Maumelle, AR

The Lakes At Maumelle Health And Rehabilitation

3-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

103 Alexandria Drive, Maumelle, AR

(501) 734-1400

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Anthony & Bryan Adams

Operator or chain grouping

Approved since

2007-04-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

38 facilities

Chain averages 4 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.56

Registered nurse staffing · state 0.40 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

3.06

Nurse aide staffing · state 2.72 · national 2.35

Total nurse hours

4.68

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.62

RN + LPN hours · state 1.35 · national 1.54

Weekend hours

3.88

Weekend nurse staffing · state 3.48 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.27 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.03 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

4.94

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

79%

Annual nurse turnover · state 51% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,864

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.84

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Baseline 7.05% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

Baseline 74.03% · Performance 78.67% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

5.65

Baseline 4.16 hours · Performance 4.69 hours · Measure score 5.65 · Achievement 5.65 · Improvement 2.76

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.97%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 61 · Observed rate 11.48% · Lower 95% interval 7.4%
Discharge to community	38.56%	50.57% 12 pts worse	No Different than the National Rate · Eligible stays 48 · Observed rate 31.25% · Lower 95% interval 28.91%
Medicare spending per beneficiary	1	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 47 · Denominator 47
Falls with major injury	2.13%	0.77% 1.4 pts worse	Numerator 1 · Denominator 47
Discharge self-care score	51.61%	53.69% 2.1 pts worse	Numerator 16 · Denominator 31
Discharge mobility score	54.84%	50.94% 3.9 pts better	Numerator 17 · Denominator 31
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 47 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.87%	7.12% 0.8 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 4.42%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 96
Staff flu vaccination coverage	27.03%	42% 15 pts worse	Numerator 40 · Denominator 148
Discharge function score	77.42%	56.45% 21 pts better	Numerator 24 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	48.39%	25.2% 23.2 pts better	Numerator 15 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.7	2.0 0.7 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.3 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.8	2.2 1.6 pts worse	1.8 2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.2 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.4%	94.9% 0.5 pts worse	93.4% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 91.1% · Q3 95.8% · Q4 95.5% · 4Q avg 94.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.2%	96.1% 3.9 pts worse	95.5% 3.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2%
Percentage of long-stay residents experiencing one or more falls with major injury	6.7%	3.9% 2.8 pts worse	3.3% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.7% · Q3 4.2% · Q4 9.1% · 4Q avg 6.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	1.4% 1.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	2.8%	4.9% 2.1 pts better	5.4% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.7% · Q3 2.3% · Q4 0.0% · 4Q avg 2.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	5.4%	21.8% 16.4 pts better	19.6% 14.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.4% · Q3 7.0% · Q4 2.7% · 4Q avg 5.4%
Percentage of long-stay residents who received an antipsychotic medication	1.0%	12.5% 11.5 pts better	16.7% 15.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	8.9%	11.4% 2.5 pts better	16.3% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.9%	10.4% 5.5 pts better	14.9% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.3% · Q3 0.0% · Q4 5.7% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.7% 0.7 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.1% 1.1 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	9.5%	14.6% 5.1 pts better	19.8% 10.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.5% · Q3 14.0% · Q4 9.0% · 4Q avg 9.5%
Percentage of long-stay residents with pressure ulcers	2.8%	4.6% 1.8 pts better	5.1% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 2.3% · Q3 0.0% · Q4 2.1% · 4Q avg 2.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	81.7%	81.8% 0.1 pts worse	81.7% About the same	Short Stay · 2024Q4-2025Q3 · Q1 63.8% · Q2 79.7% · Q3 88.5% · Q4 97.4% · 4Q avg 81.7%
Percentage of short-stay residents who had an outpatient emergency department visit	33.9%	13.8% 20.1 pts worse	12.0% 21.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.9% · Observed 36.4% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.4% 1.4 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	75.9%	77.9% 2 pts worse	79.7% 3.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 75.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.3%	25.2% 1.9 pts better	23.9% 0.6 pts better	Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 27.3% · Expected 27.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-11-25 · Fire 2025-11-25

2 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2024-06-05 · Fire 2024-06-05

11 health deficiencies

Top issue: Resident Rights (3 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 3 Health 2023-06-29 · Fire 2023-06-29

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-11-25

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-12-24

F · Potential for more than minimal harm 2025-11-25

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-12-24

F · Potential for more than minimal harm 2025-11-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-12-24

F · Potential for more than minimal harm 2024-06-05

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-03

F · Potential for more than minimal harm 2024-06-05

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-07-03

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-12-24

D · Potential for more than minimal harm 2025-11-25

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-12-24

F · Potential for more than minimal harm 2024-06-05

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-06-05

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-06-05

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-06-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-06-05

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-07-03