F, sweet potato 123.1 F, broccoli 130.3 F, milk 42.8 F, coffee 159 F, and apple juice 43.2 F. At 11:48 AM, the FSD agreed that the garlic chicken, sweet potato, and broccoli were not in range for serving temperature. The facility policy provided on 5/11/26 stated that all hot food items must be held and served at a temperature of at least 135 F, and the LNHA, DON, and VPO acknowledged the food temperatures were under that threshold.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for all Certified Nursing Assistants (CNAs). Review of personnel records for 5 of 5 CNAs showed no evidence of completed annual performance evaluations for CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5. The records reviewed included CNAs with dates of hire of 5/1/2008, 8/12/24, 4/6/18, 5/6/25, and 12/20/21, respectively. During interviews on 5/12/26, the LNHA confirmed that the CNAs had not received annual performance evaluations, and the DON also confirmed the absence of these evaluations. The DON stated that annual performance evaluations were important for identifying strengths and areas of weakness and for determining whether additional education or training was needed. The Director of Human Resources stated that she had not been involved in overseeing the annual performance evaluations. The facility’s Evaluation Process policy dated 3/2026 stated that employee work performance is to be reviewed with a formal written evaluation annually and that original evaluation tools are to be forwarded to Human Resources for processing and placement in the personnel file.
Physician Progress Notes Not Readily Available
Penalty
Summary
The facility failed to have readily accessible physician progress notes (PPN) for multiple residents whose records were reviewed. During observation, interview, and record review, the surveyor found that Resident #8, #9, #10, #35, #50, #68, and #88 did not have available PPN from the attending physician in their hybrid medical records. In each reviewed record, the only progress notes available were written by the APN, while the physician’s notes were not present in the facility chart. Resident interviews showed that several residents could not recall when they had last seen the physician, and one resident stated they were not sure who the physician was in the facility. The reviewed records showed a range of diagnoses and cognitive status, including Alzheimer’s disease, vascular dementia, depression disorder, bipolar disorder, anxiety, pulmonary fibrosis, chronic kidney disease, COPD, dysphagia, multiple sclerosis, and respiratory failure. The MDS assessments reflected varying cognition, including severe cognitive impairment, moderate cognitive function, and intact cognitive function. On interview, an LPN stated the physician completed notes in a different charting system than the facility staff used, and that the APN’s notes were available daily. The LNHA stated the physician dictated PPN into the consulting company’s system and that the notes should be sent to the facility and uploaded by Medical Records, but that the physician had not been sending the notes in a timely fashion. The facility policy stated physician progress notes are maintained for each resident and must be written, signed, and dated upon each visit.
CNA In-Service Training Deficiencies
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training and failed to include dementia training in the in-service education. On 5/11/26 at 9:00 AM, the surveyor reviewed in-service education records for five randomly selected CNA files and found that CNA #1 had 10.5 hours of in-service training, CNA #2 had 10.5 hours, CNA #3 had 9 hours, CNA #4 had 10.5 hours, and CNA #5 had 11 hours. None of the five files included dementia in-service training. On 5/12/26, the LNHA confirmed that the CNAs had not received the required 12 hours of education and had not received the mandatory dementia in-service. Later that day, the DON also confirmed that the CNAs had not received their required 12 hours of mandatory in-services. The facility policy titled Required Training, Certification and Continuing Education of Nurse Aides, dated 4/2026, stated that the facility would provide at least 12 hours of in-service training annually based on the employment date and that minimum training would include dementia management and care of the cognitively impaired.
Unsanitary Resident Rooms and Persistent Urine Odors
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms on the West Unit and Secured Unit. Surveyors observed a strong malodorous urine odor in one room on the West Unit on three consecutive days. In another room on the Secured Unit, surveyors observed a heavily soiled bathroom toilet and floor along with a strong malodorous urine odor on three consecutive days. During interviews, the Housekeeper assigned to the West Unit acknowledged the urine odor and stated the room had been cleaned on the observed dates but that it always smells like that. The Director of Housekeeping confirmed the odor, stated the room had been placed on high alert for more frequent cleaning, and did not respond when asked whether the room had been cleaned appropriately. When the surveyor and DHK entered the room, the DHK acknowledged the strong urine odor and that the toilet and bathroom floor were soiled, confirming the room had not been cleaned properly and did not provide a clean, homelike environment. In the Secured Unit room, the assigned Housekeeper stated the room had already been cleaned, but after the surveyor and DHK pointed out the bathroom concerns, the Housekeeper said, "Maybe I just gave it a quick clean." The DHK confirmed the bathroom had not been adequately cleaned and acknowledged the condition did not provide the resident with a clean, homelike environment.
Missing Care Plans for Pain Medication and Oxygen Therapy
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for two residents who were receiving ongoing treatments. One resident was interviewed and reported constant back pain and stated that a daily pain patch helped with the discomfort. Record review showed diagnoses including abnormalities of gait and mobility, disorder of bone density and structure, and pulmonary fibrosis. The physician ordered Lidocaine Patch 4% to the lower back and left knee once daily for pain, but the resident’s care plan report did not include a care plan for pain or use of pain medication. A second resident was observed in bed with eyes closed while receiving oxygen via nasal cannula at 2 liters per minute. Record review showed diagnoses including acute and chronic respiratory failure with hypercapnia and hypoxia, and the MDS indicated the resident received oxygen and had intact cognition. The physician ordered oxygen continuously at 2 liters per minute via nasal cannula, but the resident’s care plan report did not include a care plan for oxygen. Facility policy stated that pain management interventions and oxygen therapy interventions were to be incorporated into the comprehensive care plan, and the LNHA, DON, and VPO acknowledged that residents receiving pain medication and oxygen therapy should have a care plan initiated.
Low-Air-Loss Mattress Set Incorrectly
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient when the facility failed to ensure a specialty low air loss mattress was accurately set and monitored according to the resident’s weight for one resident. The resident was observed in bed lying on an air mattress that was set to 260 lbs, while the resident’s most recent documented weight was 179 lbs. The resident had diagnoses including Alzheimer’s disease and diabetes mellitus, and the Quarterly MDS indicated severe cognitive impairment and that the resident was receiving a pressure-reducing device for the bed. Record review showed no care plan for the use of a low-air-loss mattress and no physician order for the mattress. During the survey, the LPN acknowledged the mattress setting was 260 lbs and stated the pump was supposed to be set to the resident’s weight; after reviewing the weight in the eMAR, the LPN stated the mattress should have been set properly. The RN supervisor confirmed that the specialty mattress gauge should be set to the resident’s weight and that there should be a physician order for the low air loss mattress. The facility policy stated that powered support surfaces requiring air are to be checked each shift and when necessary for proper functioning and inflation.
IV Tubing Left Open to Air and Care Plan Not Updated for New Diagnosis
Penalty
Summary
Failure to provide safe, appropriate administration of IV fluids was identified for a resident with a left chest central venous catheter (CVC) who had severe cognitive impairment, metabolic encephalopathy, and psoas muscle abscesses. On multiple observations, the resident’s infusion pole had an empty bag of Zosyn with IV administration tubing draped over the pole, undated, uncapped, and with the Luer lock collar exposed and open to air. The surveyor observed the same condition on more than one occasion, and the infection preventionist and unit manager acknowledged that the tubing should have been labeled with a date and nursing initials and that the Luer lock should have been capped. Record review showed the resident was admitted with diagnoses including metabolic encephalopathy and psoas muscle abscess, and the most recent MDS indicated a BIMS score of 00 and that the resident had a left CVC and was receiving antibiotics. The infectious disease progress note stated the resident had right psoas and renal abscesses and was to continue IV antibiotics every 6 hours with no end date until the abscesses were resolved on MRI. The order summary included CVC dressing change orders, and the MAR and TAR documented repeated Zosyn therapy and CVC-related care orders, including a requirement to cap the end with a green cap at all times. The IPCP was not updated to reflect the resident’s new diagnosis, treatment plan, and significant changes. The care plan continued to focus on renal and perinephric abscess and return on antibiotic, but it was not updated after multiple readmissions or to include the CVC access and the most recent diagnosis of psoas abscess and CVC in the left chest wall. The DON stated the IPCP should have been updated with a new focus to include the new diagnosis and new infusion site, and the facility’s policies stated IV tubing should be dated, capped when disconnected, and changed every 24 hours, and that care plans should be reviewed and revised as necessary with new or modified interventions.
Hand Hygiene Failures During Meal Service
Penalty
Summary
The facility failed to follow CDC hand hygiene guidance during meal service in the west unit dining room. On 05/05/26, an LPN was observed performing hand hygiene by applying soap and immediately placing her hands under running water without first lathering, then turning off the faucet with bare hands. Afterward, she touched her surgical mask several times and assisted an unsampled resident with a meal without performing hand hygiene again. Later that same meal service, the LPN removed the lid from a garbage can, discarded trash, replaced the lid, and then assisted a resident with a meal without hand hygiene. The LPN also handed a taco directly to a resident without prior hand hygiene. On 05/06/26, the LPN was again observed serving and setting up residents, touching silverware, and touching her mask between residents without observed hand hygiene. During the same period, an AA was observed performing hand hygiene by turning on the faucet, applying soap, and immediately placing her hands under running water without first lathering, then turning off the faucet with bare hands. The facility’s handwashing policy stated that personnel are to wet hands first, rub vigorously for at least 15 seconds, rinse, dry with a disposable towel, and use a towel to turn off the faucet. The ADON acknowledged the infection control breaches observed the prior day and stated she had spoken with the LPN about the concerns.
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 | ★★★★★ | 28 | 0 |
| Clover Rest Home | 10 mi | ★★★★★ | 0 | 0 |
| Slate Belt Health & Rehabilitation Center | 12.2 mi | ★★★★★ | 6 | 0 |
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