Maplewood, NJ

Winchester Gardens Health Care Center

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

333 Elmwood Avenue, Maplewood, NJ

(973) 762-5050

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Springpoint Senior Living

Operator or chain grouping

Approved since

2018-05-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.86

Registered nurse staffing

LPN hours / resident day

1.26

Licensed practical nurse staffing

Aide hours / resident day

2.45

Nurse aide staffing

Weekend hours

5.15

Weekend nurse staffing

RN turnover

46%

Annual RN turnover

Total nurse turnover

32%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	93.0% 7 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	2.4% 2.4 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.0%	11.4% 11.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	2.4%	4.6% 2.2 pts better	5.4% 3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	7.1%	19.0% 11.9 pts better	19.6% 12.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	0.0%	13.5% 13.5 pts better	16.7% 16.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	38.2%	9.8% 28.4 pts worse	16.3% 21.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	37.5%	9.7% 27.8 pts worse	14.9% 22.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.7% 0.7 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	1.9%	0.8% 1.1 pts worse	1.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	1.9%	15.9% 14 pts better	19.8% 17.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	2.3%	6.0% 3.7 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.7%	78.7% 20 pts better	81.7% 17 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	4.2%	8.2% 4 pts better	12.0% 7.8 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.3%	1.2% 0.1 pts worse	1.6% 0.3 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.2%	80.1% 17.1 pts better	79.7% 17.5 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	17.0%	25.4% 8.4 pts better	23.9% 6.9 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-05 · Fire 2025-09-05

4 health deficiencies

Top issue: Infection Control (1 deficiency)

11 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-05-31 · Fire 2024-05-31

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-10-04 · Fire 2022-10-04

3 health deficiencies

Top issue: Resident Rights (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-05

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-12-02

F · Potential for more than minimal harm 2025-09-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2026-01-19

F · Potential for more than minimal harm 2025-09-05

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-10-31

F · Potential for more than minimal harm 2025-09-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-05

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-10-31

F · Potential for more than minimal harm 2024-05-31

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-07-22

F · Potential for more than minimal harm 2024-05-31

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-07-22

F · Potential for more than minimal harm 2024-05-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-22

F · Potential for more than minimal harm 2024-05-31

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-07-22

F · Potential for more than minimal harm 2024-05-31

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-07-22

F · Potential for more than minimal harm 2022-10-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-11-30

F · Potential for more than minimal harm 2022-10-04

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-11-30

F · Potential for more than minimal harm 2022-10-04

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-01-04

F · Potential for more than minimal harm 2022-10-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-30

F · Potential for more than minimal harm 2022-10-04

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2022-11-30

E · Potential for more than minimal harm 2022-10-04

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-11-30

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-05

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-05

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-05

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2025-10-31

D · Potential for more than minimal harm 2025-09-05

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-10-31

F · Potential for more than minimal harm 2024-05-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-22

E · Potential for more than minimal harm 2024-05-31

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-07-22

D · Potential for more than minimal harm 2024-05-31

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-07-22

F · Potential for more than minimal harm 2022-10-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-11-30

D · Potential for more than minimal harm 2022-10-04

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-11-30

D · Potential for more than minimal harm 2022-10-04