Cycle 1
Health 2025-05-01 · Fire 2025-05-01
20 health deficiencies
Top issue: Resident Rights (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Winsted, MN
The Gardens At Winsted LLC
2-star overall rating with 2-star inspections with $8,021 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
551 Fourth Street North, Winsted, MN
(320) 482-3135
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monarch Healthcare Management
Operator or chain grouping
Approved since
1987-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing
LPN hours / resident day
0.14
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
65%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.9%
1.4 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
4.3%
2.4 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.1%
0.1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
12.4%
4.6 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.5% |
17.5%
5 pts worse
|
16.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.4% |
22.5%
8.9 pts worse
|
16.3%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
18.6%
2.4 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
2.3%
1.7 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.6%
0.9 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.1% |
24.8%
12.3 pts worse
|
19.8%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 15.6% |
5.4%
10.2 pts worse
|
5.1%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
88.6%
2.9 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.9% |
14.0%
15.9 pts worse
|
12.0%
17.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.9%
0.7 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.7% |
82.7%
4 pts worse
|
79.7%
1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
23.1%
1.2 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-06
F · Potential for more than minimal harm
2024-02-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-04
F · Potential for more than minimal harm
2024-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-29
B · Minimal harm
2024-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-15
F838 · Administration Deficiencies
Health
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 2025-09-10
D · Potential for more than minimal harm
2025-08-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-15
F690 · Quality of Life and Care Deficiencies
Health
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 2025-09-10
D · Potential for more than minimal harm
2025-06-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-18
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F584 · Resident Rights Deficiencies
Health
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 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-05-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F585 · Resident Rights Deficiencies
Health
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 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-06
C · Minimal harm
2025-05-01
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-05-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-02-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-04
J · Immediate jeopardy
2024-01-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-04-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-24
E · Potential for more than minimal harm
2023-04-06
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F690 · Quality of Life and Care Deficiencies
Health
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 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-24
Penalties and ownership
What sits behind the stars
$8,021
2024-01-25
Fine
Fine · fine $8,021
Fine
Ownership
Halpert, Marc
5% Or Greater Indirect Ownership Interest · Individual
Legum, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Spartan Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Yazoma Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, William
5% Or Greater Indirect Ownership Interest · Individual
Wbs Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Jaffa, Noam
5% Or Greater Indirect Ownership Interest · Individual
Nij LLC
5% Or Greater Direct Ownership Interest · Organization
Halpert, Marc
Corporate Officer · Individual
Jaffa, Noam
Corporate Director · Individual
Legum, Joshua
Operational/Managerial Control · Individual
Monarch Healthcare Operating X LLC
Operational/Managerial Control · Organization
Stern, William
Corporate Officer · Individual
Nearby options
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Howard Lake, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
The Estates at Delano LLC
Delano, MN
3-star overall rating with 4-star inspections with $11,928 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cokato Manor
Cokato, MN
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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