Inspection Reports for
Lakewood Health and Rehab, LLC
2323 McCain Boulevard, North Little Rock, AR, 72116
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Deficiencies: 1
Date: Sep 25, 2025
Visit Reason
The inspection was conducted to review compliance with regulations regarding the facility's Arbitration Agreements, specifically to ensure that signing the Arbitration Agreement was not a condition of admission and that the agreement included the stipulation that it could be rescinded within 30 days of signing.
Findings
The facility failed to ensure that signing the Arbitration Agreement was not a condition of admission and that the agreement contained the stipulation that it could be rescinded within 30 days for two of three residents reviewed. The Administrator confirmed that the current agreements did state signing was a condition of admission and did not include the rescission clause, but corrective actions were underway.
Deficiencies (1)
Facility failed to ensure signing of the Arbitration Agreement was not a condition of admission and the agreement did not include the stipulation that it could be rescinded within 30 days for two residents.
Report Facts
Residents reviewed: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding Arbitration Agreements and corrective actions | |
| Social Service Director | Interviewed confirming details about Arbitration Agreements |
Inspection Report
Deficiencies: 2
Date: Sep 25, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the facility's Arbitration Agreement, specifically to determine if signing the Arbitration Agreement was a condition of admission and if the agreement included the stipulation that it could be rescinded within 30 days of signing.
Findings
The facility failed to ensure that signing the Arbitration Agreement was not a condition of admission and that the agreement contained the stipulation that it could be rescinded within 30 days of signing for two of three residents reviewed (Resident #19 and Resident #56). The facility acknowledged the deficiency and was in the process of updating all residents' Arbitration Agreements accordingly.
Deficiencies (2)
Signing of the facility Arbitration Agreement was a condition of admission and the agreement did not include a statement that it could be rescinded within 30 calendar days of being signed for Resident #19.
Signing of the facility Arbitration Agreement was a condition of admission and the agreement did not include a statement that it could be rescinded within 30 calendar days of being signed for Resident #56.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Confirmed that signing the Arbitration Agreement was a condition of admission and that the agreement did not contain the rescission statement. | |
| Administrator | Confirmed the Arbitration Agreements for Residents #19 and #56 indicated signing was a condition of admission and did not contain the rescission stipulation; stated the facility was correcting the agreements. |
Inspection Report
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with privacy and confidentiality regulations regarding residents' personal and medical information, specifically concerning the posting of resident photographs on the facility's social media site without written consent.
Findings
The facility failed to ensure resident privacy and confidentiality by posting photographs of residents on its social media site without obtaining written consent from the residents or their designated representatives, as confirmed by interviews and review of social media postings.
Deficiencies (1)
Facility posted photographs of residents on social media without written consent.
Inspection Report
Routine
Deficiencies: 7
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication storage, food safety, infection control, and use of bed rails and siderails.
Findings
The facility was found deficient in multiple areas including inconsistent nail care for residents, improper use and assessment of bed siderails, improper storage of inhalers, serving meals at unsafe temperatures, poor food preparation and storage practices, failure to ensure pureed food consistency, and failure to follow enhanced barrier precautions for infection control.
Deficiencies (7)
Failure to ensure nail care was consistently provided to promote good grooming and personal hygiene for Resident #39.
Failure to ensure assessment, informed consent, and proper use of siderails for Resident #60.
Failure to ensure an inhaler was properly stored after use for Resident #35.
Failure to ensure meals were served at safe and appetizing temperatures affecting multiple residents.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure proper food thawing, storage, labeling, and handling practices in the kitchen, risking foodborne illness.
Failure to consistently follow enhanced barrier precautions when administering medication and enteral feeding for Resident #42.
Report Facts
Residents affected by nail care deficiency: 1
Residents affected by siderail deficiency: 1
Residents affected by inhaler storage deficiency: 1
Residents affected by meal temperature deficiency: 53
Residents affected by pureed food consistency deficiency: 3
Residents affected by food safety deficiencies: 72
Residents affected by enhanced barrier precaution deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #16 | CNA | Confirmed nail care status for Resident #39 |
| Certified Nursing Assistant #27 | CNA | Confirmed nail care and podiatrist recommendation for Resident #39 |
| Director of Nursing | DON | Interviewed regarding siderail assessments and care planning |
| Licensed Practical Nurse #26 | LPN | Confirmed inhaler storage policy and enhanced barrier precautions |
| Licensed Practical Nurse #19 | LPN | Confirmed inhaler storage policy |
| Licensed Practical Nurse #27 | LPN | Observed not using gown during enhanced barrier precaution care for Resident #42 |
| Dietary Manager | Interviewed and observed regarding food safety, thawing, storage, and preparation | |
| Dietary Aide #3 | Dietary Aide | Observed thawing chicken and food handling |
| Dietary Aide #10 | Dietary Aide | Observed food handling and glove contamination |
| Dietary Aide #17 | Dietary Aide | Observed food delivery and temperature checks |
| Certified Nursing Assistant #14 | CNA | Conducted food temperature checks |
| Certified Nursing Assistant #15 | CNA | Conducted food temperature checks |
| Certified Nursing Assistant #16 | CNA | Conducted food temperature checks |
Inspection Report
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to assess compliance with privacy and confidentiality regulations related to residents' personal and medical information, specifically regarding the posting of resident photographs on the facility's social media site without written consent.
Findings
The facility failed to ensure resident privacy and confidentiality by posting photographs of residents on its social media site without obtaining written consent from the residents or their designated representatives. The Administrator and Consultant confirmed no consent forms were found for any residents posted on the social media page.
Deficiencies (1)
Failure to ensure resident privacy and confidentiality by posting photographs of residents on the facility's social media site without written consent.
Report Facts
Residents affected: Some residents were affected by the privacy breach
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jul 11, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, infection control, and food service at Lakewood Health and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including inconsistent nail care for residents, improper use and assessment of bed siderails, improper storage of medications, serving meals at unsafe temperatures, poor food preparation and storage practices, failure to maintain pureed food consistency, and failure to follow enhanced barrier precautions for infection control.
Deficiencies (7)
Failed to ensure nail care was consistently provided to promote good grooming and personal hygiene for Resident #39.
Failed to ensure an assessment for siderail use was completed and informed consent obtained prior to installation for Resident #60.
Failed to ensure an inhaler was properly stored after use for Resident #35.
Failed to ensure meals were served at safe and appetizing temperatures affecting multiple residents.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure proper food thawing, storage, labeling, and handling practices to prevent foodborne illness.
Failed to ensure enhanced barrier precautions were consistently followed when administering medication and enteral feeding for Resident #42.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 15
Residents affected: 10
Residents affected: 15
Residents affected: 13
Residents affected: 3
Residents affected: 72
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #16 | CNA | Confirmed nail care status for Resident #39 |
| Certified Nursing Assistant #27 | CNA | Confirmed nail care and podiatrist referral need for Resident #39 |
| Administrator | Administrator | Reported no policy on nail care and enhanced barrier precautions |
| Director of Nursing | DON | Interviewed regarding siderail assessments and care planning for Resident #60 |
| Licensed Practical Nurse #26 | LPN | Confirmed inhaler storage policy and enhanced barrier precautions |
| Licensed Practical Nurse #19 | LPN | Confirmed inhaler storage policy |
| Licensed Practical Nurse #27 | LPN | Observed not using gown during enhanced barrier precautions for Resident #42 |
| Dietary Manager | Dietary Manager | Interviewed and observed regarding food safety, thawing, storage, and preparation deficiencies |
| Dietary Aide #3 | Dietary Aide | Observed and interviewed regarding thawing chicken and food storage |
| Dietary Aide #10 | Dietary Aide | Observed improper glove use and food handling |
| Dietary Aide #17 | Dietary Aide | Observed delivering unheated food carts |
| Certified Nursing Assistant #14 | CNA | Measured food temperatures on multiple occasions |
| Certified Nursing Assistant #15 | CNA | Measured food temperatures on multiple occasions |
| Certified Nursing Assistant #12 | CNA | Interviewed about siderail use for Resident #60 |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
The inspection was conducted to ensure the facility's compliance with safety policies, specifically focusing on accident hazards and supervision related to resident smoking.
Findings
The facility failed to follow its smoking policy by allowing a resident to possess a cigarette lighter, which is against policy due to safety risks. Staff supervision of resident smoking breaks was inconsistent, and the facility lacked documentation of staff competency for supervising smoking breaks.
Deficiencies (1)
Failure to secure smoking materials for residents and inadequate supervision during smoking breaks.
Inspection Report
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with its smoking policy, specifically to ensure that smoking materials were secured and that resident smoking breaks were properly supervised.
Findings
The facility failed to follow its smoking policy by allowing a resident to possess a cigarette lighter, which is against policy. Staff supervision of resident smoking breaks was inconsistent, and the facility lacked documentation of staff competency for supervising smoking breaks.
Deficiencies (1)
Facility failed to follow the smoking policy by allowing residents to have their own cigarette lighters and inadequate supervision of smoking breaks.
