Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WINCHESTER GARDENS HEALTH CARE CENTER

MAPLEWOOD, NJ · 30 certified beds · Last Life Safety survey September 5, 2025

CMS Certification Number 315527 · first certified May 2018

Ownership

Operated by SPRINGPOINT SENIOR LIVING · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

22
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within NJ

22 citations — more than 80% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 11 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens December 2026 — about 3 months from now. This facility’s last Life Safety survey was September 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 22 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

How that compares

Citations on file over three years

Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.

This facility22NJ median15National median11
Citations on file over three years, compared
MeasureCitations
This facility22
Median facility in NJ15
Median facility nationally11

Survey history

Citations at each Life Safety survey
62022-1052024-05112025-09
Citations at each Life Safety survey
Survey dateCitations
October 4, 20226
May 31, 20245
September 5, 202511

Most-cited tags

Most-cited tags at this facility
K-03453K-03212K-03722K-03512K-09182K-03431K-03531K-03541
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32025-09-05
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22024-05-31
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22025-09-05
K-0351Install an approved automatic sprinkler system.22025-09-05
K-0918Have generator or other power source capable of supplying service within 10 seconds.22025-09-05
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.12025-09-05
K-0353Inspect, test, and maintain automatic sprinkler systems.12025-09-05
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.12024-05-31

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 13
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Emergency Preparedness Deficiencies 3
  • Egress Deficiencies 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies13
Gas, Vacuum, and Electrical Systems Deficiencies4
Emergency Preparedness Deficiencies3
Egress Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 5, 2025 — 11 citations

Citations issued on September 5, 2025
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (October 31, 2025)
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (October 31, 2025)
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has date of correction (October 31, 2025)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (October 31, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 31, 2025)
K-0343Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.Deficient, Provider has date of correction (October 31, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 31, 2025)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 2, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 19, 2026)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 31, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 31, 2025)

May 31, 2024 — 5 citations

Citations issued on May 31, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (July 22, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (July 22, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (July 22, 2024)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (July 22, 2024)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (July 22, 2024)

October 4, 2022 — 6 citations

Citations issued on October 4, 2022
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (November 30, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (November 30, 2022)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (November 30, 2022)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (January 4, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (November 30, 2022)
K-0926Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.Deficient, Provider has date of correction (November 30, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.