Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident’s code status and advance directive information were inconsistently documented across the MOST form, EHR, care plan, and an advance directives binder. The MOST form, signed by the resident and physician, indicated Full Code, while the EHR, physician orders, care plan, and a yellow DNR sticker on the binder identified the resident as DNR. The resident stated his wishes were to be Full Code and denied requesting DNR status or recalling signing DNR paperwork. The MDS nurse, Social Worker, physician, DON, and Administrator all described processes for establishing and updating code status but could not explain how the discrepancy occurred, and documentation from a care plan meeting did not support staff claims that code status had been discussed.
A resident with CHF, atrial fibrillation, and SOB had an order for continuous O2 via nasal cannula at 2 L/min to maintain SpO2 above 90%, which was reflected in the care plan and MAR with twice-daily flow-rate checks. Over several days, nurses documented in the MAR that the O2 was set at 2 L/min, but surveyor observations repeatedly found the concentrator regulator set at 3 L/min while the resident wore the nasal cannula. In interviews, one nurse admitted he had not visually checked the flow rate before documenting, and facility leadership stated that nursing staff were expected to verify and follow provider-ordered O2 settings and contact the provider if titration was needed, demonstrating a failure to administer oxygen at the ordered rate.
The facility failed to address and communicate resolution of repeated housekeeping and linen concerns raised during Resident Council meetings over several months. Residents reported ongoing problems with trash not being removed, bathrooms and bedrooms not being properly cleaned, beds not being made, inadequate linens, and excessive water left on floors after mopping, and stated they typically received only vague responses such as that staff were working on it or were short-staffed. Meeting minutes showed no documented follow-up on concerns from prior months. The Activities Assistant reported that written grievance forms were not consistently completed for Resident Council issues, grievances were handled verbally, and department managers had not attended recent meetings. The new Housekeeping Manager was unaware of the concerns, the DON was unaware that beds were not being made, and the Administrator did not attend Resident Council, was unaware of the housekeeping issues raised, and did not know grievance forms were not being used for Resident Council concerns.
A resident with a femur fracture and severe cognitive impairment developed stage 3 and unstageable pressure ulcers on the right thigh and ankle after staff failed to perform or document routine skin checks under a leg immobilizer. Nursing staff misunderstood instructions regarding the immobilizer and did not remove it for skin assessments, leading to the discovery of pressure injuries only after the resident reported pain.
The facility failed to provide palatable and warm food for residents, as confirmed by resident interviews and a breakfast test tray observation. Residents reported dissatisfaction with the taste and temperature of breakfast items, and Resident Council meetings highlighted ongoing issues with food quality. A test tray revealed that the food was cool and not appetizing, with the Dietary Manager attributing the issue to an improperly placed insulated lid.
The facility was cited for deficiencies in food storage and cleanliness. Metal pans were stacked wet in the kitchen, and an ice machine in the medical unit had mildew. The storage shed was cluttered, with dry goods and water jugs improperly stored on the floor. The Dietary Manager and Administrator acknowledged these issues.
A facility failed to protect resident privacy when a nurse left a medication cart unattended with a resident roster containing PHI visible to the public. The roster included sensitive information for 22 residents. The nurse admitted to forgetting to turn the paper over, and staff interviews confirmed the expectation to protect such information by turning it over or taking it along when leaving the cart.
The facility failed to meet residents' preferences for more frequent bingo games, offering them only three times a week despite residents' willingness to lead the games themselves. Residents expressed a desire to play bingo daily, but the Activity Director limited the sessions, leading to dissatisfaction. The Interim DON and Administrator acknowledged that the activity program should align with resident preferences.
Three residents in the facility did not receive necessary podiatry services, leading to deficiencies in foot care. One resident with diabetes had overgrown toenails and dry skin, but no consult was arranged. Another resident with neuromuscular disorder experienced pain from long toenails, yet the need for podiatry was not communicated. A third resident with onychomycosis missed podiatry services due to hospitalizations, and staff failed to document or refer for necessary care. The facility's process for identifying and referring residents for podiatry care was not effectively implemented.
A resident with Alzheimer's dementia and a history of weight loss did not receive the prescribed larger portions of grits during breakfast, despite a physician order. The resident experienced a 4.8% weight loss over six months. Facility staff confirmed the oversight was due to a misunderstanding of diet order terminology, resulting in the resident not receiving the correct portion size.
A resident dependent on staff for ADL care did not receive adequate personal hygiene, including nail care and shaving, due to staff's failure to offer alternative care when showers were refused. Despite a care plan outlining necessary interventions, refusals were not consistently reported, and alternative care was not provided, leading to the resident having long fingernails and a thick beard.
The facility did not post daily nurse staffing data at the beginning of the shift for one of the reviewed days. Observations showed that staffing data for the previous day was posted instead. The scheduler, responsible for posting the data, typically did so by 9:00 AM after verifying the schedule, unaware that it should be posted at the start of the 7 AM shift. The facility operated on a 12-hour shift schedule, and the administrator recognized the need to adjust responsibilities to ensure compliance.
A facility failed to accurately code a resident's discharge type on the MDS assessment. The resident was admitted for short-term rehab with a planned discharge to home with family and home health services. Despite this, the discharge was incorrectly coded as unplanned. Staff interviews confirmed the error, and the Interim DON acknowledged the need for correct initiation and execution of the discharge plan.
The facility failed to provide baseline care plan summaries to four residents and their families within 48 hours of admission. The Social Worker, unaware of the requirement, did not distribute the summaries, and the Administrator acknowledged the oversight. Interviews confirmed the lack of communication regarding initial goals, medication summaries, and services.
Inconsistent Documentation of Resident Code Status and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively intact resident’s advance directive and code status were consistently and accurately documented across all parts of the medical record. The resident had a MOST (Medical Orders for Scope of Treatment) form in the Advance Directives binder, signed by the resident and physician, indicating “Attempt to Resuscitate (Full Code).” However, the outside of the resident’s binder had a yellow DNR sticker, which staff used to identify residents who had elected DNR status. In contrast to the MOST form, the resident’s EHR contained an active physician order indicating DNR status, and the advance directive information under the EHR Demographics tab and Physician Orders also reflected DNR. The resident’s annual MDS assessment documented that the resident was cognitively intact, and the advance directive care plan identified the resident as DNR. During interview, the resident stated he had previously discussed code status with staff and clearly expressed that his wishes were to be Full Code. He reported that he had not told anyone he wished to be DNR and did not recall signing paperwork for DNR status. Despite this, the MDS nurse stated that the resident was a DNR per physician order and acknowledged she was responsible for updating the care plan but could not explain why the resident’s code status had not been updated to reflect the resident’s wishes and the MOST form. The Social Worker reported that code status was verified on admission and discussed at baseline care plan meetings, and that a prior audit of code statuses had been conducted due to earlier inconsistencies. She stated that at the most recent care plan meeting for this resident, code status was discussed and the resident remained DNR, although progress notes and care plan meeting notes from that date contained no documentation that code status was discussed. The Social Worker acknowledged that the MOST form had not been updated to reflect the resident’s expressed wishes and that this was an error, stating it had been overlooked by the physician and nursing staff. The physician confirmed he was responsible for advance directive orders, that the resident was cognitively capable of making his own decisions, and that the discrepancy between the MOST form (Full Code) and the EHR and DNR orders had been overlooked. The DON and Administrator both acknowledged that the resident’s code status should have been consistent across the EHR, advance directive binder, and physician orders, but could not explain how the discrepancy occurred.
Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen at the prescribed rate for a resident with significant cardiopulmonary conditions. The resident was readmitted with diagnoses including atrial fibrillation, congestive heart failure, and shortness of breath, and had a physician’s order dated 11/19/24 for continuous oxygen via nasal cannula at 2 liters per minute (L/min) to maintain oxygen saturation above 90%. This order was indefinite and was reflected in the resident’s care plan, which identified a risk for ineffective breathing pattern related to congestive heart failure and shortness of breath, with an intervention to administer oxygen as ordered. The Medication Administration Record (MAR) also contained the order for oxygen at 2 L/min via nasal cannula every day and night shift, with two 12-hour blocks per day for staff to confirm the flow rate. Record review of the January 2026 MAR showed that staff documented the oxygen flow rate as 2 L/min twice daily on multiple days, including 1/20/26, 1/21/26, and 1/22/26. Specifically, Nurse #3 documented that the oxygen was set at 2 L/min for the day shift on 1/20/26 and 1/21/26, and Nurse #1 documented that the oxygen was set at 2 L/min for the day shift on 1/22/26. However, during observations on 1/20/26 at 10:52 AM, 1/21/26 at 9:00 AM, and 1/22/26 at 10:07 AM, the resident was seen with a nasal cannula in place, and the oxygen concentrator regulator was set at 3 L/min when viewed horizontally at eye level. On 1/22/26, the 3 L/min setting was verified with Nurse #1 present. In interviews, Nurse #3 stated she followed what was listed on the MAR and would review it for medications or treatments but did not answer specific questions about the oxygen orders for this resident and was not available for follow-up. Nurse #1 acknowledged that the resident had a physician order for oxygen at 2 L/min via nasal cannula and stated he had checked the “yes” radio button in the MAR indicating the oxygen was set at 2 L/min, but he admitted he had not visually checked the flow rate earlier when administering morning medications and agreed the settings needed to be corrected. The Unit Manager, NP, ADON, DON, and Administrator each stated in interviews that nurses were expected to ensure oxygen was delivered at the provider-ordered rate, visually confirm the oxygen flow rate before documenting in the MAR, and contact the provider if any change in oxygen rate was needed. Despite these expectations, the oxygen regulator remained set at 3 L/min while staff documentation indicated 2 L/min, resulting in the failure to administer oxygen at the prescribed rate.
Failure to Address and Communicate Resident Council Housekeeping Concerns
Penalty
Summary
The facility failed to honor residents' rights to have their concerns addressed and communicated following Resident Council meetings over a four-month period. Resident Council minutes from October 2025 documented concerns about lack of available linens, towels, and washcloths. In November 2025, residents reported that housekeeping staff were not removing trash and were failing to clean bathrooms and bedrooms, but the minutes did not show any follow-up on the linen concerns from October. In December 2025, residents again raised housekeeping issues, including excessive water left on floors after mopping and inadequate bathroom cleaning, with no documented follow-up on the November concerns. In January 2026, residents continued to report that beds were not being made, bathrooms were not properly cleaned, and excessive water was left on floors after mopping, and there was again no documentation of follow-up on the December concerns. During a Resident Council group interview, multiple residents who regularly attended the meetings stated they felt staff did not truly address their concerns, noting that the only responses they typically received were that staff were working on it, were short-staffed, or lacked a housekeeping manager, while the same issues continued. The Resident Council President reported ongoing housekeeping concerns, including trash left in rooms, improperly cleaned bathrooms, and laundry issues, and residents expressed a desire for feedback from administration on efforts to resolve their concerns. The Activities Assistant acknowledged awareness of housekeeping concerns but stated that written grievances were not consistently completed for issues raised in Resident Council, that grievances were handled verbally, and that department managers had not attended Resident Council meetings for the past three months. The newly hired Housekeeping Manager reported he was unaware of the Resident Council housekeeping concerns, the DON stated she was not aware that residents' beds were not being made, and the Administrator stated he did not participate in Resident Council meetings, was unaware of the housekeeping issues raised, and did not know that grievance forms were not being used for Resident Council concerns.
