Arboretum Nursing and Rehabilitation Center of Win

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation: 1. The facility failed to ensure opened food items stored in the walk-in dry pantry area were properly sealed in plastic bags to prevent exposure to the air. 2. The facility failed to ensure food items in the facility walk-in dry storage were dated or labeled.3. The facility failed to ensure that spoiled food items were discarded.4. The facility failed to ensure the outside of food containers were free of food particles.5. The facility failed to ensure dishes were sanitized properly prior to being stored in clean area. These failure could place residents at risk of food-borne illnesses. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 4 residents reviewed for notification of changes. (Resident #6) The facility failed to consult with Resident #6's physician regarding the pattern of Resident #6's refusal to wear an arm sling related to her fractured right clavicle for 21 out of 30 opportunities on the a.m. shift and 17 out of 30 opportunities on the p.m. shift for September 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 22 residents (Residents #8, 42, and 59) reviewed for resident assessments. 1. The facility failed to refer Resident #8 for a PASRR review following a new mental illness diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) on 03/28/25. 2. The facility failed to refer Resident #42 for PASRR review following a new mental illness diagnosis of psychosis (a mental disorder characterized by a disconnection from reality) on 11/04/24. 3. The facility failed to refer Resident #59 for PASRR review following a new mental illness diagnosis of bipolar disorder on 07/22/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who enter the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable for 1 of 4 (Resident #10) reviewed for range of motion. 1. The facility failed to implement interventions to prevent the decline of Resident #10's range of motion to her left hand on 10/1/2 025. 2. The facility failed to document Resident #10's change of condition to her left hand from within functional limit to a decreased range of motion. These failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #76) of 22 resident reviewed for incontinent care. The facility failed to ensure that CNA C cleaned under the foreskin (the retractable roll of skin covering the tip of the penis) for Resident #76 while incontinent care was provided on 09/29/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #76) of 22 residents reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene before she applied clean gloves during incontinent care for Resident #76. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 (Hall B) of 4 hallways reviewed for environment. The facility failed to ensure the janitor closet, that contained potentially unsafe chemicals, on Hall B was secured on 09/29/25. This failure could result in residents coming into contact with potentially unsafe items.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 26 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was provided two persons assist with transfer from sitting in wheelchair to standing position to provide toilet hygiene on 04/22/2025 which resulted in Resident #1 being lowered to floor by CNAT C and causing discoloration with abrasion to the left buttock, small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the right distal fibula (calf bone), and a right ankle sprain. The non-compliance was identified as past non-compliance. The PNC began on 04/22/2025 and ended on 04/23/2025. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 4 of 6 residents (Residents #33, #40, #290, and #1) and prevent coffee burns for 1 of 2 residents (Resident #2) reviewed for accident hazards and supervision. 1. The facility failed to prevent Resident #33 from eloping from the facility on 04/14/2024, 06/20/2024 and 06/21/2024. 2. The facility failed to prevent Resident #40 from eloping from the facility on 08/09/2024. 3. The facility failed to prevent Resident #290 from eloping from the facility on 06/13/2024. 4. The facility failed to prevent Resident #1 from eloping from the facility on 07/13/2024. 5. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 3 of 26 residents (Resident's #29, #37, and #64) reviewed for physician services. The facility failed to ensure Resident's #29, #37, and #64 were seen by a physician within the first 30 days of their skilled admission to the facility. This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 24 residents (Residents #24) and 1 of 1 facility reviewed for pharmacy services. 1. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure Resident #24 medications were administered during the scheduled time. These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 24 residents (Resident #24 and Resident #82) and 1 of 5 medication carts (D-hall medication cart) reviewed for drugs and biologicals. 1. The facility failed to ensure LVN L secured the D-hall medication cart and keys during medication administration and while the D-hall medication cart was not in use. 2. The facility failed to ensure LVN N secured the D-hall medication cart during medication administration. 3. The facility failed to ensure the controlled medications awaiting disposal were under a double lock. 4. The facility failed to ensure Resident #82's Carbidopa-Levodopa (medication used to treat Parkinson's Disease) medication label matched her physician order. 5. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. Food items were labeled and dated. 2. Hair restraints were worn. 3. The prepared green beans were not stored beside dirty dishes. 4. Volunteer XX wore a hair net and performed hand hygiene while assisting with preparing the appetizers prior to the lunch meal on 08/19/2024. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 residents (Resident #11, Resident #15, and Resident #35) reviewed for hospice services. The facility did not ensure Resident #11 and Resident #35 had the most current hospice plan of care. The facility failed to obtain Resident #15's most current hospice certification and plan of care, nurse visit notes, and aide visit notes. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 residents (Resident #40) and 2 of 2 staff (CNA NN and CNA YY) reviewed for infection control practices and transmission-based precautions. 1. The facility did not ensure Resident #40 was provided proper incontinent care. 2. The facility did not ensure EBP were put in place for Resident #40 These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 24 residents (Resident #64) reviewed for grievances. The facility did not ensure a grievance was filed for Resident #64's black bra and 1 pair of pants when they were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and that the resident was invited to participate in developing the care plan and making decisions about his or her care for 1 of 24 residents (Resident #64) reviewed for care plan timing and revision. The facility failed to ensure Resident #64 was invited to participate in the development and review of her care plan. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good hygiene for 1 of 3 residents (Resident #32) reviewed for ADLs. The facility did not ensure Resident #32's fingernails were cleaned. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #40) reviewed for incontinent care. The facility failed to ensure Resident #40 was provided proper incontinent care. These failures could place residents at risk for urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 2 residents (Resident # 5) reviewed for respiratory care. The facility did not ensure Resident #5's oxygen concentrator was set at 2-4 liters per nasal cannula as ordered by the physician. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.

Inspectors wroteBased on observations, interviews, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 (Resident #290) of 27 residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #290's preference for meat to be chopped at table/bedside. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 residents (Resident #33, Resident #21, Resident #12 and Resident #280) reviewed for infection control. NA K did not change gloves and perform hand hygiene appropriately while performing the perineal care of Resident #33. CNA B failed to change gloves and perform hand hygiene during incontinent care for Resident #21. The treatment nurse failed to perform hand hygiene prior to exiting Resident #12's room. The treatment nurse failed to perform hand hygiene while providing wound care to Resident #280. These failures could affect all residents and place them at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 21 residents (Residents #52) reviewed for reasonable accommodations. The facility failed to ensure Resident #52's call light was accessible. This failure could place residents at risk of injuries, health complications and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 20 residents reviewed for abuse. (Resident #77) The facility failed to follow their policy when they did not report Resident #77's allegation of sexual assault on 4/10/2023 at 3:06 p.m. to HHSC. This failure could cause residents to have continued abuse, sexual abuse, and neglect.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 20 residents (Resident #77) reviewed for abuse and neglect. The facility failed to report Resident #77's allegation of sexual assault on 4/10/2023 at 3:06 p.m. to HHSC. This failure could cause residents to have continued abuse, sexual abuse, and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for 1 of 21 residents sampled (Resident #33). The facility NA applied a medication cream to bilateral buttocks of Resident #33 without qualifications to do so. This failure could place residents at risk for not receiving appropriate care and treatment outlined in their comprehensive care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of living received services to maintain grooming and personal hygiene for 1 of 2 residents reviewed for ADLs (Resident #10). The facility did not ensure Resident #10's contracted hands were free from odor and her fingernails trimmed. These failures could place residents at risk for not receiving services/care and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 21 residents (Resident #77) reviewed for therapeutic diets. The facility failed to ensure Resident #77 received finger foods as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.