The Drake

The facility failed to notify the local Department of Social Services (DSS) regarding an incident involving a resident who sustained a fall injury. Resident #4 suffered a laceration to the forehead/eyebrow region following an unwitnessed fall, which required hospitalization.

The facility failed to notify the local Department of Social Services (DSS) regarding an incident involving a resident who sustained a laceration to the forehead following an unwitnessed fall. While the incident occurred on 11/22/25, the report was not submitted to DSS until 12/02/25, exceeding the required reporting timeline.

The facility failed to ensure proper referral and follow-up for acute health care needs for two residents. Specifically, the facility failed to obtain a STAT x-ray that was ordered for Resident #1 and failed to notify a provider regarding blood sugar levels greater than 400 for Resident #2.

The facility failed to ensure that an admission care plan was properly completed and authorized. Specifically, for one of six sampled residents, the care plan lacked the required signatures from both the assessor and the Primary Care Provider within the mandated 15-day timeframe.

The facility failed to ensure required aide duty hours were met on first and second shifts for a census of 25 to 28 residents. Specifically, the facility failed to meet the required staffing hours for 5 out of 42 shifts reviewed.

The facility failed to meet required staffing levels for a census of 21 residents. Specifically, the facility did not provide the required minimum of 16 hours of aide duty for the first and second shifts as mandated by state regulations.

The facility failed to ensure that one of three sampled residents had a Special Care Unit (SCU) resident profile completed within 30 days of admission. Specifically, Resident #4, admitted on 11/06/23, did not have the required profile documented despite being recommended for the SCU level of care.

The facility failed to ensure that one of three sampled residents had a Special Care Unit (SCU) resident profile completed within 30 days of admission. Specifically, Resident #4, admitted on 11/06/23, did not have the required profile documented despite being in the SCU for the required level of care.