Inspection Reports for Winchester Gardens
333 Elmwood Ave, Maplewood, NJ 07040, United States, NJ, 07040
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
26 residents
Based on a May 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 8
May 31, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to expired medications in storage, improper food labeling and sanitation practices in the kitchen, incomplete and inaccessible medical records for multiple residents, failure to annually review the emergency preparedness plan, fire safety code violations including non-fire rated soiled linen room door, fire alarm system trouble, lack of fire watch policy for sprinkler system outages, and incomplete electrical receptacle testing.
Complaint Details
Complaint #: NJ173628. Complaint investigations were completed during this survey.
Severity Breakdown
SS=D: 1
SS=F: 5
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Expired medications were found in the medication room and treatment cart. | SS=D |
| Facility failed to maintain proper kitchen sanitation practices and food labeling, including unlabeled and outdated food items, improper hair and glove use by staff, and wet nesting of dishes. | SS=F |
| Facility failed to maintain complete and readily accessible medical records for 6 of 15 residents reviewed. | SS=E |
| Emergency Preparedness Plan was not reviewed annually; last review was February 2022. | SS=F |
| One of two soiled linen room doors lacked a one-hour fire rating tag. | SS=F |
| Fire alarm system was in trouble with a disabled active sounder power monitor. | SS=F |
| Facility lacked a policy and procedure for fire watch when sprinkler system is out of service. | SS=F |
| Non-hospital grade electrical receptacles were not tested at intervals not exceeding 12 months. | SS=F |
Report Facts
Census: 26
Expired medication count: 4
Number of residents with incomplete medical records: 6
Fire door inspection logs frequency: 7
Electrical receptacle inspection date: 2024
Inspection Report
Follow-Up
Deficiencies: 1
Oct 4, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing requirements and to follow up on previously identified deficiencies related to direct care staff-to-resident ratios.
Findings
The facility was found deficient for failing to maintain the required minimum direct care staff-to-resident ratios on one evening shift (September 13, 2022). The deficiency involved having 2 certified nurse aides (CNAs) instead of the required 3 on that shift. A plan of correction was initiated including staff in-service training and ongoing monitoring.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law on one evening shift (September 13, 2022). |
Report Facts
Deficient shifts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Involved in in-service training on importance of maintaining direct care staff-to-resident ratios | |
| Director of Nursing | Involved in in-service training and responsible for reviewing staffing assignments and resident census daily | |
| Staffing Coordinator | Involved in in-service training on importance of maintaining direct care staff-to-resident ratios |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 0
Jun 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ139102 and NJ145341.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ139102 and NJ145341 were investigated and found to be in compliance.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 16
Deficiencies: 0
Apr 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 0
Dec 18, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00132094.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint #: NJ00132094; the facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 3
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