The Gardens at Winsted LLC

In the surveyor’s words

From the most serious findings on record at The Gardens at Winsted LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 25, 2024

  Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who were at risk for elopement. This resulted in an immediate jeopardy (IJ) however, the facility implemented corrective action prior to the investigation so the deficiency remained at past non-compliance. The IJ began on 1/17/24 at 7:09 p.m. when the administrative hallway exit door alarm sounded and staff did not respond appropraitely. At 7:36 p.m. R1 on was located outside, approximately 15 feet from the building. AccuWeather temperature identified it was between 10 degrees Fahrenheit (F) and -3 degrees F on 1/17/24. The facility administrator and director of nursing (DON) were notified of the IJ on 1/25/24 at 3:02 p.m. […]

• No harm, potential for more than minimal, widespreadF838Aug 15, 2025

  Based on interview and document review the facility failed to ensure the facility assessment included the required components of involvement from direct care staff, considering staffing needs of each unit in the facility, and a plan to recruit and retain staff. This had the opportunity to affect all 33 residents. Findings include: Review of the facility assessment, dated 7/22/24, failed to include input and active involvement from direct care staff, including but not limited to registered nurses (RN), licensed practical nurses (LPN), and nursing assistants (NA). […]

• No harm, potential for more than minimal, widespreadF880May 1, 2025

  Based on observation, interview and document review, the facility failed to perform hand hygiene and change gloves appropriately for 1 of 1 residents (R2) observed for personal cares. In addition, the facility failed to develop a trending and tracking program system for monitoring residents who showed signs of illness, but were not on an antibiotic, these practices had the potential to affect all 37 residents currently residing in the facility. Findings Include: R2's 3/21/25, significant change Minimum Data Set (MDS) identified her cognition was severely impaired, and she was dependent on staff for activities of daily living (ADL)s. […]

• No harm, potential for more than minimal, widespreadF851Feb 7, 2024

  Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly or more often, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4) in Federal Fiscal Year 2023, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This has the potential to affect all 42 residents residing in the facility. Findings include: CMS PBJ Staffing Report for Fiscal Year 2023 Quarter 4 (July 1-September 30) results listed Excessively Low Weekend Staffing as triggered due to data submitted by the facility to CMS. […]

• No harm, potential for more than minimal, widespreadF880May 6, 2022

  Based on interview and document review the facility failed to analyze monthly surveillance data for trends and patterns to reduce the spread of illness and infections. This had the potential to effect all 38 residents residing in the facility. Findings include: The January 2022, infection spreadsheet identified two urinary tract infections acquired prior to admission, five facility acquired [CONDITION(S)] infections (a common, potentially serious bacterial skin infection), one prosthetic hip infection acquired prior to admission, and 3 central line infections acquired prior to admission, one which was identified as [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)], a bacterium with antibiotic resistance). […]