The Gardens at Winsted LLC

Name: The Gardens at Winsted LLC
Address: 551 FOURTH STREET NORTH, Winsted, MN, 55395, US
Telephone: 3204823135

551 Fourth Street North, Winsted, MN 55395 · Mc Leod County · 70 certified beds · avg 39 residents/day · certified since Apr 1, 1987

Part of chain: MONARCH HEALTHCARE MANAGEMENT (45 facilities, chain avg rating 2.2★)

2/5

Health inspection rating (on-site)

Serious findings on record

$8,021

Fines, last 3 years

4.07

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jan 25, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 22, 2024 (Past Non-Compliance)

All citations in the current public record (41)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 1, 2026	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
May 1, 2026	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Aug 15, 2025	F · Potential for harm, facility-wide	The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint
Aug 15, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Aug 15, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Aug 15, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Jun 18, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jun 18, 2025	D · Potential for harm, one-off	The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint
May 1, 2025	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
May 1, 2025	E · Potential for harm, repeated	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
May 1, 2025	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
May 1, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
May 1, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 1, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 1, 2025	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
May 1, 2025	C · Minimal risk, facility-wide	The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman.
Mar 19, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Feb 24, 2025	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Feb 24, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jan 3, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
May 14, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
May 14, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Feb 7, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Feb 7, 2024	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 7, 2024	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Jan 25, 2024	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 6, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 6, 2023	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 6, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (2 → 12).

Year	Citations	Serious (G–L)	Worst severity that year
2023	10	0	E
2024	6	1	J ▲
2025	23	0	F
2026	2	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $8,021.

Date	Type	Amount / length
Jan 25, 2024	Fine	$8,021

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Minnesota avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.07	4.83	3.95	bottom 18% in Minnesota; top 36% in the U.S.
Registered Nurse hours	1.30	1.22	0.69	top 34% in Minnesota; top 7% in the U.S.
Weekend total nurse staffing	3.67	4.27	3.50	bottom 21% in Minnesota; top 34% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.72	0.69	0.48	top 34% in Minnesota; top 15% in the U.S.
Total nursing staff turnover (%)	55.6	42.2	45.8	bottom 17% in Minnesota; bottom 24% in the U.S.
RN turnover (%)	83.3	38.6	42.9	bottom 4% in Minnesota; bottom 4% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.36, RN 1.07, weekend 3.03. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 1/5 · short-stay residents: 2/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Halpert, Marc	Individual	5% or Greater Indirect Ownership Interest	32%	04/01/2020
Jaffa, Noam	Individual	5% or Greater Indirect Ownership Interest	14%	04/01/2020
Legum, Joshua	Individual	5% or Greater Indirect Ownership Interest	32%	04/01/2020
Nij LLC	Organization	5% or Greater Direct Ownership Interest	14%	04/01/2020
Spartan Healthcare LLC	Organization	5% or Greater Direct Ownership Interest	32%	04/01/2020
Stern, William	Individual	5% or Greater Indirect Ownership Interest	22%	04/01/2020
WBS Holdings LLC	Organization	5% or Greater Direct Ownership Interest	22%	04/01/2020
Yazoma Holdings, LLC	Organization	5% or Greater Direct Ownership Interest	32%	04/01/2020
Halpert, Marc	Individual	Corporate Officer	NOT APPLICABLE	04/01/2020
Jaffa, Noam	Individual	Corporate Director	NOT APPLICABLE	04/01/2020
Legum, Joshua	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2020
Monarch Healthcare Operating X LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2020
Stern, William	Individual	Corporate Officer	NOT APPLICABLE	04/01/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
"How do you keep residents' medical records accurate, complete, and secure?"
"How do you decide you have enough staff and resources for your resident population, including nights and weekends?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Good Samaritan Society - Howard Lake	6.5 mi	Howard Lake, MN	★★★★☆	3/5
The Estates at Delano LLC	9.4 mi	Delano, MN	★★★★☆	4/5
Cokato Manor	10.5 mi	Cokato, MN	★★★★★	4/5
Glenfields Living with Care	14.0 mi	Glencoe, MN	★★★★☆	4/5
Lakeside Generations Health Care Center	14.6 mi	Dassel, MN	★★★★☆	4/5
Auburn Home in Waconia	15.3 mi	Waconia, MN	★★☆☆☆	2/5
Good Samaritan Society - Waconia and Westview Acre	15.4 mi	Waconia, MN	★★☆☆☆	2/5
Park View Health Care Center	16.0 mi	Buffalo, MN	★★★★★	5/5
Lake Ridge Care Center of Buffalo, INC.	16.3 mi	Buffalo, MN	★★★★☆	4/5
Harmony River Living Center	17.1 mi	Hutchinson, MN	★★★★☆	3/5
Haven Homes of Maple Plain	17.9 mi	Maple Plain, MN	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Winsted →

Facility data as of CMS processing date 2026-08-01. CCN 245459.

The Care File

Visit checklist — The Gardens at Winsted LLC

551 Fourth Street North, Winsted, MN 55395 · 3204823135

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $8,021

Most serious findings on record:

▲ Jan 25, 2024 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "How do you decide you have enough staff and resources for your resident population, including nights and weekends?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 245459 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)