Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winnfield Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was not assisted to the dining room for meals as required by their care plan, despite being dependent on staff for eating and mobility. Staff interviews and observations confirmed that the resident remained in their room during meals, contrary to documented fall prevention measures.
The facility did not ensure that two residents' discharges were properly documented or that written instructions and discharge planning were provided, including the basis for discharge, medication reconciliation, and referrals for caregiver support. Staff interviews confirmed that required discharge documentation and procedures were not completed.
Two residents were discharged without complete discharge summaries, missing required information such as a recapitulation of their stay, final status at discharge, and medication reconciliation. Documentation was either incomplete or missing key details, and staff confirmed that the necessary discharge information was not provided or properly recorded.
A resident with a history of substance use and multiple behavioral health diagnoses was not care-planned for substance abuse, and ongoing concerns about drug diversion and active substance use were not addressed by staff. Provider notes documented the resident's diversion and abuse of medications, but these issues were not acted upon, and required monthly urine drug screens were not performed as ordered.
A resident's admission and Quarterly MDS assessments failed to accurately reflect their diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, and substance use/abuse, despite these being documented in the medical record and social services assessments. Staff interviews confirmed the omissions and acknowledged that these conditions should have been included in the MDS.
A resident with multiple behavioral health diagnoses was admitted without a baseline care plan being developed within 48 hours, as required by facility policy. The DON confirmed that no baseline care plan was created to address the resident's immediate needs after admission.
A resident with multiple behavioral health diagnoses, including substance abuse, suicidal ideations, and PTSD, was not provided with a comprehensive, person-centered care plan addressing these conditions. Staff confirmed that the care plan did not include interventions for these significant issues, contrary to facility policy.
A resident with multiple mental health diagnoses and a history of substance abuse was not referred for mental health services upon admission, despite facility protocols and identified needs. The resident did not receive timely or ongoing mental health evaluations, with gaps in monthly follow-up visits while on antipsychotic and antidepressant medications.
A resident with moderate cognitive impairment was physically abused by another resident during breakfast. The aggressor, also with moderate cognitive impairment, hit the victim in the face after a dispute over milk. The incident was witnessed by CNAs, and the facility's abuse prevention policy failed to prevent this occurrence.
The facility did not meet residents' nutritional needs by failing to serve the correct portion sizes as per the menu. During lunch, six residents on a regular diet received improper portions, with five receiving one small chicken leg and one receiving two small chicken legs, which were not a double portion. The menu specified a 3 oz. portion size for Baked Chicken, but the served portions were inadequate. This was confirmed by the Dietary Manager and Regional Director of Nutritional Services.
The facility failed to adhere to professional food safety standards, as evidenced by moldy bread, expired hot dog buns, and undated cornstarch in the dry storage area, along with an unsealed, undated pad of butter in the refrigerator. These deficiencies were observed with the Dietary Manager and could impact any resident consuming meals from the kitchen.
A resident with legal blindness and cognitive impairments did not have a call light within reach, as required by her care plan. Observations showed the call bell was placed across the room, and staff interviews confirmed the issue was due to the absence of an extension cord. The resident had to yell to communicate her needs.
A resident with mental health disorders was physically abused by another resident with a history of altercations. The incident occurred when one resident tapped the other on the shoulder, leading to a physical altercation. Despite the facility's policy on abuse prevention, the measures in place were insufficient to prevent the incident.
The facility did not thoroughly investigate an incident where a resident tapped another, leading to a physical altercation. Witness statements from staff present during the incident were not obtained, and necessary safety checks on the behavioral unit were not conducted. The administrator confirmed the investigation was incomplete.
A resident with dementia and depression experienced significant weight loss due to the facility's failure to document meal intake and provide one-on-one dining assistance as care planned. Observations showed the resident eating unsafely without supervision, and the DON acknowledged the lack of documentation and assistance.
A resident with multiple diagnoses, including Down's Syndrome and Dementia, was observed with long chin hairs over several days, despite regular bathing and no refusal of care. Staff acknowledged the need for shaving, but the issue persisted, impacting the resident's dignity and quality of life.
The facility failed to implement care plans for two residents, leading to a deficiency in monitoring and recording food intake. One resident, with severe cognitive impairment, experienced a 17% weight loss over three months due to unrecorded meal intake on 36 out of 39 days. Another resident, with dementia and intellectual disabilities, had a 12% weight loss over four months, with meal intake unrecorded on 32 out of 39 days. The DON acknowledged the failure to document as required.
A resident with moderate cognitive impairment and impaired mobility was found with a broken self-release belt buckle on his wheelchair. Despite reporting the issue to a nurse, the broken buckle was observed on multiple occasions, and staff confirmed the failure to address the problem promptly.
