Arboretum Nursing and Rehabilitation Center of Win
1215 Highway 124 · Winnie, TX · 77665 · 4092968200
120 certified beds For profit - Corporation
Why this verdict
- Staffing levels are well below research benchmarks for safe care.
- Federal penalties on record: $115,498 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
$115,498 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
RN staffing in the bottom 10% nationally
0.20 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
97% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.02 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.20 | 0.55–0.75 |
| Weekend hours / resident-day | 2.64 | ≈ weekday level |
| Nursing turnover / year | 97% | median 45% |
| Fines (3-yr window) | 2 · $115,498 |
Inspection citations (28 in the current record)
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Potential for harm · E November 20, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected November 21, 2025 · Resident Rights
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Potential for harm · E November 20, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected November 21, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 20, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected November 21, 2025 · Quality of Life and Care
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Potential for harm · D November 20, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected November 21, 2025 · Quality of Life and Care
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Potential for harm · F November 20, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 21, 2025 · Nutrition and Dietary
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Potential for harm · D November 20, 2025
Provide and implement an infection prevention and control program.
Corrected November 21, 2025 · Infection Control
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Potential for harm · D November 20, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected November 21, 2025 · Environmental
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Actual harm · G August 20, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past Non-Compliance · Quality of Life and Care
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Immediate jeopardy · K August 22, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 23, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected August 23, 2024 · Resident Rights
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Potential for harm · D August 22, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected August 23, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected August 23, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected August 23, 2024 · Quality of Life and Care
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Potential for harm · E August 22, 2024
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected August 23, 2024 · Nursing and Physician Services
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Potential for harm · E August 22, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected August 23, 2024 · Pharmacy Service
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Potential for harm · E August 22, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected August 23, 2024 · Pharmacy Service
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Potential for harm · D August 22, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected August 23, 2024 · Nutrition and Dietary
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Potential for harm · E August 22, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 23, 2024 · Nutrition and Dietary
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Potential for harm · E August 22, 2024
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected August 23, 2024 · Administration
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Potential for harm · E August 22, 2024
Provide and implement an infection prevention and control program.
Corrected August 23, 2024 · Infection Control
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Potential for harm · D August 22, 2024 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected August 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 28, 2023
Reasonably accommodate the needs and preferences of each resident.
Corrected June 29, 2023 · Resident Rights
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Potential for harm · D June 28, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected June 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 28, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 28, 2023
Provide care by qualified persons according to each resident's written plan of care.
Corrected June 29, 2023 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 20, 2025 | Fine | $9,110 |
| August 22, 2024 | Fine | $106,388 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 675798 · certified since June 24, 1999. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.