Safety Report: Winfield Rehab & Nursing
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
9Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
10Requirements cited on more than one inspection
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
J
Government finding: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F604
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
K
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
K
Government finding: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F607
K
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
J
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F580
Citations by topic
10Abuse, neglect & exploitation
3Infection control
4Medications & pharmacy
4Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (11) than in the cycle before (19).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 4 | May 1, 2025; March 9, 2025; September 11, 2024; July 1, 2024 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 3 | December 10, 2025; November 21, 2025; August 2, 2023 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 3 | March 9, 2025; September 11, 2024; July 1, 2024 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F607) | 3 | March 9, 2025; July 1, 2024; August 2, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | December 10, 2025; August 2, 2023 |
| Provide and implement an infection prevention and control program. (F880) | 2 | December 10, 2025; September 11, 2024 |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. (F949) | 2 | September 11, 2024; August 2, 2023 |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (F943) | 2 | September 11, 2024; August 2, 2023 |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. (F942) | 2 | September 11, 2024; August 2, 2023 |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. (F941) | 2 | September 11, 2024; August 2, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| May 1, 2025 | Fine | $16,891 |
| September 11, 2024 | Fine | $104,562 |
| July 1, 2024 | Fine | $201,416 |
| June 12, 2024 | Fine | $16,452 |
| June 12, 2024 | Fine | $16,452 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
December 10, 2025 — 10 citations
F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F851 · corrected January 16, 2026
F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F727 · corrected January 16, 2026
E
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · corrected January 16, 2026
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected January 16, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected January 16, 2026
D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F813 · corrected January 16, 2026
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected January 16, 2026
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected January 16, 2026
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · complaint · corrected January 16, 2026
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · complaint · corrected January 16, 2026
November 21, 2025 — 1 citation · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected November 22, 2025
May 1, 2025 — 2 citations (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected April 28, 2025
J
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · complaint · corrected April 28, 2025
March 9, 2025 — 3 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 4, 2025
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 3, 2025
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected April 3, 2025
September 11, 2024 — 14 citations (includes serious)
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected September 12, 2024
E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F949 · corrected October 8, 2024
E
Provide training in compliance and ethics.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F946 · corrected October 8, 2024
E
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F945 · corrected October 8, 2024
E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F944 · corrected October 8, 2024
E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F940 · corrected October 8, 2024
E
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F919 · corrected October 8, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected October 8, 2024
D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F947 · corrected October 8, 2024
D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · complaint · corrected October 8, 2024
D
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F942 · corrected October 8, 2024
D
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F941 · corrected October 8, 2024
D
Have policies on smoking.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F926 · corrected October 8, 2024
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected October 8, 2024
July 1, 2024 — 7 citations (includes serious) · complaint investigation
K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected July 2, 2024
K
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Immediate jeopardy to resident health or safety · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected July 2, 2024
K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected July 2, 2024
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected July 2, 2024
F
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Widespread · Resident Rights Deficiencies · F584 · complaint · corrected July 25, 2024
E
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F728 · complaint · corrected July 25, 2024
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected July 25, 2024
June 12, 2024 — 2 citations (includes serious) · complaint investigation
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected June 6, 2024
J
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Immediate jeopardy to resident health or safety · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected June 6, 2024
August 2, 2023 — 9 citations
E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F949 · corrected September 4, 2023
E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · corrected September 4, 2023
E
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F942 · corrected September 4, 2023
E
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F941 · corrected September 4, 2023
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected September 4, 2023
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected September 4, 2023
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected September 4, 2023
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected September 4, 2023
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected September 4, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare