Arboretum Nursing And Rehabilitation Center Of Win
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Preventive Strategies to reduce fall risk undated 10/05/2016, indicated Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: After risk is assessed, individualize nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating
the resident/family's, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. The facility implemented the following interventions before the survey entrance
on 08/18/2025. During an interview on 08/20/2025 at 1:00 p.m., RN F, Clinical educator, said she now stressed to all CNA trainees they were not to provide any hands-on skills unless approval from her as the clinical educator. Record review of in-service training titled, Incontinent care dated 04/22/2025 for nursing staff indicated 39 staff in attendance. Summary: Provide incontinent care on all residents with lower extremity weakness, requires two-person assistance with transfers and/or utilize mechanical lift for transfers
in the bed only. Record review of in-service training titled, CNA trainers dated 04/22/2025 for CNA's indicated 36 staff in attendance. CNA trainers do not allow student nurses' aides or trainees to perform direct resident task without supervision. Record review of in-service training titled, How to use Kardex to communicate resident information and needs to the CNAs. Ensure you follow all care planned interventions including how much staff is required to perform an ADL. If unable to have the proper number of staff to assist a resident, do not perform the task until the proper amount is present. Do not rush. If for any reason
the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, incontinent care, then you should contact the charge nurse, ADON and/or DON. If more assistance is required than what is on the Kardex, report to the DON, ADON or MDS case manager immediately so Kardex can be adjusted. Charge nurse- through assessment of affected residents for injury or pain and report findings to the NP/MD dated 04/22/2025 with 38 staff in attendance. Record review of in-service training titled, Transfer training dated 04/23/2025 for all nursing staff indicated 40 staff in attendance.
Summary safe, effective transfer training with demonstrations. Interviews with 36 staff members from all shifts from 08/18/2025 at 8:50 a.m. to 08/20/2025 at 2:30 p.m. the following staff LVN A, CNA B, CNAT C, CNA D, LVN E, RN F, LVN G, RN H, RN J, LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, COTA LL, ST MM, OT NN, SNA OO, CNAT PP, CNAT QQ, CNAT RR, CNA SS, and CNA/MA TT confirmed completion of
in services/training of incontinent care, always follow the plan of care, care plan and Kardex when providing resident care, look at the Kardex for resident required assistance, transfer training, and if a trainer with the CNA trainees or student do not allow student nurses' aides or trainees to perform direct resident task without supervision. The staff, CNA trainees and students were able to verbalize understanding and information provided in the in-service/training. During an observation on 08/19/2025 at 1:30 p.m. SNA OO was observed providing one person transfer with Resident #5 using correct procedure. During an
observation on 08/20/2025 at 9:35 a.m. CNA/MA TT and CNA AA were observed providing a two person transfer with Resident #6 using correct procedure. 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.
Event ID:
Facility ID:
If continuation sheet
ARBORETUM NURSING AND REHABILITATION CENTER OF WIN in WINNIE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINNIE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ARBORETUM NURSING AND REHABILITATION CENTER OF WIN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.