Arboretum Nursing and Rehabilitation Center of Win

In the surveyor’s words

From the most serious findings on record at Arboretum Nursing and Rehabilitation Center of Win, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 22, 2024

  Based 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. […]

• Actual harm, isolatedF689Aug 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF580Nov 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF644Nov 20, 2025

  Based 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. […]