Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winchester Gardens Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain complete medical records for two residents. One resident with cognitive impairment, multiple fractures, and a high fall risk required substantial assistance with ADLs, yet there was no documentation that the private aide assigned to provide companionship was educated on the resident’s care needs or instructed not to provide hands-on care, even though the aide later reported independently assisting the resident after a fall. For another cognitively impaired resident with an indwelling Foley catheter, progress notes documented that the catheter had dislodged, but did not include any recorded vital signs or pain assessment at the time of the event, despite facility policies requiring complete documentation of services, changes in condition, and vital sign monitoring when clinically indicated.
Unsanitary Kitchen Equipment: The facility failed to keep kitchen equipment sanitary when a surveyor observed a thick black grease-like substance on 3 of 12 burner stoves in the food prep area. The residue was easily dislodged with the tip of a pen while the FSD was present.
A resident’s admission MDS was completed and signed, but the MDSC/RN did not transmit it within the required timeframe. The MDSC/RN later stated she thought it had been submitted, then confirmed it was late after providing the CMS validation report. The DON stated the facility follows the RAI manual.
A resident with dementia, severe cognitive impairment, and behavioral disturbance was receiving quetiapine, venlafaxine, and donepezil when the physician ordered a psych consult. The consult was not completed, and an LPN confirmed it had been recommended but not done; the DON stated the psychiatrist was on vacation. The facility’s behavioral management policy did not address dementia care for a resident on psychotropic medication.
Failure to Document COVID-19 Vaccine Offer and Education: A resident with hemiplegia following CVA and CKD, who was cognitively intact with a BIMS of 15, had no documentation in the EMR or hard chart showing that the COVID-19 vaccine was offered, administered, or refused, and no evidence that vaccine education was provided. The RN/UM and DON confirmed the missing documentation, and the resident’s care plan did not include any vaccination-related focus, goals, or interventions.
The facility failed to maintain proper kitchen sanitation and food storage practices, resulting in a repeat deficiency. Observations included unlabeled food items, improper use of hair and beard restraints by staff, and inadequate labeling of opened food items. The facility's policies were not followed, leading to these deficiencies.
The facility failed to maintain complete and accessible medical records for several residents, as physician progress notes were missing from their hybrid records. Despite having various medical conditions, the required documentation was not found, highlighting issues during the transition to an electronic medical record system. The facility's policy required documentation at each visit, but this was not adhered to, leading to the deficiency.
Expired medications, including Enteric Coated tablets and Bacitracin Ointment, were found in the medication room and treatment cart on the 4th floor. The deficiency was confirmed by an LPN, the Nursing Home Administrator, DON, and Assisted Living Coordinator, indicating non-compliance with NJAC 8:39-29.2 (d).
Incomplete Documentation of Private Aide Education and Foley Catheter Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation for two residents. For the first resident, who had multiple fractures, lack of coordination, cognitive impairment with a BIMS score of 9/15, and required substantial/maximal assistance with transfers, the facility allowed a private aide to be present without documented education on the resident’s care needs or limitations. The resident’s baseline care plan required one-person assistance for all ADLs, and the comprehensive care plan identified the resident as a fall risk with a prior fall and right shoulder fracture. On the night of the incident, the private aide reported to the RN that the resident fell at approximately 4:15 AM, was found standing at the foot of the bed, slid onto the floor mat, and was then picked up and placed back in bed by the aide without calling staff for assistance. Although nursing staff and the DON stated that private aides were verbally instructed not to provide hands-on care and to use the call bell for assistance, there was no documentation in the medical record that this private aide was educated on the resident’s required level of care or that the aide understood these instructions. For the second resident, who had encephalopathy, dementia with a BIMS score of 4/15, urinary retention, diarrhea, and Non-Hodgkin lymphoma, and who had an indwelling urinary catheter, the facility failed to document a complete assessment when the resident’s Foley catheter became dislodged. The resident’s care plan included monitoring vital signs, labs, and diagnostics as ordered by the physician. A change in condition progress note created by an RN documented that the Foley catheter had dislodged and that the physician was to be notified as necessary, but the note did not include any documentation that vital signs were taken or that pain was assessed at the time of the event. The DON later stated that when a Foley catheter becomes dislodged, the nurse should assess the site, obtain vital signs, and assess for pain, and that this information should be documented in the progress notes so that everyone is aware of the resident’s status. Additional facility policies required that private duty services support resident safety and community standards, and that all services provided to residents, including treatments, services performed, and changes in condition, be completely and accurately documented. The facility’s vital signs policy required that vital signs be taken at clinically appropriate intervals and when there were changes in a resident’s condition. Despite these policies, there was no documented evidence that the private aide for the first resident was educated on the resident’s care needs and restrictions, and there was no documentation in the second resident’s medical record that vital signs and pain were assessed and recorded when the Foley catheter became dislodged, even though an electronic communication later indicated that vital signs were at baseline and no signs of bleeding or trauma were observed. These omissions resulted in incomplete medical records for both residents.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and the potential for the development of a food borne illness. During an observation on 9/2/2025 at 10:00 AM with the Food Services Director present, the surveyor observed a thick black grease-like substance on 3 of the 12 burner stoves in the food preparation area. The residue was easily dislodged using the tip of a pen. The deficiency was identified as a repeat deficiency under NJAC 8:39-17.2(g).
Late Transmission of Admission MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) assessment in accordance with federal guidelines for one resident. During the review of resident assessment records, the surveyor identified that the resident’s admission MDS had an assessment reference date of 4/20/25 and was signed as completed on 4/22/25, but it was not transmitted until 9/3/25. The report states that the MDS is a federally mandated comprehensive assessment tool that must be electronically transmitted within 14 days of completion. On 9/3/25, the MDS Coordinator/Registered Nurse told the surveyor that she thought she had submitted the resident’s admission MDS in April, but later acknowledged that it had not been submitted on time. On 9/4/25, she provided a CMS final validation report confirming the assessment was transmitted late. The surveyor also met with the LNHA and DON regarding the concern, and the DON stated that they follow the RAI manual.
