Arboretum Nursing and Rehab: Transfer Safety Violations - TX
The violation at Arboretum Nursing and Rehabilitation Center of Winnie centered on how staff moved residents, one of the most physically dangerous routine tasks in a nursing home. Done wrong, a transfer from bed to wheelchair or toilet can fracture a hip, tear a shoulder, or send a resident to the floor. The inspection report classified the harm level as actual, not potential.
The non-compliance began on April 22, 2025, and ended the following day. That 24-hour window, brief as it sounds, was enough for federal regulators to classify it as a deficiency affecting a few residents.
What happened on April 22 and 23 tells its own story. The facility convened an in-service training on that date, pulling together 38 staff members to cover transfer safety and reporting findings to the nurse practitioner or physician on duty. The next day, a second session went further, gathering 40 nursing staff for what records described as safe, effective transfer training with demonstrations. The speed of the response suggests the facility recognized it had a problem and moved to contain it within hours.
The training covered more than just how to move a body safely. Staff were instructed to follow the plan of care, consult the Kardex before providing any resident assistance, and ensure that CNA trainees and student nurses' aides never performed direct resident tasks without supervision from a certified trainer. That last point is significant. When trainees work without oversight, residents absorb the risk of their inexperience.
By the time inspectors arrived in August, the facility had interviewed 36 staff members across all shifts over two days. The list ran long: LVN A through LVN Q, CNA B through CNA TT, a certified occupational therapy assistant, a speech therapist, an occupational therapist, and multiple CNA trainees. Every one of them confirmed completing the in-service training. Every one could verbalize what they had been taught.
Inspectors did not take that on faith. On August 19, at 1:30 in the afternoon, they watched a staff nursing assistant identified in the report as SNA OO perform a one-person transfer with Resident 5. The technique was correct. The next morning, at 9:35, two staff members, CNA/MA TT and CNA AA, performed a two-person transfer with Resident 6. Also correct.
The inspectors closed the deficiency as past non-compliance, meaning the facility had identified and fixed the problem before the survey began.
That classification matters in how the public reads inspection records. A facility that catches its own failures and retrains its staff before federal surveyors arrive is doing something different from one that waits to be caught. The correction here was rapid and documented in detail. Forty staff in a single training session is not a quiet acknowledgment of a problem. It is a response that touches nearly everyone on the floor.
What the report does not say is what happened to the residents affected during that April window, what the original transfer failures looked like, or whether anyone was hurt. The inspection record confirms actual harm occurred. It does not describe it.
That gap is not unusual in inspection documents, which often capture the corrective response more fully than the harm that prompted it. For the residents involved, the distinction between past non-compliance and ongoing violation means little. For the families reading these records, it means everything to know what the harm actually was.
Arboretum's floors were observed moving residents correctly by August. Whether that would have been true in April, before anyone called a training session, is the question the report raises and does not fully answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arboretum Nursing and Rehabilitation Center of Win from 2025-08-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Arboretum Nursing and Rehabilitation Center of Win in WINNIE, TX was cited for violations during a health inspection on August 20, 2025.
Done wrong, a transfer from bed to wheelchair or toilet can fracture a hip, tear a shoulder, or send a resident to the floor.
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.