Warren Haven Rehab and Nursing Center

Inspectors wroteComplaint 2800212Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable temperature on 1 of 2 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 5/7/26 at 11:25 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Food Service Director (FSD). At 11:35 AM, the surveyor and FSD observed the food truck arrive on the 1st floor unit. The surveyor and FSD observed the first lunch tray being served at 11:36 AM. At that time a test tray of a regular diet and pureed consistency was identified by the surveyor and FSD, this tray was removed from the food truck and placed on top of the food cart by the FSD. After the last meal tray was delivered to a resident at 11: [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to conduct annual performance evaluations for all Certified Nursing Assistants (CNAs). This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following:1. Review of the personnel file for CNA #1, with a date of hire of 5/1/2008, revealed no evidence of a completed annual performance evaluation. 2. Review of the personnel file for CNA #2, with a date of hire of 8/12/24, revealed no evidence of a completed annual performance evaluation. 3. Review of the personnel file for CNA #3, with a date of hire 4/6/18, revealed no evidence of a completed annual performance evaluation. 4. Review of the personnel file for CNA #4, with a date of hire 5/6/25, revealed no evidence of a completed annual performance evaluation. 5. [...]

Inspectors wroteRepeat DeficiencyBased on observation, interview, record review and review of facility policy, it was determined that the facility failed to have readily accessible physician progress notes (PPN). This deficient practice was identified for 7 of 8 residents reviewed, (Resident #8, #9, #10, #35, #50, #68, and #88) and was evidenced by the following:1. On 5/5/26 at 10:32 AM, the surveyor observed and interviewed Resident #10 in the dayroom. Resident #10 stated they were not sure when they had seen the facility primary physician (PP#1). On 5/5/26 at 11:28 AM, the surveyor reviewed Resident #10's hybrid medical record (HMR) a combination of electronic and paper medical record. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required and failed to include Dementia training for the CNAs. This deficient practice was identified for 5 of 5 CNA files reviewed for in-service training and was evidenced by the following:On 5/11/26 at 9:00 AM, the surveyor reviewed in-service education hours for five randomly selected CNAs files provided by the facility. The surveyor reviewed the following:CNA #1 was hired on 5/1/2008, had a total of 10.5 hours of in-service training, and this training did not include Dementia in-service training. CNA #2 was hired on 8/12/24, had a total of 10.5 hours of in-service training, and this training did not include Dementia in-service training. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed in 2 resident rooms on 2 of 2 nursing units (West Unit and Secured Unit) and was evidenced by the following:On 5/526, 5/6/26, and 5/7/26, the surveyor observed in room [ROOM NUMBER] on the west nursing unit a strong malodorous urine odor. On 05/5/26, 5/6/26, and 5/7/26, the surveyor observed in room [ROOM NUMBER] in the secured nursing unit a heavily soiled bathroom toilet and floor, and a strong malodorous urine odor. On 5/7/26 at 9:43 AM, during an interview with the surveyor, Housekeeper (HK #1) assigned to the west nursing unit acknowledged the strong urine odor present in room [ROOM NUMBER]. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to implement a comprehensive person-centered care plans (CP) that included: pain medication and b. oxygen (O2). The deficient practice was identified for 2 of 3 residents (Resident #9 and #88) reviewed for care plans.1. On [DATE] at 10:43 AM, the surveyor interviewed Resident 9, who complained of constant back pain. Resident #9 furthered revealed they receive a daily pain patch, which helped with back discomfort. On [DATE] at 12:30 PM, the surveyor reviewed Resident #9's electronic medical record (e-MAR). A review of Resident #9's Face sheet (FS) (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a specialty low air loss mattress (a medical-grade mattress that uses continuous airflow to keep the skin dry, cool, and pressure-free, help that to prevent and treat pressure injuries) was accurately set and monitored according to the resident's weight for 1 of 6 residents (Resident #22). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) maintain intravenous (IV) administration tubing in accordance with infection prevention and professional standards of practice, and b) maintain an Individual Personalized Care Plan (IPCP) for new diagnosis, treatment plans and significant changes according to professional standards of practice for 1 of 18 residents reviewed. (Resident # 87). As evidenced by the following:On 5/5/26 at 10:17 AM, the surveyor observed Resident #87, with a left chest central venous catheter (CVC), (long, flexible tube inserted into a large vein (usually in the chest or neck), with a dressing dated 5/5/26. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to follow Center for Disease Control recommendations and guidelines for Hand Hygiene and minimize the potential spread of infection to residents during meal service for 2 of 4 staff members (Licensed Practical Nurse (LPN)) and (Activity Assistant (AA)) observed in 1 of 2 dining rooms (West Unit). This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. [...]

Inspectors wroteComplaint: 2989444 Based on interviews, record review, and review of other pertinent facility documents on 04/24/2026, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) the fall with injury and the elopement of a cognitively impaired resident (Resident #1). This deficient practice was identified for 1 of 4 residents reviewed for accident and incidents and was evidenced by the following:According to the admission Record, Resident #1 was admitted to the facility with diagnoses including but not limited to: follicular lymphoma (slow-growing cancer of lymph nodes, bone marrow and other organs); schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves), auditory hallucinations (hearing sounds, voices, or noises that are not present in reality). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to have physician progress notes (PPN) readily accessible in the facility. This deficient practice was identified for 7 of 12 residents reviewed, (Resident #207, #5, #48, #16, #21, #6, #45) and was evidenced by the following. 1. On 12/17/24 at 10:42 AM, the surveyor observed Resident #207 in the dayroom watching television. The resident stated to the surveyor they have seen their primary physician (PP) a few times since their admission. A review of Resident #207's Face sheet (FS) (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis, type 2 diabetes, peripheral vascular disease, and heart failure. [...]

