Inspection Reports for The Drake
1195 Drake Mill Lane SW Concord, NC 28025, Concord, NC, 28025
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 2, 2025
Visit Reason
The Adult Care Licensure section and the Cabarrus County Department of Social Services conducted a complaint investigation and follow up survey on 09/30/25 through 10/02/25.
Complaint Details
The complaint investigation was triggered by concerns related to resident care plans, supervision, notification of elopement, and resident rights violations involving end-of-life care.
Findings
The facility failed to have an admission care plan signed by the assessor and the Primary Care Provider within 15 days for 1 of 6 sampled residents. The facility failed to provide supervision for 1 resident who eloped from the building without staff knowledge and was found outside attempting to re-enter. The facility failed to notify the local Department of Social Services of the elopement incident. The facility failed to ensure a resident receiving end-of-life care was treated with dignity and respect when sent to the hospital against her wishes. The facility failed to send the resident's Do Not Resuscitate order and hospice records with the resident when transferred to the hospital.
Deficiencies (5)
Failed to have an admission care plan signed by the assessor and Primary Care Provider within 15 days for 1 of 6 sampled residents.
Failed to provide supervision for 1 resident who eloped from the building without staff knowledge and was found outside attempting to re-enter.
Failed to notify the local Department of Social Services of an incident involving a resident who eloped from the facility.
Failed to ensure residents were treated with dignity and respect related to 1 resident receiving end-of-life care who was sent to the hospital against her wishes documented in her Hospice plan of care.
Failed to send the Do Not Resuscitate order and hospice records with 1 resident on end-of-life care when transferred to the hospital.
Report Facts
Sampled residents: 6
Resident #4 elopement duration: 15
Correction date for Type A1 violations: Nov 1, 2025
Correction date for Type B violation: Nov 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for completing care plans, authorizing hospital transfers, and updating medical records |
| Special Care Coordinator | Special Care Coordinator (SCC) | Responsible for care plan completion and supervision oversight |
| Facility Manager | Facility Manager | Located resident during elopement and involved in incident follow-up |
| Administrator | Administrator | Oversaw care plan and supervision issues, communicated with POA and hospice, and reviewed incident reports |
| Medication Aide | Medication Aide (MA) | Witnessed resident behavior during elopement and assisted with hospital transfer documentation |
| Hospice Social Worker | Hospice Social Worker | Provided hospice care and communicated resident wishes regarding hospital transfer |
Inspection Report
Annual Inspection
Census: 25
Capacity: 34
Deficiencies: 9
Date: Jul 30, 2025
Visit Reason
The Adult Care Licensure Section and Cabarrus County Department of Social Services conducted an annual, follow-up survey and complaint investigation from July 23, 2025 through July 30, 2025. The complaint investigation was initiated by the Cabarrus County Department of Social Services on June 16, 2025.
Complaint Details
The complaint investigation was initiated by the Cabarrus County Department of Social Services on June 16, 2025.
Findings
The facility failed to ensure required staffing hours were met on first and second shifts based on a census of 25 to 28 residents for 5 out of 42 shifts. The facility failed to ensure 2 of 5 sampled residents had current FL2 medical examinations completed annually. The facility failed to develop and implement accurate, resident-centered care plans for 5 of 9 sampled residents, including missing physician signatures. The facility failed to provide supervision for 3 sampled residents with multiple falls and a resident with dementia left alone in extreme heat. The facility failed to administer medications as ordered for 3 of 8 sampled residents and failed to maintain accurate medication administration records. The facility failed to ensure medication provision for residents on temporary leave and failed to notify the local county Department of Social Services of reportable incidents. The facility failed to ensure required staffing hours were met in the Special Care Unit for 6 out of 42 shifts.
Deficiencies (9)
Failed to ensure required staffing hours were met on first and second shifts based on census of 25 to 28 residents for 5 out of 42 shifts.
Failed to ensure 2 of 5 sampled residents had current FL2 medical examinations completed annually.
Failed to develop and implement accurate, resident-centered care plans for 5 of 9 sampled residents, including missing physician signatures.
Failed to provide supervision for 3 sampled residents with multiple falls and a resident with dementia left alone in extreme heat, resulting in serious neglect and physical harm.
Failed to administer medications as ordered during medication pass on 07/24/25 for 3 of 8 sampled residents related to depression, mood, prostate, high blood pressure and hyperthyroidism medications.
Failed to ensure medication administration records were accurate for 3 of 8 sampled residents related to medications for mood, hyperthyroidism, and application/removal of TED hose.
Failed to ensure provision of medication for 2 of 2 sampled residents on temporary leave from the facility without instructions for all medications and without medication reconciliation after medications were brought in from outside pharmacy.
Failed to notify local county Department of Social Services for incidents involving 4 of 7 sampled residents who received injuries requiring emergency medical treatment.
Failed to ensure required staffing hours were met on all three shifts in the Special Care Unit based on a census of 21 residents for 6 out of 42 shifts.
Report Facts
Staffing shortage: 9.25
Staffing shortage: 2
Staffing shortage: 5
Staffing shortage: 1.8
Staffing shortage: 4.5
Staffing shortage: 1.05
Medication error rate: 15
Medication doses missed: 3
Medication doses missed: 16
Medication doses missed: 8
Medication doses missed: 15
Medication doses missed: 3
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for completing schedule, ensuring coverage, updating staffing schedule, and medication re-ordering |
| Administrator | Administrator | Responsible for receiving accident reports, notifying DSS, overseeing medication and staffing issues |
| Medication Aide | Medication Aide (MA) | Responsible for medication administration, notifying RCC of medication issues, and medication cart audits |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for completing after-fall assessments and medication re-ordering |
| Special Care Coordinator | Special Care Coordinator (SCC) | Responsible for reviewing accident reports and care plan updates |
| Adult Home Specialist | Adult Home Specialist (AHS) | Reported not receiving accident/incident report for Resident #2 fall |
| Power of Attorney | Resident #9's Power of Attorney (POA) | Reported medication ordering and pharmacy issues for Resident #9 |
| Pharmacist | Facility's contracted pharmacist | Reported medication order and dispensing issues for Resident #9 and Resident #5 |
| Pharmacist | Resident #9's pharmacy pharmacist | Reported medication order and dispensing issues for Resident #9 |
| Medication Aide | Medication Aide (MA) | Reported medication administration and documentation issues for Resident #9 and Resident #5 |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 4, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual survey on January 03, 2024 to January 04, 2024.
Findings
The facility failed to ensure that 1 of 3 sampled residents (Resident #4) had a Special Care Unit resident profile completed within 30 days of admission as required by regulation.
Deficiencies (1)
Failed to ensure 1 of 3 sampled residents (Resident #4) had a Special Care Unit resident profile completed within 30 days of admission.
Report Facts
Number of sampled residents: 3
Admission date: Nov 6, 2023
Date of record review: Jan 4, 2024
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