Failure to Implement Person-Centered Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident with multiple complex diagnoses, including schizoaffective disorder, bipolar type, type 2 diabetes, hypertensive heart disease, anxiety, a history of falling, and dementia with agitation. The resident was assessed as having severe cognitive impairment and was dependent on staff for eating, mobility, transfers, and personal hygiene. The care plan specifically instructed that the resident should be assisted to the dining room for all meals as part of fall prevention measures. Despite these documented care plan instructions, observations and staff interviews confirmed that the resident was not assisted to the dining room for breakfast or lunch on the day in question. The resident was found in her room with a lunch tray, having only consumed milk and leaving the rest of the food untouched. Multiple staff members, including CNAs and an LPN, acknowledged that the resident should have been assisted to the dining room for meals but was not, in direct contradiction to the care plan.
Failure to Document and Prepare Safe Resident Discharges
Penalty
Summary
The facility failed to ensure proper documentation and preparation for the discharge of two residents, as required by its own policies and regulatory standards. For both residents, there was no documentation in the medical record specifying the basis for their discharge, nor evidence that written discharge instructions were provided to or discussed with the residents or their responsible parties. Additionally, there was no documentation of discharge planning that addressed caregiver support or referrals to local contact agencies, despite the facility's policy requiring such actions. One resident, admitted with multiple complex diagnoses including a right tibia fracture, MRSA infection, diabetes, and a history of venous thrombosis, was noted to have intact cognition and expressed a desire to return home. The resident's insurance coverage ended, and although the resident was informed of the option to pay out of pocket, this discussion and the resident's refusal were not documented. The discharge form was only partially completed, and there was no record of medication reconciliation, discharge instructions, or coordination of care in the resident's file. The second resident, admitted for short-term therapy following a stroke and with diagnoses including Alzheimer's disease and hemiplegia, also had no documentation in the medical record regarding the reason for discharge or any instructions about medications provided at discharge. Progress notes indicated the resident was discharged home with medications and that a follow-up evaluation was planned, but there was no evidence of written instructions or comprehensive discharge planning. Interviews with facility staff confirmed that required documentation and discharge procedures were not completed for either resident.
Incomplete Discharge Summaries and Missing Required Documentation
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for two of three residents reviewed for discharge. For both residents, the discharge summaries were missing essential elements required by facility policy and federal regulations, including a recapitulation of the residents' stay with diagnoses, course of illness or treatment, pertinent lab, radiology, and consultation results, a final summary of the residents' status at the time of discharge, and a reconciliation of all pre-discharge medications with post-discharge medications. For one resident, the medical record review showed an incomplete discharge summary document, lacking the required information and only partially filled out. The document was provided to the resident at discharge, but it did not include a comprehensive summary of the resident's stay, status at discharge, or medication reconciliation. Interviews with facility staff confirmed that the discharge summary was not completed as required and that the responsibility for discharge documentation was not clearly followed. For the second resident, the discharge documentation included a progress note and a discharge summary form, but these also lacked critical information. There was no documentation of the reason for discharge, no list of medications provided at discharge, and no record of instructions given to the resident. The discharge summary form was not signed by the resident and did not include a summary of the resident's diagnoses, treatment course, or status at discharge. Staff interviews confirmed these omissions and acknowledged that the required documentation was not present in the resident's medical record.
Failure to Provide Behavioral Health Services and Monitor Substance Use
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of substance use and multiple behavioral health diagnoses, including adverse effects of methamphetamines, cannabis abuse, suicidal ideations, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. The resident's comprehensive care plan did not address their history of substance use/abuse, despite this being known at admission and confirmed by both the administrator and MDS coordinator. Additionally, the resident's Minimum Data Set (MDS) assessments did not indicate substance use/abuse or PTSD, contrary to the resident's medical history. Provider progress notes documented ongoing concerns, including drug diversion, active substance abuse within the facility, and the resident taking medications not prescribed to them. These concerns were not addressed by facility staff, and the administrator was unaware of these issues at the time of the resident's death. Furthermore, although there was a physician's order for monthly urine drug screens (UDS), these were not performed as ordered after the initial positive result for methamphetamine. Staff interviews confirmed that the required monthly UDS were not completed.
Inaccurate MDS Assessments for Resident with Psychiatric and Substance Use History
Penalty
Summary
The facility failed to ensure that both the admission and Quarterly Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. Specifically, the MDS assessments did not include the resident's diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, or substance use/abuse, despite these being documented in the resident's medical record and social services assessments. The resident's admission and Quarterly MDS both recorded a BIMS score indicating intact cognition and omitted critical psychiatric and substance use diagnoses. Interviews with facility staff confirmed that the resident's social services history and initial assessment identified PTSD, increased anxiety, and a history of substance use/abuse, but these were not reflected in the MDS assessments. The omission was acknowledged by both the Social Services Director and the Administrator, who confirmed that the relevant diagnoses and history should have been included in the MDS documentation.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan is required to be created promptly upon admission to address the resident's immediate needs until a comprehensive care plan is completed. Record review showed that the resident, admitted with multiple complex diagnoses including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder, did not have a baseline care plan in place. During an interview, the Director of Nursing confirmed that a baseline care plan was not developed for this resident, despite policy requirements.
Failure to Develop Comprehensive Care Plan for Resident with Complex Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident, as required by its own policy. The resident was admitted with multiple diagnoses, including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, a history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. Review of the resident's medical record and care plan revealed that the care plan did not address suicidal ideations, history of suicidal behavior, PTSD, or substance use/abuse. Facility staff interviews confirmed that these issues were not included in the care plan, despite the expectation that they should have been.
Failure to Provide Timely and Ongoing Mental Health Services
Penalty
Summary
The facility failed to provide mental health services in accordance with professional standards for a resident admitted with multiple mental health diagnoses, including PTSD, generalized anxiety disorder, bipolar disorder, major depressive disorder, and a history of substance abuse and suicidal behavior. Upon admission, the resident's social services assessment identified significant mental health needs, but a timely referral for mental health services was not made. Although facility protocol required automatic referral for residents with mental health diagnoses, this was not followed, and the resident was not referred for mental health services until several weeks after admission. Additionally, the facility did not ensure that mental health services were provided on a continual basis. After the initial psychiatric evaluation and two follow-up visits, there were no further mental health encounters documented for the resident, despite ongoing use of antipsychotic and antidepressant medications. Staff interviews confirmed that the resident should have been seen monthly by the mental health nurse practitioner, but this did not occur after the last documented visit.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #3, who has a history of schizoaffective disorder, bipolar type, anxiety disorder, major depressive disorder, depression, glaucoma, legal blindness, and cognitive communication deficit, was involved in an incident with Resident #5. Resident #3 has a BIMS score indicating moderate cognitive impairment. During breakfast, Resident #3 accused Resident #5 of taking her milk, which led to Resident #5 physically hitting Resident #3 in the face. This incident was witnessed by two CNAs who were present in the dining room. Resident #5, who also has a history of schizoaffective disorder, depressive type, anxiety disorder, diffuse traumatic brain injury, and cognitive social or emotional deficit following cerebrovascular disease, was identified as the aggressor in this incident. Resident #5 has a BIMS score indicating moderate cognitive impairment. The facility's incident report and witness statements confirm that Resident #5 made contact with Resident #3's face with her fist, resulting in discoloration to Resident #3's upper lip. The facility's policy on abuse prevention was not effectively implemented to prevent this incident of resident-to-resident abuse.
Failure to Meet Nutritional Needs Due to Improper Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the established portion sizes as outlined in the menu. During an observation of lunch preparation, it was noted that six residents on a regular diet were served improper portion sizes. Specifically, five residents received only one small chicken leg, and one resident received two small chicken legs, which were incorrectly considered a double portion. According to the facility's Production Sheet Main Menu, the portion size for Baked Chicken was specified as 3 oz. An interview with the Dietary Manager and the Regional Director of Nutritional Services confirmed that one chicken leg without the bone was approximately 2 oz., and residents should have been served two chicken legs to meet the 3 oz. portion size requirement.
Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety. During an observation of the kitchen's dry food storage area, a loaf of bread with mold was found, along with two packages of hot dog buns that had expired. Additionally, an opened and undated box of cornstarch was discovered. In the walk-in refrigerator, a used pad of butter was found unsealed and undated. These deficiencies were identified during an observation with the Dietary Manager and had the potential to affect any resident consuming meals from the facility's kitchen.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident #30, by not ensuring the availability of a call light within reach. Resident #30, who was admitted with diagnoses including legal blindness, major depressive disorder, schizoaffective disorder, and cognitive communication deficit, had a care plan that specified the need for a call light to be within reach due to her sensory and perception alterations. Despite this, observations revealed that the call bell was placed on a nightstand across the room, out of reach, and not accessible to the resident. Interviews with the resident and staff confirmed the deficiency. The resident expressed difficulty in locating the call bell at night due to her blindness. A CNA explained that the call bell was not in use because its cord would obstruct the walkway if positioned near the resident's bed. The RN confirmed the call bell's inaccessibility, attributing it to the absence of an extension cord, which the facility was awaiting. This situation left the resident to resort to yelling to communicate her needs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #76, who has a history of mental health disorders including Bipolar Disorder, Schizophrenia, and Dementia, was physically abused by Resident #68. The incident occurred when Resident #76 tapped Resident #68 on the shoulder, causing Resident #68 to become frightened and grab Resident #76's hair. This resulted in Resident #76 falling to the ground. The facility's policy on abuse prevention, which includes protection from resident-to-resident abuse, was not effectively implemented in this case. Resident #68, who has a history of altercations and is diagnosed with Paranoid Schizophrenia and other mental health conditions, was involved in the altercation. The incident was reported by a CNA who witnessed the event and intervened to separate the residents. Despite the facility's awareness of Resident #68's history of altercations, the measures in place were insufficient to prevent the incident. The facility's failure to ensure adequate supervision and intervention led to the physical abuse of Resident #76.