Inspection Report
Routine
Deficiencies: 16
Date: Aug 18, 2023
Visit Reason
The inspection was a routine regulatory survey of Lakewood Health and Rehab, LLC to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, and food service.
Findings
The facility was found deficient in multiple areas including privacy breaches with medication carts, inaccurate resident assessments, incomplete care plans, inadequate nail and facial hair care, medication administration errors, improper respiratory care, food service issues including improper meal preparation and serving temperatures, and poor food storage and sanitation practices.
Deficiencies (16)
Failed to ensure privacy and confidentiality of personal and medical information on medication carts.
Failed to ensure resident assessments were accurately coded for oxygen therapy.
Failed to complete pre-admission screening and resident review (PASARR) process for residents with serious mental health diagnoses.
Failed to ensure baseline care plans were accurately completed for oxygen therapy upon admission.
Failed to include oxygen therapy and anticoagulant medications in individualized comprehensive care plans.
Failed to involve residents and family representatives in care plan meetings.
Failed to provide nail care and facial hair care for dependent residents.
Failed to ensure medications and respiratory treatments were administered only with a physician's order.
Failed to ensure catheter drainage bag was positioned off the floor.
Failed to ensure respiratory care equipment was properly maintained and oxygen cylinders safely stored.
Failed to ensure licensed nurses demonstrated competency with administering medications through gastrostomy tubes and respiratory services.
Medication error rate was 15.38%, including failure to administer ordered medications and administration without physician orders.
Failed to ensure meals were prepared and served according to the planned menu to meet nutritional needs.
Failed to serve meals at acceptable temperatures and maintain palatable appearance.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure foods stored in kitchen were covered, sealed, dated, and stored properly to prevent foodborne illness; failed to maintain clean and sanitary conditions in ice machines and scoop holders; failed to ensure dietary staff washed hands before handling clean equipment or food.
Report Facts
Medication error rate: 15.38
Medication pass opportunities: 26
Medication errors: 4
Residents affected by respiratory care issues: 18
Residents affected by pureed diet issues: 4
Residents affected by meal temperature issues: 45
Residents affected by food storage and sanitation issues: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication administration errors and competency findings |
| Director of Nursing | DON | Interviewed regarding privacy, care plans, medication administration, respiratory care, and facility policies |
| Dietary Employee #2 | Dietary Staff | Interviewed and observed regarding food preparation, storage, and sanitation deficiencies |
| Certified Nursing Assistant #3 | CNA | Observed assisting with meal service and interviewed regarding food temperature and consistency |
Inspection Report
Routine
Deficiencies: 16
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including privacy and confidentiality of resident information, accurate resident assessments and care planning, medication administration errors, respiratory care, food safety and handling, and dietary services. Several deficiencies were noted with minimal harm potential affecting a few to many residents.
Deficiencies (16)
Failed to ensure privacy and confidentiality of personal and medical information on medication carts.
Failed to ensure accurate coding of oxygen therapy on resident assessments.
Failed to complete pre-admission screening and resident review (PASARR) process for residents with serious mental health diagnoses.
Failed to ensure baseline care plans accurately reflected oxygen therapy needs upon admission.
Failed to include oxygen therapy and anticoagulant use in individualized comprehensive care plans.
Failed to involve residents and family representatives in care plan meetings.
Failed to provide nail care and facial hair care for dependent residents.
Administered medications and respiratory treatments without physician orders for some residents.
Failed to ensure catheter drainage bag was positioned off the floor.
Failed to ensure respiratory care equipment was properly maintained, oxygen flow rates were correct, and oxygen cylinders were safely stored.
Failed to demonstrate competency in medication administration through gastrostomy tubes and respiratory services.
Medication error rate was 15.38%, including failure to administer ordered medications and administration of medications without orders.
Failed to prepare and serve meals according to the planned menu and nutritional needs.
Failed to serve meals at safe and appetizing temperatures and maintain palatable appearance.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure food storage, preparation, and handling met professional standards including proper dating, sealing, cleanliness, and hand hygiene.
Report Facts
Medication pass opportunities: 26
Medication errors: 4
Medication error rate: 15.38
Residents affected by respiratory care deficiencies: 18
Residents affected by pureed diet issues: 4
Residents affected by meal temperature issues: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration errors and competency issues |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy policy, medication administration, respiratory care, and care planning |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding resident assessments and care planning |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed regarding nail care for residents |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding respiratory care and nail care |
| Dietary Employee #2 | Dietary Employee | Interviewed regarding food preparation and storage deficiencies |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed and interviewed regarding meal service and food temperature |
Viewing
Loading inspection reports...