Inspectors wroteBased on observation, interview, record reviews, it was determined that the facility failed to follow a.) appropriate infection control practices for handling and storing clean clothes observed in the laundry room and b.) the policy and procedure of the facility's Water Management Program to prevent the growth of Legionella (a waterborne pathogen). This deficient practice was evidenced by the following: 1. On 12/19/24 at 9:35 AM, the surveyor together with the facility's Infection Preventionist (IP) toured the laundry room. The surveyor observed a rack of hangers of clothes covered with a clean blanket touching the laundry room floor. The surveyor interviewed the Housekeeping Manager (HM) who stated those clothes clean. The HM also stated the clothes were washed and brought to the residents who would need them. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included anti-anxiety medication. This deficient practice was identified for 1 of 12 residents (Resident #6) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 12/17/24 at 10:10 AM, the surveyor observed Resident #6 seated in their wheelchair. On 12/19/24 at 12:03 PM, the surveyor reviewed the hybrid (paper and electronic) medical records of Resident #6, which revealed the following: A review of the admission Record (an admission summary) reflected that Resident #6 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory). [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record to the facility staff and attending physician. This deficient practice was identified for one (1) of fourteen (14) residents reviewed, (Resident #40) for medication management and was evidenced by the following: On 12/18/24 at 11:45AM, the surveyor observed Resident #40 in the facility activity room. The resident was seated in a wheelchair and was observed coloring pictures. The surveyor reviewed Resident #40's medical records. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; [...]

Inspectors wroteBased on interview, record review and review of pertinent facility provided documents, it was determined that the facility failed to rule out abuse for an injury of unknown origin and an allegation of sexual abuse, for 1 of 2 residents reviewed for reportable events (Resident #29). Resident #29 had diagnoses which included but were not limited to; Dementia, major depressive disorder, anxiety, and paroxysmal atrial fibrillation (irregular heartbeat). A review of an Accident/Incident report, signed by a Licensed Practical Nurse (LPN), dated 01/26/23, revealed a right-hand bruise with no indication of the origin or if the bruise had been witnessed or unwitnessed. Further review of the Accident/Incident report revealed an attached Investigation/Witness Statement dated 01/24/23 at 6:45 PM, which included that the resident .was in bed [Resident #29] was screaming rape . [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 2 residents, (Resident #49, Resident #50) reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: 1. On 09/06/23 at 10:22 AM, the surveyor toured the East Unit of the facility and observed Resident #49 in bed. A strong foul urine odor permeated as the surveyor approached the resident's bed. On 09/06/23 at 10:35 AM, the surveyor exited the room and while in the hallway heard an alarm sounding. The surveyor returned to the room and observed the resident was now out of the bed and was wearing a blue incontinent brief that was observed bulging in the rear. [...]

Inspectors wroteRepeat Deficiency Based on observation, interviews, record and review of other pertinent facility documentation, it was determined that the facility failed to: a.) ensure that a cognitively impaired resident admitted with a known history of falls was appropriately supervised and/ or monitored to prevent falls including falls with injury on 08/27/23 when Resident #50 had an unwitnessed fall and sustained front forehead wound and lump measuring 1.5 centimeter x 1.3 and 0.1., and b.) follow fall prevention interventions per the Care Plan, and ensure that assistive devices to alert staff of falls were functional. This deficient practice was identified for 2 of 3 residents reviewed for incident/ accidents (Resident #49 and #50) and was evidenced by the following: On 09/06/23 at 10:22 AM, the surveyor observed Resident #49 in bed, and a strong odor of urine permeated the room. [...]

Inspectors wroteComplaint # NJ 165178 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to: a) provide supervision for resident's who were at risk for falls, who sustained multiple unwitnessed falls, b) consistently provide resident's with assistance to get out of bed, and c) provide appropriate incontinence care. The deficient practice occurred on two of two resident units and was evidenced by the following: Refer to 689E Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. [...]

Inspectors wroteBased on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 2 of 2 sampled residents (Resident # 29 and #50) reviewed for injuries of unknown origin. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #50 was admitted to the facility with diagnoses which included but were not limited to; Neurocognitive disorder with Lewy Bodies (chemical deposits in the brain that can affect thinking), Parkinson's disease, and malignant neoplasm of tonsillar pillar. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an injury of unknown origin and an allegation of rape. This deficient practice was identified for 2 of 2 residents (Resident #29 and #50) reviewed for accidents and incidents. The deficient practice was evidenced by the following: 1. According to the medical records, Resident #50 was admitted with diagnoses which included but were not limited to; Parkinson's disease and neurocognitive disorder. A review of the Care Plan (CP) revealed a focus area of impaired cognitive function related to neurocognitive disorder. Another focus area of at risk for falls related to Parkinson's Disease. A review of a facility provided, Resident Accident/Incident Report dated 10/24/22 at 10:30 AM, included but was not limited to; Description and facts of even: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a.) follow acceptable standards of clinical practice and inform the physician that Resident #28 had been refusing Insulin (a medication to control blood sugar), and b.) ensure the accuracy of physician orders for Resident #44. This deficient practice was identified for 2 of 6 residents reviewed during the medication pass observation and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; [...]