Failure to Monitor Skin Under Immobilizer Resulting in Pressure Ulcers
Penalty
Summary
A resident with a right femur fracture was admitted and later readmitted to the facility, initially with a cast and subsequently with a leg immobilizer following an orthopedic appointment. The immobilizer was ordered to be worn at all times to stabilize the fracture, and the resident was non-weight bearing. The resident was severely cognitively impaired and required extensive assistance with mobility and transfers. Despite these conditions, there were no physician orders or documentation for routine skin assessments under the immobilizer during the initial period after its application. Nursing staff did not perform or document skin checks under the immobilizer, as they believed the device should not be removed based on the orthopedic provider's instructions. This misunderstanding led to the immobilizer remaining in place without regular inspection of the underlying skin. The lack of skin assessments continued until the resident began complaining of pain, at which point the immobilizer was removed and pressure ulcers were discovered on the resident's right thigh and ankle. The ulcers were subsequently assessed as stage 3 and unstageable, respectively. Interviews with nursing staff, nurse practitioners, and the DON confirmed that the omission of skin checks was due to a failure to clarify or implement appropriate orders for skin monitoring under the immobilizer. The responsible party and multiple clinical staff acknowledged that the immobilizer was not opened or the skin checked until the pressure injuries were identified. The deficiency was attributed to the absence of orders and the staff's misinterpretation of the immobilizer instructions, resulting in the development of significant pressure ulcers.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature for eight residents. Interviews with residents revealed dissatisfaction with the taste and temperature of the food, particularly breakfast items such as meat, eggs, pancakes, and coffee. Resident Council meeting minutes from several months highlighted ongoing issues with food and coffee temperatures, food texture, and flavor. During a Resident Council meeting, residents reported problems with cold coffee, tough meat, and a broken microwave, which limited their access to coffee. A breakfast test tray observation confirmed these issues, as the food was found to be cool to the touch and not warm, with no steam rising from the food or coffee. The Dietary Manager (DM) acknowledged the problem, attributing it to an improperly placed insulated lid that allowed heat to escape. Despite the DM's belief that breakfast was the best meal of the day, the test tray results and resident feedback indicated otherwise. The DM was unable to provide information on when the last test tray had been completed, although she claimed that test trays were routinely performed.
Deficiencies in Food Storage and Cleanliness
Penalty
Summary
The facility was found to have several deficiencies related to food storage and cleanliness during a survey. In the kitchen, metal pans were observed to be stacked while still wet, with water dripping down the sides when separated. The Dietary Manager (DM) acknowledged that the pans should have been air-dried completely before stacking. An interview with a staff member revealed that the pans were stacked with wet hands, leading to the issue. Additionally, an ice machine in the medical unit's nourishment room was found to have a wet, slimy, black material, identified as mildew, along the seal of the door. The Maintenance Director, responsible for cleaning the ice machines, admitted that the machine was cleaned once a month, and the last cleaning was done nearly a month prior. Furthermore, the storage shed used for storing dry goods and emergency supplies was cluttered with various items, including medical records, decorations, and resident possessions. The DM had to move items to access the dry goods, which were improperly stored directly on the floor. Gallon jugs of water were also found on the floor, some tipped over and partially filled, with a dusty, stained pillow on top. A pallet of rolled oats was similarly tipped over and lying on the floor. The DM admitted to not having checked the storage shed for some time and was unaware of its disorganized state. The Administrator confirmed that the pans should be dry before stacking, the ice machines should be checked for mildew, and the storage shed should be organized with food stored off the floor.
Resident Privacy Breach Due to Unattended Medication Cart
Penalty
Summary
The facility failed to protect resident privacy by leaving an unattended resident roster with personal health information (PHI) on top of a medication cart in the hallway, visible to the public. This incident involved one of the three medication carts reviewed for privacy and confidentiality, specifically the 700 Hall Medication Cart. The resident roster contained sensitive information such as room numbers, names, code status, history of diagnoses, and report items for 22 residents. During the observation period, Nurse #8 left the medication cart unattended with the resident roster exposed while entering a resident's room. During this time, two residents and one visitor passed by the cart, potentially viewing the PHI. Upon returning to the cart, Nurse #8 acknowledged forgetting to turn the resident roster paper over, which was the expected protocol to maintain privacy. Nurse #9, upon being shown the exposed roster, confirmed that it should not have been left visible to the public. Interviews with Unit Manager #10 and the Interim Director of Nursing further confirmed that the nurses were expected to either turn the roster paper upside down or take it with them when leaving the medication carts to protect resident privacy. This oversight had the potential to affect the privacy of 22 residents on the 700 hall.
