The Gardens at Winsted: Call Light Failures Leave Resident Wet - MN
Nobody came for twenty minutes.
When a nursing assistant finally responded at 2:00 p.m., the resident — identified in the inspection report as R5 — had already urinated in his brief. He told the aide he had been waiting a half hour. "I don't like sitting in wet pants," he said.
R5 is cognitively intact. He has heart disease, renal insufficiency, and benign prostatic hyperplasia, a condition affecting the prostate that is associated with urinary urgency. His care plan directed staff to assist him to and from the toilet and to help with personal hygiene. He uses a wheelchair independently and can transfer himself from the chair to the bed and to the toilet. He was not waiting because he couldn't move. He was waiting because no one came.
"This happens often," he told inspectors the following day. He said it is worse late in the evening and in the middle of the night.
The device activity report confirmed his call light was active for twenty minutes starting at 1:40 p.m. The inspection report does not indicate anyone disputed this.
State inspectors arrived at The Gardens at Winsted on August 15, 2025, following a complaint. What they documented was not a single bad afternoon. R5 described a pattern, one that his own words placed across multiple shifts and multiple nights, a recurring experience of pressing a button and waiting and ultimately sitting in wet clothing because no one arrived in time.
The director of nursing told inspectors she expected call lights to be answered as soon as possible, but within fifteen minutes. The administrator said the same thing — fifteen minutes. Neither offered an explanation for why R5 waited twenty on August 14th, or addressed his account of it happening repeatedly after dark.
There was no toileting schedule in place for R5. The director of nursing acknowledged this directly, telling inspectors that toileting schedules should be implemented for R5 to promote continence. His quarterly assessment, completed before the inspection, noted that no trial of a toileting program had ever been implemented or attempted. His care plan, updated August 5th, ten days before inspectors arrived, directed staff to assist him to and from the toilet and to change his incontinence products as needed. It said nothing about a scheduled toileting routine.
The facility's own policy, dated March 2023, stated that care and services must be person-centered, that staff across all shifts and departments must understand and honor each resident's quality of life, and that residents' abilities in daily living activities must not diminish unless their clinical condition makes that unavoidable. Toileting is listed by name in that policy as one of the activities of daily living the facility committed to support.
R5 told inspectors the experience made him feel anxious and mad.
Those words appear in the inspection report without elaboration, and they don't need any. A man who is mentally sharp, who can wheel himself across a room and transfer himself to a toilet without help, pressed a button and asked for assistance before anything had gone wrong. He waited. He lost the chance to stay dry. He sat in wet pants and felt anxious and mad, and then told inspectors it keeps happening, that the nights are worse, and that this is simply how things go.
The violation was cited at the lowest level of harm. The facility's plan of correction is not included in the publicly available inspection document.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Gardens At Winsted LLC from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
THE GARDENS AT WINSTED LLC in WINSTED, MN was cited for violations during a health inspection on August 15, 2025.
Nobody came for twenty minutes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.