The Gardens at Winsted LLC
551 Fourth Street North, Winsted, MN 55395
The Gardens at Winsted LLC is a nursing home in Winsted, Minnesota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (320) 482-3135
- Last standard health inspection
- July 24, 2026 (3 months ago)
- Certified beds
- 70
- Residents per day, on average
- 34.7
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Gardens at Winsted LLC
- Chain
- Monarch Healthcare Management
- Takes part in
- Medicare and Medicaid
More health citations than the Minnesota average (39 vs 23).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
8 citations
Health inspection on July 24, 2026
CMS lists this as a standard inspection.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on September 4, 2026.
CMS has cited this home for F0725 2 times since 2026.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 4, 2026.
Citation F0882. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on September 4, 2026.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on September 4, 2026.
CMS has cited this home for F0554 2 times since 2025.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on September 4, 2026.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on September 4, 2026.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on September 4, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on September 4, 2026.
6 citations
Fire safety inspection on July 24, 2026
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 4, 2026.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 4, 2026.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 4, 2026.
CMS has cited this home for K0321 2 times since 2025.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 4, 2026.
CMS has cited this home for K0363 2 times since 2025.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 4, 2026.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on September 4, 2026.
2 citations
Health inspection on May 1, 2026
CMS lists this as a complaint inspection.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on June 8, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on June 8, 2026.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of March 25, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.3 to 2.8 hours per resident per day.
4 citations
Health inspection on August 15, 2025
CMS lists this as a complaint inspection.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on September 10, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 10, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 10, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on September 10, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
2 citations
Health inspection on June 18, 2025
CMS lists this as a complaint inspection.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 11, 2025.
Citation F0943. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on July 11, 2025.
13 citations
Health inspection on May 1, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 6, 2025.
CMS has cited this home for F0880 3 times since 2025.
Citation F0576. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on June 6, 2025.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 6, 2025.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on June 6, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on June 18, 2025.
Citation F0565. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on June 6, 2025.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 6, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 6, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 6, 2025.
CMS has cited this home for F0689 2 times since 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 6, 2025.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on June 6, 2025.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on June 6, 2025.
Citation F0577. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
CMS lists it as corrected on June 6, 2025.
4 citations
Fire safety inspection on May 1, 2025
CMS lists this as a standard inspection.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 6, 2025.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on June 6, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 6, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 6, 2025.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
1 citation
Health inspection on March 19, 2025
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 14, 2025.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Health citation
CMS removed citation F0851 from the health inspection on February 7, 2024.
2 citations
Health inspection on February 24, 2025
CMS lists this as a complaint inspection.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on March 14, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 14, 2025.
1 citation
Health inspection on January 3, 2025
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on January 20, 2025.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Fine
CMS changed the fine from May 6, 2022 from $10,644 to $10,883.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from January 25, 2024 from $12,340 to $8,021.
CMS update of June 26, 2024
Fine
CMS changed the fine from May 6, 2022 from $10,000 to $10,644.
2 citations
Health inspection on May 14, 2024
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 12, 2024.
CMS has cited this home for F0580 2 times since 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 18, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
3 citations
Health inspection on February 7, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on March 4, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 4, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on March 4, 2024.
3 citations
Fire safety inspection on February 7, 2024
CMS lists this as a standard inspection.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on March 4, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 29, 2024.
Citation K0353. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 29, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
1 citation
Health inspection on January 25, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
54 of 337 Minnesota homes (16%) got a citation at the immediate jeopardy level in 2024.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 22, 2024.
Fine
January 25, 2024 (2 years ago)
CMS fine of $8,021 on January 25, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- NIJ LLC5% or greater direct ownership interest · 14% · since 04/01/2020
- SPARTAN HEALTHCARE LLC5% or greater direct ownership interest · 32% · since 04/01/2020
- WBS HOLDINGS LLC5% or greater direct ownership interest · 22% · since 04/01/2020
- YAZOMA HOLDINGS, LLC5% or greater direct ownership interest · 32% · since 04/01/2020
- HALPERT, MARC5% or greater indirect ownership interest · 32% · since 04/01/2020
- JAFFA, NOAM5% or greater indirect ownership interest · 14% · since 04/01/2020
- LEGUM, JOSHUA5% or greater indirect ownership interest · 32% · since 04/01/2020
- STERN, WILLIAM5% or greater indirect ownership interest · 22% · since 04/01/2020
- MONARCH HEALTHCARE OPERATING X LLCOperational/managerial control · not applicable · since 04/01/2020
- LEGUM, JOSHUAOperational/managerial control · not applicable · since 04/01/2020
Questions
When was The Gardens at Winsted LLC last inspected?
CMS lists July 24, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does The Gardens at Winsted LLC have?
CMS lists 39 health citations since January 25, 2024. CMS also calls these deficiencies.
Has The Gardens at Winsted LLC been fined?
CMS lists 1 fine in the past three years, $8,021 in total.
What is the CMS star rating of The Gardens at Winsted LLC?
Its CMS overall star rating is 2 of 5.
Is The Gardens at Winsted LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.