The Gardens At Winsted Llc

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

quarterly MDS, dated [DATE REDACTED], indicated had heart disease, renal insufficiency, and BPH. The MDS indicated he was cognitively intact and required partial to moderate assistance with personal and toileting hygiene. The MDS indicated Resident R5 used his wheelchair independently and was independent with transfers from the chair to the bed and from the chair to the toilet. The MDS indicated Resident R5 was always incontinent of urine and always continent of bowel. It also indicated no trial of a toileting program had been implemented or trialed for Resident R5. Resident R5's care plan, dated 8/5/25, indicated he had alteration in elimination related to impaired mobility. The care plan directed assistance of one staff to/from toileting, assist with peri cares, provide incontinent products, and assist to change as needed. The device activity report indicated Resident R5 had his call light on for 20 minutes, starting at 1:40 p.m., on 8/14/25. On 8/14/25, at 2:40 p.m., Resident R5 stated he had been waiting for a half an hour when the NA responded to his call light at 2:00 p.m. He stated when he pressed

the call light, he had not been incontinent yet, but due to the wait he urinated in his brief. Resident R5 stated this made him feel anxious and mad. He also stated, I don't like sitting in wet pants. Resident R5 stated, This happens often, and that it occurs more often late in the evening and in the middle of the night. On 8/15/25, at 10:10 a.m., the director of nursing (DON) stated she expected call lights to be answered as soon as possible, but within 15 minutes. She stated toileting schedules should be implemented for Resident R4 and Resident R5 to promote continence. On 8/15/25, at 11:50 a.m., the administrator stated the NA's should be answering call lights within 15 minutes. A facility document, Activities of Daily Living (ADLs) Maintain Abilities Policy, dated 3/31/23, directed It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living.3. The facility will provide care and services for the following activities of daily living: hygiene, mobility, elimination, dining, and communication.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Gardens at Winsted LLC

551 Fourth Street North Winsted, MN 55395

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

he had not been incontinent yet, but due to the wait he urinated in his brief. Resident R5 stated this made him feel anxious and mad. He also stated, I don't like sitting in wet pants. Resident R5 stated, This happens often, and that it occurs more often late in the evening and in the middle of the night. Resident R5 stated he was not on a toileting schedule. On 8/14/25, at 4:43 p.m., NA-A stated residents who cannot use their call lights are on toileting schedules every two hours She stated all other residents use their call light when they need to use the restroom and call lights are answered in the order they are pressed. She stated Resident R4 and Resident R5 were assisted to

the bathroom as they requested it and were not on a schedule. On 8/15/25, at 9:48 a.m., NA-C stated Resident R4 and Resident R5 were supposed to be on a toileting schedule on the odd hours, but it was not followed. She stated it was implemented by the previous director of nursing (DON). On 8/15/25, at 10:10 a.m., the DON stated toileting schedules were intended to prevent incontinence episodes, by assisting the resident to the restroom on a regular basis and promote continence. She stated Resident R4 was on a toileting schedule every two hours while awake. She stated the bladder assessment, dated 7/9/25 was not accurate, as it indicated Resident R4 was continent. She also stated it was incomplete as it did not include pertinent diagnosis and medications related to urinary urgency and frequency. The DON stated Resident R5 was not on a toileting schedule. The DON stated based on Resident R5's bladder assessment, dated 12/27/24, she would expect the facility to have implemented a toileting schedule to offer him assistance to the restroom every 2 -3 hours, with a follow up to determine effectiveness. A facility document, Care Planning, dated 11/2024, directed in accordance with state and federal regulations, each resident will have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will be consistent with the resident's rights to identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident. The resident has the right and is encouraged to participate

in the development of their care plan. The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident.

The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Gardens at Winsted LLC

551 Fourth Street North Winsted, MN 55395

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm

and services for the following activities of daily living: hygiene, mobility, elimination, dining, and communication.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Gardens at Winsted LLC

551 Fourth Street North Winsted, MN 55395

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

She stated at the last resident council meeting another resident stated he had waited over 2 1/2 hours for his call light to be answered. On 8/14/25, at 4:43 p.m., NA-A stated the facility was cutting staff, due to empty beds in the facility. She stated, One person has to go home at 9:00 p.m. She stated the staff has attempted to address their staffing concerns with management, but felt management did not care. On 8/14/25, at 4:48 p.m., NA-B stated, I feel like a lot of call lights are on for a long time, it's been busy, and residents are waiting. She also stated one NA has to leave the shift early, at 9:00 p.m. NA-AD stated some of the residents had complained about the response time to the call lights. NA-AD stated several residents required the assistance of two staff for transfers. On 8/14/25, at 4:53 p.m., RN-A stated she did not feel the facility had enough staff. She said the residents had to wait for their call lights to be answered, causing them to be incontinent by the time the staff responded. RN-A stated residents had complained about the length of time they had to wait. She stated it was hard when one of the NA's was required to leave at 9:00 p.m., due to low census. RN-A stated she shared these concerns with management. On 8/15/25, at 8:30 a.m., the staffing coordinator (SC) stated the staffing level was determined by census and nursing hours per patient day (PPD). She stated the facility was trying to cut hours to meet labor and census. She stated

she felt it was unsafe to cut any additional hours as they were already getting quite low on floor staff. She stated the staff reported they felt they needed more help to her. The SC stated she was cutting hours by having the evening shift come in late and having someone leave the evening shift early. On 8/15/25, at 9:52 a.m., the therapeutic recreation director stated she attended every resident council meeting. She stated call light response times were addressed in almost every meeting and she shared the concerns addressed in

the meeting with the appropriate department leaders. On 8/15/25, at 10:10 a.m., the DON stated she felt

the facility had enough staffing and had not been told of any concerns by the residents. She stated the call light response times were evaluated if there was a complaint concerning them. The DON stated the call lights should be answered as soon as possible, but within 15 minutes. The DON stated a 45-minute call light response time was not acceptable. On 8/15/25, at 11:50 a.m., the administrator stated the facility assessment was to be completed annually. She stated some residents take two people to be transferred requiring longer time with staff, resulting in residents complaining about the wait times. She stated she reviewed the call light logs if there were complaints. She stated she had not observed any extended call light response times over the last 30 days. The administrator stated the call lights should be answered within 15 minutes. She stated she evaluated the call light response times by running average response times. The facility lacked a policy for the facility assessment.

Event ID:

Facility ID:

If continuation sheet