The Lakes At Maumelle Health And Rehabilitation

F 0600 Level of Harm - Minimal harm or potential for actual harm

information nor complaints of wound care not being provided for a resident. He reported the facility did have

a treatment nurse but if the treatment nurse did not provide wound care the floor nurses were able to complete that care. He indicated if a resident had wound care orders and the wound care was not done it would be considered neglect. He reported it was important for a resident to receive wound care as ordered so they will heal.

Residents Affected - Some

On 09/19/2025 at 5:15 PM, during an interview, the DON verified that she first knew about Resident #42 not receiving wound care dressing changes on 08/18/2025. The DON reported she spoke with LPN #5 on 08/19/2025 and gave a verbal warning. The DON added LPN #5 did not disagree that the wound care was not completed. She reported on 09/09/2025 she in serviced LPN #5, gave a written warning to LPN #5 and instructed LPN #5 you will report to me once a week on all the treatments in the facility with pictures and measurements. The DON reported she met with LPN #5 on 09/12/2025 and discussed the treatments with LPN #5 in the DON's office. She reported LPN #5 was placed on medical leave 09/18/2025. The DON indicated it was undetermined if LPN #5 would continue employment when returning from medical leave.

The DON indicated when a resident had ordered wound care and did not receive that wound care it can be seen as neglect.

On 09/19/2025 the DON provided a Performance Plan for LPN #5 dated 09/09/2025. The plan was signed

on 09/09/2025 by LPN #5, the DON and Administrator.

A review of a facility document titled admission Documents included [State]Patient Rights section, dated 05/2017, which indicated the residents have the right to be adequately informed of their health, medical conditions, treatments, refuse medication or treatment and be notified of the consequences of refusals.

Residents have the right to 8. Receive adequate and appropriate health care, protective and support services with recognized practice standards.

A review of a facility policy titled Abuse Prevention dated 2001, revised 04/2021, indicated Residents have

the right to be free from abuse, neglect. The policy interpretation indicated residents will be protected from abuse, neglect by facility staff and any other individual.

A review of a facility titled Inservice Education Report dated 05/02/2025 stated g. neglect is defined as 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 review of a facility document titled Wound Care indicated the purpose of wound care is to promote healing of wounds. The wound care includes verify physician's orders, assemble the supplies that are needed, utilize personal protective equipment (PPE), wash hands thoroughly, clean wound, apply treatments as indicated, dress wound, and document findings.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Lakes at Maumelle Health and Rehabilitation

103 Alexandria Drive Maumelle, AR 72113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, and facility policy review, the facility failed to ensure a Physician's Order for the administration of oxygen was received for one (Resident #50) of two residents reviewed for oxygen administration.

Residents Affected - Few

The findings include:

A review of Resident #50's admission Record from the Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses which included chronic obstructive pulmonary disease (COPD) and congestive heart failure.

A review of Resident #50's Physician's Orders from the resident's EHR revealed there was no order for the administration of oxygen.

A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/14/2025, revealed Resident #50 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #50 received oxygen therapy while a resident at

the facility.

A review of Resident #50's Care Plan Report, initiated on 02/07/2025, did not reveal a focus area of oxygen usage or interventions for oxygen usage.

A review of Resident #50's electronic Medication Administration Record (eMAR)for February 2025, did not reveal an order for oxygen administration.

A review of Resident #50's Progress Notes revealed the following: -On 02/08/2025 at 5:20 PM, the resident arrived to the facility at approximately 2:30 PM, using oxygen by way of a nasal cannula at 4 liters. -On 02/13/2025 at 5:40 AM, oxygen was in use by way of nasal cannula with no shortness of breath. -On 02/19/2025 at 5:39 PM, pulse oximetry 96% at 5:19 AM, and oxygen via nasal cannula was in use. -On 02/22/2025 at 11:37AM, oxygen saturation at 96% on 4 liters of oxygen per minute by way of nasal cannula.

During an interview with the Director of Nursing (DON) on 09/19/2025 at 5:49 PM, she stated the nurses knew how much oxygen to administer to a resident by [looking at] the Medication Administration Record (MAR). The DON also stated the resident should have an order [from the medical provider] for oxygen to be administered, unless it was a situation where the resident was short of breath, but the nurses should call

the doctor [for an order for this].

A review of an Oxygen Administration policy, revised October 2010, revealed the purpose for the policy was to provide guidance for safe oxygen administration and that in preparation for oxygen administration, the Physician's Order should be verified.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet