The Gardens at Winsted LLC
551 Fourth Street North · Winsted, MN · 55395 · 3204823135
70 certified beds For profit - Corporation Chain: Monarch Healthcare Management
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
64% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 3.38 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.99 | 0.55–0.75 |
| Weekend hours / resident-day | 3.12 | ≈ weekday level |
| Nursing turnover / year | 64% | median 45% |
| Fines (3-yr window) | 1 · $8,021 |
Inspection citations (39 in the current record)
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Potential for harm · D August 15, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 10, 2025 · Resident Rights
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Potential for harm · D August 15, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 15, 2025 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected September 10, 2025 · Quality of Life and Care
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Potential for harm · F August 15, 2025 · found via complaint
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected September 10, 2025 · Administration
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Potential for harm · D June 18, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 18, 2025 · found via complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected July 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 1, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected June 18, 2025 · Resident Rights
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Potential for harm · D May 1, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected June 6, 2025 · Resident Rights
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Potential for harm · E May 1, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected June 6, 2025 · Resident Rights
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Potential for harm · D May 1, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected June 6, 2025 · Resident Rights
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Potential for harm · E May 1, 2025
Provide activities to meet all resident's needs.
Corrected June 6, 2025 · Quality of Life and Care
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Potential for harm · D May 1, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 6, 2025 · Quality of Life and Care
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Potential for harm · D May 1, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected June 6, 2025 · Quality of Life and Care
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Potential for harm · D May 1, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected June 6, 2025 · Infection Control
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Potential for harm · D May 1, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 6, 2025 · Quality of Life and Care
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Potential for harm · D May 1, 2025 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected June 6, 2025 · Quality of Life and Care
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Potential for harm · F May 1, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected June 6, 2025 · Infection Control
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Potential for harm · E May 1, 2025 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected June 6, 2025 · Resident Rights
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No harm found · C May 1, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected June 6, 2025 · Resident Rights
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Potential for harm · D March 19, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 14, 2025 · Infection Control
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Potential for harm · D February 24, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 14, 2025 · Infection Control
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Potential for harm · E February 24, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected March 14, 2025 · Environmental
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Potential for harm · D January 3, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 20, 2025 · Pharmacy Service
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Potential for harm · D May 14, 2024 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected June 12, 2024 · Resident Rights
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Potential for harm · D May 14, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected June 18, 2024 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 25, 2024 | Fine | $8,021 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245459 · certified since April 1, 1987. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.