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
Chain footprint
45 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.14
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,560
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.03
Baseline 20.09% · Performance 20.03% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Healthcare-associated infections
3.59
Baseline 7.04% · Performance 6.76% · Measure score 3.59 · Achievement 3.59 · Improvement 0.86
Total nurse turnover
1.92
Performance 55.81% · Measure score 1.92 · Achievement 1.92 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.77
Baseline 3.46 hours · Performance 3.30 hours · Measure score 0.77 · Achievement 0.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 10.53% · Lower 95% interval 7.17% |
| Discharge to community | 46.56% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 42.37% · Lower 95% interval 36.92% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 71.88% |
53.69%
18.2 pts better
|
Numerator 23 · Denominator 32 |
| Discharge mobility score | 65.63% |
50.94%
14.7 pts better
|
Numerator 21 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 42 · Adjusted rate 2.73% |
| Healthcare-associated infections requiring hospitalization | 6.76% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 6.82% |
8.2%
1.4 pts worse
|
Numerator 6 · Denominator 88 |
| Staff flu vaccination coverage | 15.56% |
42%
26.4 pts worse
|
Numerator 14 · Denominator 90 |
| Discharge function score | 84.38% |
56.45%
27.9 pts better
|
Numerator 27 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 23.81% |
25.2%
1.4 pts worse
|
Numerator 5 · Denominator 21 |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 0.0% · Q2 3.1% · Q3 3.2% · Q4 3.4% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 4.3% · Q2 4.3% · Q3 4.5% · Q4 13.6% · 4Q avg 6.7% |
| 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 · Q1 4.2% · Q2 0.0% · Q3 3.8% · Q4 8.3% · 4Q avg 4.0% |
| 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 · Q1 4.0% · Q2 8.0% · Q3 7.4% · Q4 12.0% · 4Q avg 7.8% |
| 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 · 4Q avg 22.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 31.4% · Used in QM five-star |
| 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 · Q1 28.0% · Q2 20.8% · Q3 23.1% · Q4 12.0% · 4Q avg 21.0% · Used in QM five-star |
| 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 · Q1 4.4% · Q2 2.1% · Q3 2.4% · Q4 7.8% · 4Q avg 4.0% · Used in QM five-star |
| 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 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 34.7% · Q2 45.9% · Q3 37.4% · Q4 28.9% · 4Q avg 37.1% |
| 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 · Q1 18.7% · Q2 23.2% · Q3 11.6% · Q4 7.9% · 4Q avg 15.6% · Used in QM five-star |
| 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 · Q1 91.5% · Q2 90.2% · Q3 90.8% · Q4 93.4% · 4Q avg 91.5% |
| 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 · Adjusted 29.9% · Observed 32.3% · Expected 12.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.3% · Q3 4.8% · Q4 3.7% · 4Q avg 2.6% · Used in QM five-star |
| 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 · 4Q avg 78.7% |
| 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 · Adjusted 24.3% · Observed 25.8% · Expected 25.3% · Used in QM five-star |
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
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#3
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