Inspection Reports for
The Lakes at Maumelle Health and Rehabilitation
103 Alexandria Drive, Maumelle, AR, 72113
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
The inspection was conducted due to complaints regarding neglect in wound care for Resident #42 and lack of physician's order for oxygen administration for Resident #50.
Complaint Details
The complaint investigation focused on neglect related to wound care for Resident #42, substantiated by missed wound care treatments and worsening wound condition. The oxygen administration issue for Resident #50 was also identified during the investigation.
Findings
The facility failed to ensure Resident #42 received ordered wound care, resulting in neglect with missed dressing changes and worsening wound condition. Additionally, the facility failed to obtain a physician's order for oxygen administration for Resident #50, despite oxygen therapy being provided.
Deficiencies (2)
Failure to provide ordered wound care and dressing changes for Resident #42, resulting in neglect and worsening wound condition including presence of maggots.
Failure to ensure a Physician's Order for oxygen administration for Resident #50 despite oxygen therapy being provided.
Report Facts
Missed wound care/dressing changes: 14
Residents reviewed for wound care: 3
Residents reviewed for oxygen administration: 2
Oxygen liters per minute: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in wound care neglect finding; received verbal and written warnings and was placed on medical leave |
| DON | Director of Nursing | Interviewed regarding wound care neglect and oxygen administration; involved in corrective actions and warnings |
| Administrator | Interviewed regarding wound care complaints and facility policies | |
| Advance Practice Registered Nurse | APRN | Interviewed regarding Resident #42 wound care and condition |
| Wound care clinic doctor | Interviewed regarding wound care provided to Resident #42 and wound condition |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 25, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to safe and appropriate respiratory care, specifically focusing on oxygen administration for residents.
Findings
The facility failed to ensure a Physician's Order for oxygen administration was received for one of two residents reviewed for oxygen therapy. Documentation review and interviews revealed oxygen was administered without a physician's order, contrary to facility policy.
Deficiencies (1)
Failure to ensure a Physician's Order for oxygen administration was received for one resident receiving oxygen therapy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding oxygen administration procedures and physician order requirements. |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident environment cleanliness, maintenance of heating and air conditioning units, medication storage, and food palatability at The Lakes at Maumelle Health and Rehabilitation.
Findings
The facility was found to have deficiencies including unsanitary resident rooms and common areas, a heating and air conditioning unit missing a temperature adjustment knob, unlocked medication carts, and failure to provide palatable and properly prepared food to residents.
Deficiencies (4)
Facility failed to ensure residents' rooms were sanitary, clean, and homelike; observed unpleasant odors, sticky floors, spills, and clutter in Resident #4's room and common areas.
Heating and air conditioning unit in Resident #6's room missing a temperature adjustment knob, limiting resident's ability to control temperature.
Medication carts were left unlocked and unattended, posing risk of unauthorized access to drugs and biologicals.
Facility failed to provide palatable food; meals were bland, overcooked, missing ordered condiments, and residents reported dissatisfaction with food quality.
Report Facts
Assessment Reference Date: Apr 12, 2024
Brief Interview for Mental Status (BIMS) score: 15
Date of last dietary assessment: Jul 5, 2022
Date of Care Plan: Nov 19, 2021
Date of Minimum Data Set (MDS): Feb 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding heating and air conditioning unit and medication cart policies |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food preparation and meal tray issues |
| Housekeeping Supervisor | Housekeeping Supervisor (HS) | Interviewed about cleaning procedures and odor control |
| Maintenance Director | Maintenance Director | Interviewed about heating and air conditioning unit maintenance |
| Licensed Practical Nurse #8 | Licensed Practical Nurse (LPN) | Observed leaving medication cart unlocked |
| Licensed Practical Nurse #9 | Licensed Practical Nurse (LPN) | Confirmed leaving medication cart unlocked |
| Certified Nurse Aide #07 | Certified Nurse Aide (CNA) | Interviewed about adjusting Resident #6's heating and air conditioning unit |
Inspection Report
Routine
Deficiencies: 11
Date: Jun 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, privacy of resident health information, accuracy of resident assessments, care planning, fall prevention, medication storage, food quality and safety, infection control, and equipment maintenance at The Lakes at Maumelle Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure residents self-administer medications only when clinically appropriate, failure to protect resident health information privacy, inaccurate Minimum Data Set assessments, incomplete care plans for fall prevention, improper placement and maintenance of fall mats, unlocked medication carts, unpalatable and improperly prepared food, inadequate dishwasher sanitation, failure to follow infection control protocols during wound care, and unsafe kitchen equipment conditions.