Inadequate Activity Program for Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing individual and group activity program that met the preferences of its residents, specifically regarding the frequency of bingo games. Residents expressed a desire to play bingo more often, ideally daily, during Resident Council meetings. Despite their willingness to lead the bingo games themselves, the facility limited the activity to three times per week, which did not align with the residents' preferences. This issue was highlighted during a Resident Council meeting attended by a state surveyor, where multiple residents reiterated their desire for more frequent bingo games. Resident #49 and Resident #76, both with intact cognition and a strong interest in participating in their favorite activities, were among those who expressed dissatisfaction with the current bingo schedule. Their care plans indicated a need to encourage participation in activities of interest, including bingo. However, despite their clear communication and understanding, the facility did not accommodate their requests for more frequent bingo sessions. The activity calendars from February to October 2024 showed that bingo was offered only two to three times per week, which was insufficient according to the residents' expressed preferences. The Activity Director (AD) acknowledged the residents' requests during interviews and Resident Council meetings but maintained that three bingo sessions per week were sufficient, citing a desire to provide a variety of activities. The Interim Director of Nursing and the Administrator, however, stated that the activity program should be based on resident preferences, and residents should be allowed to play bingo daily if they wished, especially if they were willing to lead the activity themselves. This discrepancy between the residents' preferences and the facility's offerings led to the deficiency noted in the report.
Deficiency in Podiatry Services for Residents
Penalty
Summary
The facility failed to ensure proper foot care for three residents, leading to deficiencies in podiatry services. Resident #28, who was admitted with diabetes type 2 and vascular dementia, had not received podiatry services since admission. Despite being independent in some activities, he required assistance with footwear due to a decline in functional status. Observations revealed thick, overgrown toenails and dry skin, yet no podiatry consult was arranged. The nursing staff, including Nurse Aide #3 and Nurse #1, failed to report the need for podiatry care, and the Social Worker was not informed to schedule a consult. Resident #1, with a history of atherosclerotic heart disease and neuromuscular disorder, also did not receive podiatry services since admission. Despite weekly skin checks by Nurse #7, the need for toenail trimming was not communicated to the Social Worker. Resident #1 expressed pain due to long toenails during a Resident Council meeting, but the process for referral was not followed, and he was not included in the podiatry list for upcoming visits. Resident #63, diagnosed with onychomycosis and peripheral vascular disease, missed podiatry services due to hospitalizations and was not included in the list for subsequent visits. Despite having a care plan for regular foot care, his toenails were observed to be long and curling towards the skin. Staff failed to document the need for podiatry services on shower sheets, and the Social Worker was not informed to arrange a consult. The facility's process for identifying and referring residents for podiatry care was not effectively implemented, leading to unmet needs for these residents.
Failure to Provide Prescribed Larger Portions to Resident at Risk for Weight Loss
Penalty
Summary
The facility failed to provide larger portions per physician order to a resident at risk for weight loss due to a history of weight loss. The resident, diagnosed with Alzheimer's dementia, mild cognitive impairment, hyperlipidemia, and hypertension, experienced a weight loss of approximately 4.8% over six months. Despite a physician order for larger portions and high-calorie supplements, the resident did not receive the prescribed larger portions of grits during breakfast observations on two consecutive days. The resident expressed a preference for larger portions of grits, which were not provided as per the diet order. Interviews with facility staff, including the Registered Dietitian and Certified Dietary Manager, confirmed that the resident should have received an 8-ounce portion of grits instead of the standard 4-ounce portion. The oversight was attributed to a misunderstanding of the diet order terminology on the tray cards, which led to the dietary staff not providing the correct portion size. The Interim Director of Nursing acknowledged that residents should receive the portion size of foods as ordered.
