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Health Inspection Summary

The Lakes at Maumelle Health and Rehabilitation

103 Alexandria Drive

Maumelle, AR 72113

(501) 734-1400

Deficiency Category	Inspection Date: 6/5/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 6/29/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 4/22/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	2	0
Quality of Life and Care Deficiencies	1	4	8
Infection Control Deficiencies	1	1	2
Resident Assessment and Care Planning Deficiencies	2	0	2
Nursing and Physician Services Deficiencies	0	0	1
Resident Rights Deficiencies	2	0	3
Nutrition and Dietary Deficiencies	2	2	3
Pharmacy Service Deficiencies	1	0	1
Environmental Deficiencies	1	0	1
Administration Deficiencies	0	0	0

Detailed result for inspection on 6/5/24

Date of last standard health inspection:	6/5/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in Arkansas:	7.5
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep residents' personal and medical records private and confidential.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Few
Allow residents to self-administer drugs if determined clinically appropriate.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep all essential equipment working safely.	6/5/24	7/3/24	2 - Minimal harm or potential for actual harm	Few

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 6/29/23

Date of last standard health inspection:	6/29/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	11/29/23Read the full report (PDF) 11/9/23Read the full report (PDF) 6/29/23Read the full report (PDF) 6/9/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	9
Average number of Health Deficiencies in Arkansas:	8.2
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	6/9/23	6/9/23	2 - Minimal harm or potential for actual harm	Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/29/23	12/21/23	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe and appropriate respiratory care for a resident when needed.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Some
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Some
Provide safe and appropriate respiratory care for a resident when needed.	11/9/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement policies and procedures for flu and pneumonia vaccinations.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Many
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/22/22

Date of last standard health inspection:	4/22/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	1/12/23Read the full report (PDF) 10/7/22Read the full report (PDF) 4/22/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	1/12/23Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	21
Average number of Health Deficiencies in Arkansas:	8.5
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe and appropriate respiratory care for a resident when needed.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Provide care and assistance to perform activities of daily living for any resident who is unable.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	1/12/23	2/10/23	2 - Minimal harm or potential for actual harm	Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Provide safe and appropriate respiratory care for a resident when needed.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Report COVID19 data to residents and families.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Reasonably accommodate the needs and preferences of each resident.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Allow residents to self-administer drugs if determined clinically appropriate.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Many
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident’s drug regimen must be free from unnecessary drugs.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	6/9/23	6/9/23	2 - Minimal harm or potential for actual harm	Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/29/23	12/21/23	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Some
Provide safe and appropriate respiratory care for a resident when needed.	11/9/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Many
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	6/29/23	7/28/23	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Provide care and assistance to perform activities of daily living for any resident who is unable.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	1/12/23	2/10/23	2 - Minimal harm or potential for actual harm	Some
Provide safe and appropriate respiratory care for a resident when needed.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some
Reasonably accommodate the needs and preferences of each resident.	4/22/22	5/20/22	2 - Minimal harm or potential for actual harm	Some
Allow residents to self-administer drugs if determined clinically appropriate.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	10/7/22	11/7/22	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	1/12/23	2/10/23	2 - Minimal harm or potential for actual harm	Some

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