Failure to Complete Ordered Psych Consult for Resident With Dementia
Penalty
Summary
The facility failed to follow up on a psychiatry consult that had been ordered by the physician for a resident with dementia and behavioral disturbance who was receiving antipsychotic medication. The resident was admitted with unspecified dementia, severe cognitive impairment, and behavioral disturbance, and the admission MDS showed a BIMS score of 6 out of 15. The resident was also receiving quetiapine for behavior disturbance, venlafaxine for depression, and donepezil for dementia, and the MDS indicated use of antipsychotic and antidepressant medications. The medical record showed a telephone order on 7/10/25 for a psych consult for the resident while on quetiapine, divalproex, Aricept, and Effexor, and physician progress notes documented dementia care as part of the plan. During interview, an LPN stated the psych consult had been recommended but was not done, and the DON stated the psychiatrist was on vacation, which was why it was not completed. The facility policy provided, titled Behavioral Management, did not address dementia care for a resident receiving psychotropic medication, and the DON stated no other policy for dementia care or psychotropic use was available.
Failure to Document COVID-19 Vaccine Offer and Education
Penalty
Summary
The facility failed to offer a resident a COVID-19 immunization and failed to provide documentation of education regarding the vaccine for Resident #12. The resident’s record showed diagnoses including hemiplegia following cerebral infarction affecting the right dominant side and chronic kidney disease. The comprehensive MDS dated 8/25/25 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The resident’s active care plan did not include any focus, goals, or interventions for vaccinations, and the electronic medical record did not contain a COVID-19 immunization administration record. Survey review and staff interviews confirmed that the resident’s chart did not reflect that the COVID-19 immunization was offered, administered, or refused, and there was no evidence that education was provided. The RN/UM stated that admission staff recorded historical vaccination information through resident interview, family interview, or prior medical records, but the surveyor and RN/UM found no documentation in the medical record showing the vaccine was offered or that education was provided. The DON also confirmed the absence of documentation. The facility policy for immunization, revised on 9/4/25, stated that residents would receive education regarding immunization benefits before being offered the vaccine and that refusal would be documented in the resident’s medical record.
Repeat Deficiency in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store potentially hazardous foods correctly, leading to a repeat deficiency. During the survey, it was observed that items in a staff refrigerator were not labeled with names and dates as required. In the kitchen, several staff members were not wearing hair and beard restraints properly, and opened food items in refrigerators and freezers were missing labels indicating open and use-by dates. The Executive Chef acknowledged these issues, including the improper handling of opened juices and the lack of gloves worn by servers while preparing food. Additional observations included wet nesting of dishes in the dishwashing area, unclean fans in the walk-in refrigerator, and frost build-up in the walk-in freezer with food stored too close to the ceiling. The facility's policies, which were provided to the surveyor, clearly outlined the requirements for labeling, dating, and discarding food items, as well as dress code guidelines for kitchen staff. Despite these policies, the facility did not adhere to them, resulting in the noted deficiencies. The Licensed Nursing Home Administrator acknowledged that the kitchen was not up to their standards.
Deficiency in Maintaining Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for six out of fifteen residents reviewed. The surveyor identified that physician progress notes were missing from the hybrid medical records of these residents. The residents had various diagnoses, including hypertension, dementia, diabetes, and Alzheimer's disease, and their cognitive abilities ranged from severe impairment to intact cognition. Despite these conditions, there were no documented physician progress notes in the medical records, which is a critical component of managing and monitoring their care. The surveyor's investigation revealed that the facility was in the process of transitioning to an electronic medical record (EMR) system for documenting physician progress notes. However, during this transition, some notes were still being documented in paper charts, leading to inconsistencies and missing documentation. Interviews with the Assisted Living coordinator and the Director of Nursing (DON) confirmed that the facility expected physicians to document their progress notes in the EMR or have them faxed to the facility within 24 hours of a visit. Despite these expectations, the required documentation was not found in the residents' records at the time of the survey. The facility's policy required attending physicians to review the resident's total program of care and document their findings at each visit. However, the surveyors found that this policy was not being followed, as evidenced by the absence of physician progress notes in the residents' medical records. The DON acknowledged the deficiency and provided the survey team with copies of the missing notes, which had been faxed from the physician's office after the surveyors raised the issue. The primary physician was unavailable for interview, and no additional information was provided by the facility.
Expired Medications Found in Medication Room and Treatment Cart
Penalty
Summary
The facility failed to ensure the removal of expired medications from the medication room and treatment cart, as observed during a survey on the 4th floor. The surveyor, accompanied by an LPN, identified expired medications, including two bottles of Adult low dose Enteric Coated 81mg tablets with an expiration date of August 2023, and two tubes of Bacitracin Ointment with an expiration date of January 2024, one of which was opened and stored inside the treatment cart. The deficiency was confirmed during a discussion with the facility's Licensed Nursing Home Administrator, Director of Nursing, and Assisted Living Coordinator, who acknowledged the presence of expired medications. This issue was identified as a failure to comply with NJAC 8:39-29.2 (d), which mandates proper labeling and storage of drugs and biologicals in accordance with professional principles.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Maplewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Care Rehabilitation And Nursing Center | 0.6 mi | ★★★★★ | 1 | 0 |
| South Mountain Hc | 2.1 mi | ★★★★★ | 0 | 0 |
| Brookhaven Health Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| White House Healthcare And Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Axia Care Center Of Orange | 3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.