Deficiencies (11)
Allowed resident to self-administer medication without prior clinical assessment.
Failed to protect resident's personal and medical information by leaving computer screen unlocked.
Failed to complete an accurate Minimum Data Set for a resident regarding anticoagulant use.
Failed to develop and implement a complete care plan addressing fall mat use for residents.
Failed to ensure fall mats were properly placed and maintained, increasing fall risk.
Failed to keep housekeeping carts and janitor closets locked, exposing chemicals to residents.
Failed to store drugs and biologicals in locked compartments; medication carts left unlocked and unattended.
Failed to provide palatable, properly seasoned, and complete meals to residents.
Failed to ensure dishwasher reached proper sanitizing temperatures consistently.
Failed to ensure staff washed hands between glove changes and avoided cross contamination during wound care.
Failed to maintain kitchen equipment in safe working condition; dishwasher leaking water and possible mold present.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Assessment Reference Date: Apr 9, 2024
Assessment Reference Date: Feb 29, 2024
Assessment Reference Date: Apr 17, 2024
Assessment Reference Date: Apr 12, 2024
Assessment Reference Date: Feb 10, 2024
Dishwasher temperature: 182.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #8 | Licensed Practical Nurse | Left medication cart unlocked and left computer screen unlocked displaying PHI |
| LPN #9 | Licensed Practical Nurse | Left medication cart unlocked and confirmed medication cart was unattended |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication self-administration, PHI privacy, fall mat placement, medication storage, and housekeeping cart lock |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate MDS assessment and care planning for fall mats |
| CNA #6 | Certified Nurse Aide | Interviewed regarding condition of fall mat |
| Housekeeping Staff #10 | Housekeeping Staff | Reported broken lock on housekeeping cart |
| Housekeeping Supervisor | Housekeeping Supervisor | Reported staff education on housekeeping cart lock issue |
| Dietary Manager | Dietary Manager | Interviewed regarding food palatability, dishwasher temperature, and kitchen sanitation |
| Dietary Consultant | Dietary Consultant | Checked dishwasher temperature and documentation |
| LPN #1 | Licensed Practical Nurse | Observed providing wound care with multiple hand hygiene and cross contamination failures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of physical abuse involving Resident #1.
Complaint Details
The complaint investigation involved an allegation by Resident #1 of physical abuse (rape) by an employee. The allegation was not reported immediately by staff members including a Floor Nurse, Certified Nursing Assistant, and Human Resource Director. The investigation included interviews and review of documentation. The allegation was substantiated by hospital and Adult Protective Services reports.
Findings
The facility failed to ensure staff members reported an allegation of physical abuse immediately to the Administrator. Resident #1 alleged being raped by an employee during care, but staff delayed reporting the allegation. Interviews revealed confusion and failure to report within the required timeframe.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents affected: 4
Reporting timeframe for physical abuse: 2
Reporting timeframe for non-abuse violations: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in failure to report abuse allegation | |
| Certified Nursing Assistant #1 | Named in failure to report abuse allegation | |
| Human Resource Director | Named in failure to report abuse allegation and responsible for orientation and reporting | |
| Administrator | Interviewed regarding reporting timeframes and facility policy |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, specifically the provision of humidification for oxygen therapy to residents.
Findings
The facility failed to ensure that a humidification bottle was present to humidify oxygen for one sampled resident receiving oxygen therapy. Observations and interviews confirmed the absence of humidification despite physician orders and facility policy requiring it.
Deficiencies (1)
Failure to ensure a humidification bottle was present to humidify oxygen for a resident receiving oxygen therapy.
Report Facts
Residents affected: 1
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding humidification for Resident #1 | |
| Director of Nursing (DON) | Interviewed regarding humidification for Resident #1 |
Inspection Report
Routine
Census: 50
Deficiencies: 6
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, food services, respiratory care, and immunization practices at The Lakes at Maumelle Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide timely bathing assistance to residents, unsafe storage of germicidal wipes posing accident hazards, improper oxygen administration not following physician orders, failure to accommodate resident food preferences, unsafe food storage and handling practices in the kitchen, and failure to timely administer pneumococcal vaccinations to residents with consent.
Deficiencies (6)
Failed to provide bathing assistance for 3 of 16 sampled residents who required staff assistance with bathing.
Failed to ensure the residents environment was free of potential accident hazards related to unattended germicidal disposable cloth wipes accessible to residents.
Failed to ensure oxygen was administered per physicians' orders for 1 of 5 sampled residents.
Failed to ensure resident food preferences were communicated and accommodated for 1 of 11 sampled residents.
