Gardens at Winsted: Care Plan Failures Leave Residents Wet - MN
The man, identified in inspection records only as Resident 5, told inspectors he urinated in his brief while waiting for staff to respond. "I don't like sitting in wet pants," he said. He described feeling anxious and mad. He said it happens often, and that the problem is worse late at night and in the early morning hours.
Inspectors from the Centers for Medicare and Medicaid Services visited The Gardens at Winsted on August 15, 2025, following a complaint. What they found was a facility where care plans existed on paper and fell apart in practice, where a toileting schedule meant to prevent exactly this kind of incident had simply not been followed, and where the assessment meant to guide his care was, by the facility's own director of nursing, wrong.
Resident 5 was not the only one.
A second resident, identified as Resident 4, was supposed to be on a toileting schedule every two hours while awake. The facility's bladder assessment for Resident 4, dated July 9, 2025, listed him as continent. The director of nursing told inspectors that assessment was not accurate. She also said it was incomplete, because it left out diagnoses and medications directly related to urinary urgency and frequency.
The nursing assistant who spoke with inspectors on the afternoon of August 14 said residents who cannot use their call lights are placed on scheduled toileting every two hours. Everyone else, she said, uses the call light and gets helped in the order they rang. Resident 4 and Resident 5, she said, were assisted as they requested it. Neither was on a schedule.
That was not what a second nursing assistant said the following morning.
On August 15, at 9:48 a.m., a nursing assistant told inspectors that Resident 4 and Resident 5 were supposed to be on a toileting schedule on the odd hours. She said it had been put in place by the previous director of nursing. She said it was not being followed.
The current director of nursing confirmed it. Resident 4 had a toileting schedule, every two hours while awake. Resident 5 did not, but based on his bladder assessment from December 2024, the director said she would have expected the facility to offer him bathroom assistance every two to three hours, with follow-up to check whether it was working.
None of that happened.
The facility's own care planning policy, dated November 2024, states that each resident will have a person-centered care plan developed by an interdisciplinary team, that care plan interventions will come from a thorough assessment, and that the plan will be used to guide daily care routines and updated as a resident's needs change. The policy describes the care plan as something staff will actually use.
Resident 5's bladder assessment pointed toward a toileting schedule. No schedule was implemented. Resident 4 had a schedule. Staff weren't following it. His assessment was inaccurate and incomplete. The director of nursing said so herself.
The deficiency was cited at a level of minimal harm or potential for actual harm, one of the lower rungs on the federal violation scale. But Resident 5 did not describe minimal harm. He described sitting in wet pants, feeling anxious and mad, and said it happens often, especially in the hours when the building is quiet and the night stretches long and the call light goes unanswered a little too long.
He said he was not on a toileting schedule.
He was right.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
THE GARDENS AT WINSTED LLC in WINSTED, MN was cited for violations during a health inspection on August 15, 2025.
The man, identified in inspection records only as Resident 5, told inspectors he urinated in his brief while waiting for staff to respond.
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.