Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winfield Rest Haven Ii, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical limitations fell from a whirlpool bath chair due to a CNA's failure to apply a safety belt, resulting in a head laceration requiring sutures. The facility's policy required safety belt use, but it was not consistently followed, leading to the incident.
The facility failed to ensure accurate MDS assessments for two residents. One resident, with severe cognitive impairment, was incorrectly documented as using bed rails as a restraint, while observations showed they were used for positioning. Another resident, with hemiplegia, was inaccurately assessed as having no extremity impairments, despite requiring substantial assistance and a mechanical lift for transfers.
Two residents' care plans were not updated to include enhanced barrier precautions (EBP) for catheter use. One resident's care plan lacked instructions for PPE during catheter care, and staff were observed not wearing gowns despite EBP signage. Another resident's care plan did not reflect EBP needs, although staff used PPE. The facility failed to revise care plans as residents' conditions changed.
A facility failed to monitor a resident's use of antipsychotic medication, Seroquel, as per their policy. The resident, with severe cognitive impairment and a history of cerebral infarction, was not assessed with the required AIMS assessment upon initiation of the medication. The first assessment was conducted months later, and no further assessments were documented, contrary to the facility's policy of quarterly assessments.
The facility failed to ensure staff used appropriate PPE for residents on enhanced barrier precautions (EBP), leading to potential cross-contamination and infection spread. Observations revealed staff provided care to residents with PEG tubes and indwelling catheters without wearing gowns, despite facility policy requiring such precautions. The lack of adherence to EBP guidelines resulted in unsafe and unsanitary care.
Failure to Secure Resident in Whirlpool Bath Chair Results in Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during a whirlpool bath, resulting in a fall and injury. The resident, who had a history of hemiplegia, cerebral vascular accident, seizure disorder, agitation, and expressive aphasia, was assessed with severely impaired cognition and required substantial assistance with activities of daily living, including bathing. Despite the care plan instructions to use a safety belt during bathing, a Certified Nurse Aide (CNA) did not apply the safety belt while transferring the resident out of the whirlpool bath chair. Consequently, the resident fell from the chair, hit his head on the floor, and sustained a laceration above the right eye that required eight sutures. Interviews with staff revealed that the CNA did not consistently use the safety belt on the whirlpool bath chair prior to the incident. The facility's policy required the use of a safety belt for all residents using the whirlpool bath chair, except for two residents who refused, which did not include the injured resident. The facility's policy also instructed staff to hold firmly onto residents during transfers, but it lacked additional safety instructions. The failure to adhere to these safety protocols directly led to the resident's fall and subsequent injury.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident 12, who had severe cognitive impairment and used bed rails, was inaccurately assessed as using the rails as a restraint. Observations and interviews with staff revealed that the resident used the rails for positioning and assistance with bed mobility, not as a restraint. Despite this, the MDS was incorrectly coded, as confirmed by administrative staff, indicating a failure to accurately document the resident's use of the positioning rail. Resident 35, who had severe cognitive impairment and physical limitations due to hemiplegia and other conditions, was inaccurately assessed in the Admission MDS as having no impairments in his extremities. However, observations and staff interviews confirmed that the resident had functional limitations and required substantial assistance with activities of daily living, including the use of a mechanical lift for transfers. The discrepancy between the MDS and the resident's actual condition, as noted in the ADL Functional/Rehabilitation Potential Care Area Assessment, highlighted the inaccuracy in the MDS documentation.
Failure to Revise Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to review and revise care plans for two residents, R26 and R30, to include enhanced barrier precautions (EBP) related to the use of catheters and nephrostomy tubes. For Resident 26, the care plan did not provide instructions for the required use of personal protective equipment (PPE) during care involving an indwelling catheter. Observations revealed that staff, including Administrative Nurse E and Certified Nurse Aide (CNA) P, did not wear isolation gowns while providing catheter care, despite the presence of an EBP sign and PPE container outside the resident's room. This oversight was confirmed by both CNA P and Administrative Nurse E, who acknowledged the necessity of wearing gowns to prevent cross-contamination and infection spread. Resident 26 had a history of transient ischemic attack, cerebral infarction, morbid obesity, and incontinence with catheter use due to a terminal illness. The resident was admitted to hospice services and required staff assistance with activities of daily living. Despite these needs, the care plan lacked specific guidance on EBP, which was crucial given the resident's use of an indwelling catheter and the potential for infection. Similarly, Resident 30's care plan did not include instructions for EBP, despite the resident's diagnoses of renal failure, hydronephrosis, and the use of suprapubic and nephrostomy catheters. Observations showed that CNA Q donned gloves and a gown to empty the catheters, and the resident's room had signage indicating EBP. However, the care plan did not reflect this requirement. Administrative Nurse D and Consulting Staff GG confirmed the need for EBP due to the resident's catheter use, highlighting the facility's failure to update the care plan as the resident's condition changed.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to adequately monitor a resident for the use of antipsychotic medications, specifically Seroquel, which was prescribed for restlessness, agitation, and anxiety. The resident, who had a severe cognitive impairment and a history of cerebral infarction, was receiving antipsychotic medication on a routine basis. However, the facility did not complete the required Abnormal Involuntary Movement Scale (AIMS) assessment when the medication was first prescribed in June, as per their policy. The first and only AIMS assessment was conducted in October, which showed no involuntary movements, but no further assessments were documented. The facility's policy, revised in July 2022, mandates that an AIMS assessment be completed upon the initiation of antipsychotic medications and then quarterly thereafter. Despite this policy, the facility did not adhere to these guidelines, as confirmed by Administrative Staff A, who acknowledged the oversight and stated that the facility expected staff to complete the assessment at least every 90 days. This lapse in monitoring could potentially lead to unrecognized adverse reactions in the resident receiving antipsychotic medication.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) to prevent the spread of infection. During an observation, a licensed nurse provided care to a resident with a PEG tube without wearing a gown, and the resident's room lacked signage indicating the need for PPE. Another observation revealed the same nurse provided wound care to a resident without a gown, despite the resident having a history of MRSA in the wound culture. The facility's policy required staff to don gloves and a gown for high-contact care activities, but this was not followed. In another instance, a resident with an indwelling catheter was not provided care with the required PPE. The resident's care plan did not include instructions for EBP, and staff entered the resident's room and provided care without wearing isolation gowns. The resident's catheter leaked, and staff assisted with bathing and catheter care without the necessary PPE, despite the presence of an EBP sign and PPE container outside the room. The facility policy stated that gowns should be used during high-contact activities, including catheter care, but this was not adhered to. The facility's failure to implement EBP for residents with high-contact care needs, such as those with PEG tubes and indwelling catheters, resulted in a lack of safe and sanitary care. The observations and interviews confirmed that staff did not follow the facility's policy on EBP, leading to potential cross-contamination and the spread of infection among residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winfield Senior Living Community | 0.5 mi | ★★★★★ | 0 | 0 |
| Cumbernauld Village | 1.6 mi | ★★★★★ | 2 | 0 |
| Kansas Veterans Home | 2 mi | ★★★★★ | 1 | 0 |
| Anew Healthcare Oxford | 10.5 mi | — | 0 | 0 |
| Medicalodges Arkansas City | 11 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.