Failure to Provide Adequate ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate care for a resident dependent on staff for activities of daily living (ADL). The resident, who had diagnoses including heart failure and dilated cardiomyopathy, was observed with long fingernails and a thick beard, indicating a lack of personal hygiene care. Despite being dependent on staff for ADL, the resident was not offered a bed bath, nail care, or shaving on multiple occasions when he refused a shower. The care plan for the resident included interventions such as providing personal hygiene, inspecting skin, and notifying a nurse of any abnormal changes. However, documentation revealed that the resident refused showers on several occasions, and there was no indication that alternative care was offered or that refusals were reported to a nurse. Staff interviews confirmed that the resident's refusals were not consistently reported, and alternative care options were not provided. The facility's staff, including nurse aides and the unit manager, acknowledged the lack of communication and failure to provide necessary care. The interim Director of Nursing stated that ADL care should be offered multiple times and that refusals should be reported to a nurse, who should then offer alternative care. However, these procedures were not followed, resulting in the resident not receiving the required personal hygiene care.
Failure to Post Nurse Staffing Data at Shift Start
Penalty
Summary
The facility failed to post daily nurse staffing data at the beginning of the shift for one of the four days reviewed. On 10/21/24, observations at 9:18 AM and 9:45 AM revealed that the nurse staffing data posted was for the previous day, 10/20/24. The scheduler, responsible for posting the staffing data for the 7 AM to 7 PM shift, stated that she typically posted the data by 9:00 AM after verifying and adjusting the staffing schedule upon her arrival at work between 8:00 AM and 8:30 AM. She was unaware that the staffing data should be posted at the beginning of the 7 AM shift. The facility operated on a 12-hour shift schedule, and the administrator acknowledged the need to adjust responsibilities to ensure compliance with posting requirements.
Inaccurate Coding of Discharge Type on MDS Assessment
Penalty
Summary
The facility failed to accurately code the type of discharge on a Discharge Minimum Data Set (MDS) assessment for a resident who was reviewed for discharge planning. The resident was admitted to the facility from the hospital for short-term rehabilitation services with the goal of discharging to the community. The resident expressed the intention to discharge home with family and home health services, which was discussed from the beginning of her stay. However, the Discharge MDS recorded the type of discharge as unplanned, despite documentation and staff interviews indicating that the discharge was planned. Interviews with the Social Worker and MDS Coordinators confirmed that the discharge was intended and planned, and the coding of the discharge as unplanned was an error. The MDS Coordinator reviewed the medical record and found no evidence to support an unplanned discharge. The Interim Director of Nursing and Administrator acknowledged that the anticipated discharge plan should have been initiated and carried out correctly, indicating a lapse in accurately coding the discharge type on the MDS assessment.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to residents and their families within 48 hours of admission, as required. This deficiency was identified for four residents, each of whom did not receive initial goals, a summary of medications, or a summary of services or treatments to be administered by the facility. The baseline care plans for these residents were completed but not communicated to the residents or their families. Interviews with family members and residents confirmed that they had not received the necessary information regarding the care plans. The Social Worker, who had been in her position for 4 1/2 months, admitted to not providing any residents with a baseline care plan summary during her tenure. She was unaware of the requirement to provide such summaries, as she believed the admission nurse was responsible for initiating the baseline care plan. The Administrator acknowledged that the Social Worker was new and had not yet learned all necessary procedures, but he expected all new admissions to receive a summary of their baseline care plan, including initial goals, medication summaries, and services or treatments to be administered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indian Trail
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Park Rehabilitation & Health Center | 4.2 mi | ★★★★★ | 8 | 0 |
| Willowbrooke Court Sc Ctr At Matthews Glen | 4.2 mi | ★★★★★ | 4 | 0 |
| Matthews Health & Rehab Center | 6 mi | ★★★★★ | 2 | 0 |
| Pruitthealth-union Pointe | 6.1 mi | ★★★★★ | 0 | 0 |
| Brookdale Carriage Club Providence | 9.3 mi | ★★★★★ | 1 | 0 |
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