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation of an incident involving resident-to-resident abuse. On August 11, 2024, a Certified Nursing Assistant (CNA) reported that while distributing snacks in the special care unit's common area, one resident tapped another on the shoulder, causing the second resident to become frightened and grab the first resident's hair. During the altercation, the first resident fell to the ground. The residents were immediately separated, and the second resident was placed on one-to-one supervision before being sent to a behavioral hospital the following day. The facility's investigation into the incident was incomplete. Witness statements were not obtained from the CNA, a Licensed Practical Nurse (LPN), or the Registered Nurse (RN) on duty at the time of the incident. The facility also failed to conduct body audits and safety rounds on all residents in the behavioral unit. The administrator confirmed that the investigation was not completed and acknowledged the failure to obtain necessary witness statements from staff who observed the incident.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not implementing appropriate interventions for weight loss. Specifically, the facility did not document the meal intake for a resident as care planned and failed to provide one-on-one assistance during meals. The resident, who had diagnoses including Major Depressive Disorder, Unspecified Dementia, Cellulitis, and Hypertension, experienced a significant weight loss of 17.15% over six months. The resident's care plan included interventions such as one-on-one dining assistance, monitoring food intake, and reporting any decline to the physician and dietician. Observations revealed that the resident was left unattended during meals, leading to unsafe eating behaviors, such as attempting to eat plastic wrap. The staff failed to document the resident's meal intake consistently, with numerous instances of missing documentation over several days. The Director of Nursing acknowledged these failures, confirming that the resident was care planned for one-on-one assistance with dining, which was not provided.
Failure to Maintain Resident's Personal Hygiene and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not maintaining her personal hygiene, specifically by allowing her to have long, curly chin hairs. The resident, who has multiple diagnoses including Down's Syndrome, Major Depressive Disorder, and Dementia, was observed on multiple occasions with facial hair that was approximately an inch long, covering her entire chin. Despite being bathed regularly and not refusing personal care, the resident's facial hair was not addressed by the staff. Interviews with the facility's staff, including CNAs and the DON, confirmed that the resident had been observed with long chin hairs over several days. The staff acknowledged the need for the resident to be shaved, yet the issue persisted over multiple observations. The resident's care plan indicated she required assistance with personal hygiene, but this aspect of her care was neglected, impacting her dignity and quality of life.
Failure to Monitor and Record Food Intake
Penalty
Summary
The facility failed to implement the care plans for two residents, resulting in a deficiency related to monitoring and recording food intake. Resident #1, who has severe cognitive impairment and a history of weight loss, was not monitored for food intake as required by their care plan. The care plan included interventions such as dietician evaluation, determining food preferences, and monitoring food intake at each meal. However, the Meal Report revealed that food intake was not recorded on 36 out of 39 days, leading to a significant weight loss of 17% over three months. Similarly, Resident #2, who has multiple diagnoses including dementia and moderate intellectual disabilities, also experienced a failure in care plan implementation. The resident's care plan required monitoring and recording food intake at each meal, but the Meal Report showed that this was not done on 32 out of 39 days. This lack of documentation coincided with a significant weight loss of 12% over four months. The Director of Nursing acknowledged the failure to document meal intake for both residents as instructed in their care plans.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition for Resident #3. Resident #3, who has a history of hypertension, cerebrovascular disease, type 2 diabetes mellitus, and insomnia, was observed with a broken self-release belt buckle on his wheelchair. The resident, who has moderate cognitive impairment and impaired mobility, reported the broken buckle to a nurse but could not recall which nurse. Despite this report, the broken buckle was observed on multiple occasions over several days, indicating a failure to address the issue promptly. On two separate observations, the broken buckle was noted, and interviews with the resident and staff confirmed the issue. The LPN acknowledged that the buckle should not have been broken and that nursing staff are responsible for routinely monitoring the self-release belt. The facility administrator also confirmed the broken buckle, highlighting a lapse in maintaining essential equipment in safe working condition for the resident.
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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.
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Nursing homes near Winnfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Leaves Nursing And Rehab Ctr, Llc | 2.3 mi | — | 0 | 0 |
| Wyatt Manor Nursing And Rehab Ctr, Inc | 15.7 mi | — | 10 | 1 |
| Forest Haven Nursing & Rehab Ctr, Llc | 20.8 mi | — | 0 | 0 |
| Natchitoches Community Care Center | 27.7 mi | — | 0 | 0 |
| Colfax Nursing And Rehab, Llc | 28.4 mi | — | 0 | 0 |
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