The Gardens at Winsted: Staffing Cuts Left Residents Waiting - MN
On August 14, 2025, the day before inspectors arrived at The Gardens at Winsted, a nursing assistant identified in the inspection report as NA-A described what working the evening shift had become. The facility was cutting staff because of empty beds, she said. One aide had to leave at 9:00 p.m., every shift, sent home early to save money on labor. She said staff had tried raising their concerns with management. She said it felt like management did not care.
NA-B, interviewed five minutes later, put it plainly: "I feel like a lot of call lights are on for a long time, it's been busy, and residents are waiting."
A third nursing assistant, identified as NA-AD, said some residents had complained about response times. She noted that several of those residents required two staff members to be safely transferred, meaning when one aide left early, the math got worse fast.
The registered nurse on duty that evening, RN-A, told inspectors she did not believe the facility had enough staff. She described what the delays actually meant for residents: they were waiting so long for someone to answer their call lights that they became incontinent before anyone arrived. She said residents had complained directly about the wait times. She said she had shared her concerns with management.
At the last resident council meeting before the inspection, one resident reported waiting more than two and a half hours for his call light to be answered.
The staffing coordinator, interviewed the morning of the inspection, confirmed the mechanics of what was happening. The facility was cutting hours to match census and hit labor targets. She was doing it by staggering the evening shift, having aides come in late and leave early. She told inspectors she already felt it was unsafe to cut further. "We're already getting quite low on floor staff," she said. She acknowledged that staff had come to her saying they needed more help.
The director of nursing told inspectors she felt the facility had adequate staffing. She said no residents had brought concerns to her. She said call light response times were only evaluated when a specific complaint came in. She said lights should be answered as soon as possible, but set 15 minutes as the outer limit. She said 45 minutes was not acceptable.
She was not asked about two and a half hours.
The administrator, interviewed shortly before noon, said she had not observed any extended call light response times in the past 30 days. She said she evaluated response times by running averages, and that she reviewed the logs only when complaints came in. She acknowledged that some residents needed two-person transfers and that this contributed to longer waits.
The gap between what the nursing staff described and what the director of nursing told inspectors is not subtle. One group described residents sitting in wet clothes waiting for someone to come. The other said she hadn't heard anything about it.
The therapeutic recreation director told inspectors that call light response times came up at almost every resident council meeting, and that she relayed those concerns to department leaders each time. The director of nursing said she had not been told of any resident concerns.
Inspectors also found the facility had no written policy for its facility assessment, a document that is supposed to guide staffing decisions in the first place.
The violation was cited at the level of minimal harm or potential for actual harm, and inspectors noted it affected many residents. The facility's own staffing coordinator had already concluded what the aides on the floor knew: there wasn't enough staff, and cutting more would make it worse. That assessment was made internally, passed up the chain, and the evening shift kept leaving at 9:00 p.m. anyway.
The resident who waited two and a half hours for his call light was not identified by name in the inspection report. He raised it himself, at the council meeting, in front of staff who were there to listen.
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 4, 2026 · Our methodology
THE GARDENS AT WINSTED LLC in WINSTED, MN was cited for violations during a health inspection on August 15, 2025.
The facility was cutting staff because of empty beds, she said.
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.