Warren Haven Rehab: Unreported Fall, Window Exit - NJ
Both decisions were wrong. Both decisions were made by the same facility. And when inspectors arrived at Warren Haven Rehab and Nursing Center on April 24, 2026, the administrator was still defending them.
The administrator, identified in the inspection report only by title, told inspectors that Resident #1's fall had not been reported to the New Jersey Department of Health because the facility had been unable to get information from the hospital about the extent of the resident's injuries. That explanation does not appear anywhere in the facility's own written policies as a reason to skip mandatory reporting. The policies, reviewed by inspectors during the same visit, say a fall is any unintentional event where a resident comes to rest on the ground or another lower level, and that unless there is evidence suggesting otherwise, a resident found on the floor should be considered a fall.
There was no ambiguity about what happened. A registered nurse at the facility had already noted, in the course of the inspection, that the resident's condition could be a sign of a broken leg. The facility sent the resident to the hospital. And still, no report went to the state.
The window exit produced its own justification, one the administrator offered without apparent hesitation. The resident had not left the facility grounds, the administrator said, so it was not considered an elopement.
The facility's own elopement policy defines the event differently. Under that policy, an elopement occurs when a resident leaves the premises or a safe area without authorization and without the necessary supervision. Climbing out a window, without staff knowledge or permission, fits that definition on its face. The policy also states explicitly that appropriate reporting requirements to the state survey agency shall be conducted when a resident goes missing.
Warren Haven's policies were not old or outdated. Each one reviewed by inspectors carried an implementation date of May 2025 and a reviewed and revised date of April 2026, the same month as the inspection. The facility had looked at these policies within weeks of the incidents and still did not follow them.
The inspection was triggered by a complaint, not a routine survey cycle. Someone had raised a concern serious enough to bring inspectors to Oxford. What they found when they got there was an administrator who had constructed explanations for why two serious incidents involving the same resident did not require the state to be told anything at all.
The registered nurse's observation about the possible broken leg came up in the inspection record without elaboration. The report does not say whether the fracture was confirmed, what treatment the resident received, or how long the resident waited before being transported. What the report does say is that RN #1 recognized the sign, named it, and the facility's response was to wait for the hospital to call back rather than file a report.
Nursing homes in New Jersey are required under state regulation to notify appropriate agencies no later than two hours after discovering or forming a suspicion of certain incidents. That two-hour window is written into the facility's own compliance policy, which was reviewed and revised in April 2026. The administrator's explanation, that the facility was waiting on the hospital, describes a process that could take days. It does not describe a two-hour reporting window being met.
The elopement policy's reporting requirement is not conditional on how far a resident travels. It does not say report if the resident leaves the grounds, or report if the resident makes it to the street. The procedure for locating a missing resident concludes with a step requiring appropriate reporting to the state survey agency. A resident who exits through a window, without authorization and without supervision, has triggered that procedure regardless of whether they were found in the parking lot or three blocks away.
The administrator's reasoning, that proximity to the building negated the obligation to report, is not a legal standard. It is a judgment call that the facility made unilaterally, in its own favor, about an incident involving a vulnerable resident who left the building through a window.
Warren Haven's incident and accident policy is detailed. It defines an accident as any unexpected or unintentional incident that results or may result in injury or illness to a resident. It defines an incident as any occurrence not consistent with the routine care of a resident. It lists elopements and falls specifically as events requiring incident reports. It states that one purpose of incident reporting is to meet regulatory requirements for analysis and reporting. And it states that incidents rising to the level of neglect will be managed and reported according to the facility's abuse prevention policy.
The abuse and neglect reporting policy requires notification to appropriate agencies immediately, no later than two hours after discovery or suspicion. That policy also was reviewed and revised in April 2026.
The inspection report classifies the level of harm as minimal harm or potential for actual harm. That classification reflects the regulatory scale used by the Centers for Medicare and Medicaid Services, where findings are graded from no harm to immediate jeopardy. Minimal harm with potential for actual harm sits near the lower end of that scale, but the classification describes the harm to the resident, not the significance of the facility's conduct. A nursing home that decides on its own which incidents the state gets to know about, and constructs post-hoc rationales for those decisions, presents a compliance problem that the harm level alone does not fully capture.
What the report does not say is whether Resident #1 recovered. It does not say whether the leg was broken or bruised or something else. It does not say how long the resident was on the floor before being found, or how long it took to get to the hospital, or whether anyone at the facility felt the two-hour reporting clock ticking while they waited for a return call that apparently never came.
The administrator was still at the facility on the afternoon of April 24, still offering the same explanations, when inspectors wrapped up their interviews at 4:05 in the afternoon. Whether a report was ever filed, and what the state intends to do about the ones that weren't, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Warren Haven Rehab and Nursing Center from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Warren Haven Rehab and Nursing Center in OXFORD, NJ was cited for violations during a health inspection on April 24, 2026.
Both decisions were made by the same facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.