Cycle 1
Health 2026-01-22 · Fire 2024-10-24
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Indian Trail, NC
Lake Park Nursing and Rehabilitation Center
3-star overall rating with 2-star inspections with $44,005 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3315 Faith Church Road, Indian Trail, NC
(704) 882-3420
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
2000-06-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
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
0.93
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,267
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9901
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.02
Baseline 16.94% · Performance 18.64% · Measure score 6.02 · Achievement 6.02 · Improvement 0
Healthcare-associated infections
1.48
Baseline 5.75% · Performance 7.39% · Measure score 1.48 · Achievement 1.48 · Improvement 0
Total nurse turnover
1.48
Baseline 75.46% · Performance 65.41% · Measure score 1.48 · Achievement 0 · Improvement 1.48
Adjusted total nurse staffing
5.72
Baseline 3.83 hours · Performance 4.71 hours · Measure score 5.72 · Achievement 5.72 · Improvement 4
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 8.04% · Lower 95% interval 6.8% |
| Discharge to community | 55.22% |
50.57%
4.6 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 51.11% · Lower 95% interval 45.85% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 84.48% |
95.27%
10.8 pts worse
|
Numerator 49 · Denominator 58 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 58 |
| Discharge self-care score | 43.75% |
53.69%
9.9 pts worse
|
Numerator 21 · Denominator 48 |
| Discharge mobility score | 41.67% |
50.94%
9.3 pts worse
|
Numerator 20 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 2 · Denominator 58 · Adjusted rate 3.59% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 184 |
| Staff flu vaccination coverage | 10.14% |
42%
31.9 pts worse
|
Numerator 22 · Denominator 217 |
| Discharge function score | 52.08% |
56.45%
4.4 pts worse
|
Numerator 25 · Denominator 48 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 4 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.2% |
91.5%
9.3 pts worse
|
93.4%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 77.9% · Q3 79.8% · Q4 79.5% · 4Q avg 82.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 46.7% |
94.1%
47.4 pts worse
|
95.5%
48.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 46.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.6%
0.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.3% · Q3 2.4% · Q4 7.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.8%
4.5 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
7.2%
3.8 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.7% · Q3 2.8% · Q4 2.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
21.6%
2.6 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 20.0% · Q3 16.7% · Q4 17.6% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
15.0%
2.3 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 11.6% · Q3 14.1% · Q4 12.3% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 14.1% |
21.5%
7.4 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 11.4% · Q3 18.3% · Q4 14.6% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
16.8%
1.6 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 12.9% · Q3 16.7% · Q4 23.5% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 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 | 1.5% |
2.6%
1.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.4% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.6% |
21.2%
11.6 pts better
|
19.8%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 9.4% · Q3 10.3% · Q4 11.7% · 4Q avg 9.6% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
6.0%
2.4 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 13.0% · Q3 7.4% · Q4 4.7% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
79.9%
17.1 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 96.6% · Q3 97.4% · Q4 97.3% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
13.2%
1.8 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 10.1% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
78.1%
15.4 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
22.9%
5.1 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 15.9% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-24 · Fire 2023-05-05
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-05-05 · Fire 2021-06-16
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-15
D · Potential for more than minimal harm
2024-10-24
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 2025-02-15
D · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-15
D · Potential for more than minimal harm
2024-10-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-15
D · Potential for more than minimal harm
2024-10-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-15
D · Potential for more than minimal harm
2024-10-24
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-02-15
D · Potential for more than minimal harm
2023-05-05
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 2023-06-30
D · Potential for more than minimal harm
2023-05-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F578 · Resident Rights Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
B · Minimal harm
2026-01-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Not marked corrected
G · Actual harm
2025-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-16
E · Potential for more than minimal harm
2024-10-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-24
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-21
C · Minimal harm
2024-10-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-21
B · Minimal harm
2024-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-21
B · Minimal harm
2024-10-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-21
G · Actual harm
2023-11-03
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 2023-11-27
G · Actual harm
2023-05-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-02
G · Actual harm
2023-05-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-05-05
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 2023-06-02
D · Potential for more than minimal harm
2023-05-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-05-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-05-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-06-02
B · Minimal harm
2023-05-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-06-02
Penalties and ownership
What sits behind the stars
$25,490
2025-04-24
Fine
Fine · fine $25,490
Fine
$8,745
2023-11-03
Fine
Fine · fine $8,745
Fine
$4,885
2023-05-05
Fine
Fine · fine $4,885
Fine
$4,885
2023-05-05
Fine
Fine · fine $4,885
Fine
Ownership
Principle It Services, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Hill, Robert
5% Or Greater Indirect Ownership Interest · Individual
Hill, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Hill, Raymond
5% Or Greater Indirect Ownership Interest · Individual
Boice, Gale
Corporate Officer · Individual
Jackson, Rafael
Operational/Managerial Control · Individual
Johnson, Dianne
Corporate Officer · Individual
Principle Long Term Care, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Royal Park Rehabilitation & Health Center
Matthews, NC
2-star overall rating with 2-star inspections with $52,201 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Willowbrooke Court SC Ctr at Matthews Glen
Matthews, NC
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Matthews Health & Rehab Center
Matthews, NC
1-star overall rating with 1-star inspections with $82,703 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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