Warren Haven Rehab and Nursing Center

In the surveyor’s words

From the most serious findings on record at Warren Haven Rehab and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 25, 2023

  Based 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. […]

• Actual harm, patternF689Jul 18, 2022

  Based on observation, interview, and record review, it was determined that the facility failed to provide adequate monitoring and supervision to prevent falls with injury, as well as failed to revise, reassess, and reevaluate for appropriate interventions to the care plan (CP) for a resident with a high risk for falls who sustained multiple falls with injuries. This deficient practice was identified for 1 of 4 residents (Resident #35) reviewed for falls, and for 8 out of 10 falls from 5/12/22-7/8/22, which resulted in multiple injuries that included the comminuted fracture of the right mandibular (chin) condyle with a dislocation of the right temporo-mandibular joint requiring hospitalization . […]

• No harm, potential for more than minimal, widespreadF804May 12, 2026

  Complaint 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. […]

• No harm, potential for more than minimal, widespreadF842Dec 24, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Dec 24, 2024

  Based 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. […]