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)
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
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
30
Certified beds
Average residents
24
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
Chain footprint
8 facilities
Chain averages 4 overall / 3 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.86
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
5.57
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
3.12
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
5.15
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
1.37
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.85
CMS adjusted RN staffing hours
Adjusted total hours
5.52
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.73% · Performance 22.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.48% · Performance 8.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.46
Baseline 48.72% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9
Adjusted total nurse staffing
4.89
Performance 4.47 hours · Measure score 4.89 · Achievement 4.89 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 4.76% · Lower 95% interval 6.36% |
| Discharge to community | 64.13% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 133 · Observed rate 60.15% · Lower 95% interval 55.88% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 30 · Denominator 65 |
| Discharge mobility score | 73.85% |
50.94%
22.9 pts better
|
Numerator 48 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 74 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 9.64% · Lower 95% interval 5.28% |
| Staff COVID-19 vaccination coverage | 1.61% |
8.2%
6.6 pts worse
|
Numerator 1 · Denominator 62 |
| Staff flu vaccination coverage | 97.96% |
42%
56 pts better
|
Numerator 48 · Denominator 49 |
| Discharge function score | 56.92% |
56.45%
0.5 pts better
|
Numerator 37 · Denominator 65 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 54 · Denominator 54 |
| Resident COVID-19 vaccinations up to date | 54.29% |
25.2%
29.1 pts better
|
Numerator 19 · Denominator 35 |
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 · 4Q avg 100.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 2.4% |
| 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 · 4Q avg 7.1% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 38.2% · Used in QM five-star |
| 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 · 4Q avg 37.5% · Used in QM five-star |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 1.9% |
| 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 · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 98.4% · Q2 98.6% · Q3 98.8% · Q4 98.9% · 4Q avg 98.7% |
| 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 · Adjusted 4.2% · Observed 3.6% · Expected 9.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.9% · Q3 1.5% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| 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 · 4Q avg 97.2% |
| 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 · Adjusted 17.0% · Observed 14.3% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
Ownership
Argondizza, Anthony
Operational/Managerial Control · Individual
Argondizza, Anthony
Corporate Officer · Individual
Kopec, Marybeth
Operational/Managerial Control · Individual
Midgett, Garrett
Operational/Managerial Control · Individual
Midgett, Garrett
Corporate Officer · Individual
Springpoint Senior Living Inc
Operational/Managerial Control · Organization
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#3
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