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.
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
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
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.