Failed to ensure food items stored in the kitchen were sealed, labeled, dated, and handled properly to prevent foodborne illness for residents.
Failed to ensure residents with consents for pneumococcal vaccine received the immunization in a timely manner after admission for 1 of 5 sampled residents.
Report Facts
Residents sampled for bathing assistance: 16
Residents affected by bathing deficiency: 3
Residents sampled for oxygen administration: 5
Residents sampled for food preferences: 11
Residents affected by food preference deficiency: 1
Residents receiving meals from kitchen: 49
Total census: 50
Residents sampled for immunization review: 5
Residents affected by pneumococcal vaccine deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #5 | CNA | Interviewed regarding bathing schedule and resident complaints |
| Director of Nurses | DON | Interviewed regarding bathing schedule, oxygen monitoring, and food preference process |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding bathing frequency and food preference process |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding bathing frequency |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding oxygen administration |
| Dietary Manager | DM | Interviewed regarding food preference process and kitchen practices |
| Dietary Consultant | Consultant | Interviewed regarding food storage and spoilage |
| Certified Nursing Assistant #3 | CNA | Observed leaving shower room door open near germicidal wipes |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding risks of unattended germicidal wipes |
| Infection Preventionist | IP | Interviewed regarding pneumococcal vaccination documentation |
Inspection Report
Routine
Census: 50
Deficiencies: 3
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, food service, and facility operations at The Lakes at Maumelle Health and Rehabilitation.
Findings
The facility failed to provide adequate bathing assistance to residents requiring help, failed to ensure resident food preferences were properly communicated and accommodated, and failed to maintain proper food storage and handling practices in the kitchen, potentially affecting resident health and well-being.
Deficiencies (3)
Failed to provide bathing assistance for 3 of 16 sampled residents who required staff assistance with bathing.
Failed to ensure resident food preferences were communicated and accommodated for 1 of 11 sampled residents.
Failed to ensure food items stored in refrigerators, freezers, and dry storage were sealed, labeled, and dated; discarded expired or spoiled items promptly; and dietary staff washed hands and handled plates properly during meal service.
Report Facts
Residents sampled for bathing assistance: 16
Residents affected by bathing deficiency: 3
Residents sampled for food preference: 11
Residents affected by food preference deficiency: 1
Total census: 50
Resident weight loss percentage: 10.26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #5 | Interviewed about bathing schedule and resident complaints | |
| Director of Nurses (DON) | Interviewed about bathing scheduling and food preference processes | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about bathing frequency and food preference communication | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about bathing frequency | |
| Dietary Manager (DM) | Interviewed about process for determining residents' food preferences | |
| Cook #1 | Interviewed about food storage and labeling | |
| Cook #2 | Observed and interviewed about handwashing and plate handling | |
| Dietary Consultant | Provided assessment of food storage conditions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 9, 2023
Visit Reason
The inspection was conducted due to complaints and investigations related to misappropriation of medications and tampering with the Emergency Medication kit (E-kit) at The Lakes at Maumelle Health and Rehabilitation.
Complaint Details
The complaint investigation was substantiated with findings of medication misappropriation involving Residents #1, #2, and #3. The investigation included video surveillance, medication counts, and interviews. The Director of Nursing and other staff confirmed the incidents. The misappropriation involved narcotics and other medications replaced with non-prescribed pills. The Emergency Medication kit was also compromised.
Findings
The facility failed to prevent medication misappropriation involving three residents and tampering with the narcotic E-kit. Investigations revealed that an LPN was observed on video removing and replacing medications with other pills, including narcotics, resulting in missing controlled substances. The facility policies and staff interviews confirmed these findings, with no residents showing signs of distress.
Deficiencies (1)
Failure to protect residents from wrongful use of their medications, including misappropriation of narcotics and tampering with the Emergency Medication kit.
Report Facts
Missing Lorazepam pills: 15
Missing Hydrocodone pills: 12
Compromised narcotics in E-kit: 27
Forged narcotic signatures: 3
Missing narcotics for Resident #3: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed on video removing and replacing medications; admitted to the act without explanation. | |
| Licensed Practical Nurse (LPN) #2 | Identified discrepancies in medication counts and reported misappropriation. | |
| Director of Nursing (DON) | Interviewed regarding the incident; confirmed findings and described medication reconciliation processes. | |
| Administrator | Participated in investigation and medication examination. | |
| Assistant Director of Nursing (ADON) | Participated in investigation and medication examination. | |
| Unit Manager | Noted discrepancies in medication cards and participated in investigation. |
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