The Lakes at Maumelle: Respiratory Care Failures - AR
The facility's Director of Nursing first learned about the wound care failures on August 18, 2025, involving a resident identified only as Resident #42. The next day, she confronted LPN #5 about the missed treatments.
"LPN #5 did not disagree that the wound care was not completed," the Director of Nursing told inspectors during a September 19 interview. She issued a verbal warning that same day.
The problems persisted.
Three weeks later, on September 9, the Director of Nursing escalated her response. She provided additional training to LPN #5, issued a written warning, and implemented enhanced oversight requiring weekly reports on all facility treatments with photographs and measurements.
The nurse signed a Performance Plan on September 9, acknowledging the disciplinary action alongside the Director of Nursing and facility administrator. Three days later, the Director of Nursing met with LPN #5 in her office to review treatment protocols.
By September 18, LPN #5 was placed on medical leave. The Director of Nursing indicated it remained "undetermined" whether the nurse would continue employment upon returning from leave.
The facility's own policies clearly define the stakes. According to a 2021 revision of the facility's Abuse Prevention policy, residents have the right to be protected from neglect by staff and other individuals. The policy specifically states that neglect includes "failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition."
A facility training document from May 2025 reinforced this definition, describing neglect as the failure to provide necessary goods and services to prevent physical harm or mental deterioration.
Both the Director of Nursing and facility administrator acknowledged the seriousness of the violations. The Director of Nursing told inspectors that when a resident has ordered wound care and does not receive it, "it can be seen as neglect." The administrator separately confirmed that failing to provide ordered wound care "would be considered neglect."
The administrator explained the facility's wound care structure to inspectors. While the facility employs a dedicated treatment nurse, floor nurses are expected to provide wound care when the treatment nurse is unavailable. He emphasized the importance of following wound care orders, noting that proper treatment is essential for healing.
The facility's wound care protocol, outlined in policy documents, establishes a comprehensive process. Nurses must verify physician orders, assemble necessary supplies, use personal protective equipment, wash hands thoroughly, clean wounds, apply treatments as indicated, dress wounds, and document findings. The stated purpose is to promote wound healing.
Resident rights documents from 2017 guarantee patients adequate and appropriate health care according to recognized practice standards. The same documents affirm residents' rights to be informed about their health conditions and treatments, and to receive protective and support services.
The inspection occurred following a complaint, though the specific nature of the complaint was not detailed in available records. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and noted it affected "some" residents.
The case highlights ongoing challenges in nursing home wound care, where missed treatments can lead to infections, delayed healing, and complications requiring more intensive medical intervention. Proper wound care requires consistent attention and adherence to physician orders, particularly for elderly residents whose healing capacity may be compromised.
The facility's response included immediate disciplinary action, enhanced monitoring, and additional training. However, the progression from verbal warning to written warning to medical leave suggests the problems were not easily resolved through initial interventions.
LPN #5's cooperation with the investigation, including acknowledging the failures and signing the performance plan, did not prevent the escalating consequences. The Director of Nursing's requirement for weekly treatment reports with photographs and measurements represented an attempt to create accountability and documentation.
The uncertain employment status of LPN #5 leaves questions about the facility's long-term staffing and quality assurance measures. The case demonstrates how individual staff failures can compromise resident care and trigger regulatory scrutiny.
The facility's policies establish clear expectations for wound care delivery and staff responsibilities. The gap between written protocols and actual practice led to the disciplinary actions and ongoing uncertainty about the nurse's future employment.
Federal regulations require nursing homes to provide necessary care and services to maintain each resident's highest practicable physical, mental, and psychosocial well-being. Wound care represents a fundamental aspect of this obligation, particularly for residents with healing impairments or chronic conditions.
The Lakes at Maumelle's handling of the situation included documentation of the failures, progressive discipline, and enhanced oversight. The facility's acknowledgment that missed wound care constitutes neglect aligns with federal standards and resident protection requirements.
The inspection findings reflect broader concerns about nursing home staffing adequacy and supervision. When licensed nurses fail to complete ordered treatments, facilities must balance corrective action with maintaining adequate staffing levels to serve all residents.
The case of Resident #42 and LPN #5 illustrates how individual lapses in care can trigger facility-wide policy reviews and enhanced monitoring systems. The Director of Nursing's weekly reporting requirement suggests ongoing concerns about treatment compliance beyond this single incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Lakes At Maumelle Health and Rehabilitation from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE LAKES AT MAUMELLE HEALTH AND REHABILITATION in MAUMELLE, AR was cited for violations during a health inspection on November 25, 2025.
The facility's Director of Nursing first learned about the wound care failures on August 18, 2025, involving a resident identified only as Resident #42.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.