**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 50> Review of a 04/07/2025 quarterly assessment showed Resident 50 admitted to the facility on [DATE] with medically complex conditions, to include dementia, repeated falls, and impaired vision. This assessment showed the resident had moderately impaired cognition, required supervision or touching assistance from the staff for ADLs (Activities of Daily Living) and experienced falls since their admission to the facility or their prior assessment. The assessment showed Resident 50 was always continent of bowel and bladder and was not on a toileting program. In an observation on 05/15/25 at 8:36 AM, Resident 50 was seated in their wheelchair, eating their breakfast in front of a small table against the wall. The call light was approximately five feet away from the resident, clipped to its own cord attached to the wall above the bed. Signage on the opposite wall showed instructions that said, Play it safe. Use your call light for help. An interview and observation on 05/12/2025 at 10:55 AM showed Resident 50 in bed and stated, I fall quite frequently. I have progressive palsy (loss or reduction of movement in a part of the body, often accompanied by shaking or trembling) and they've gone over things that I do that cause the falls like how I turn and so forth. The resident said they had fallen five times since admission to the facility. Review of Resident 50's 11/04/2024 care plan showed the staff identified the resident fell because of dementia, an unsteady walk, leaning forward in their wheelchair to pick items up from the floor and transferring from bed or wheelchair unassisted. The care plan showed the 04/05/2024 goal of the resident will be free of fall related injuries. The care plan informed the staff Resident 50 required assistance for transfers. The care plan showed that on the day of admission, 04/05/2024, the staff added the following interventions, Provide direct supervision while resident is toileting, Reinforce safety awareness: use call light, lock brakes on chair before transferring. When rising from a lying position, sit/rest at edge of the bed at least 10 seconds before transferring, Respond to resident requests timely. Anticipate needs. Keep call light and bedside table items within reach. On 12/01/2024, the staff added, Pharmacist to review medications quarterly and prn when falls occur to address fall risk side effects. Develop plan with risks and benefits as indicated. On 01/06/2025, the staff added, will get ice cream if [the resident] does not have a fall in 30 days. On 02/05/2025, the staff added, Resident agreed to wear pull ups at night for urine urgency. On 04/21/2025, the staff added, make sure to help remind [resident] to position the wheelchair at a 45-degree angle facing the bed, so that [the resident] can still reach the arm rests and make small steps, and travel a shorter distance, to decrease risk of falls. On 05/08/2025, the staff added, Educate resident to call out for help and to wait for assistance as it is [their] preference not to use the call light. Review of a toileting care plan initiated on 04/05/2024 showed Resident 50 was continent of urine and required assistance to the bathroom. The care plan informed the staff on 04/05/2024 the resident, manages toileting and incontinent episodes and assist with maintaining supplies as needed and to toilet the resident with morning and afternoon cares, before meals, at bedtime and as needed. On 01/14/2024, the care plan instructed the staff to place a stack of washcloths on bedside table for resident use. On 01/28/2025, the care plan instructed the staff to help the resident use the urinal by lowering their pants to their knees, tuck folded washcloth under penis (Keep stack on bedside table), and Wait a minute before removing cloth until dribbling stops. A 04/05/2024 ADLs care plan showed on 05/13/2024, it instructed the staff to complete Frequent rounding with the 4P's to help anticipate resident needs. Help keep room free from clutter. The 4P's stand for: Pain, Position, Placement, and Personal Needs. This approach may be used by anyone who entered a resident room for any reason to help prevent falls and developed a culture that checked in with the resident and addressed their needs at different times of the day. Review of progress notes from 04/05/2024 to 05/17/2025 showed staff identified Resident 50 fell frequently, was impulsive, forgetful to use their call light, and self-transferred in and out of bed or wheelchair. Documentation showed the staff continued to ask the resident to use the call light or call for help even though it was identified Resident 50 was impulsive and does not call for help/assistance with transfers or mobility and transfers without use of call light. Sometimes will yell help when is about to fall or needs help. Requires frequent reminders. Review of the progress notes showed Resident 50 fell 36 times (4/30/2024, 05/03/2024, 05/06/2024, 05/09/2024, 05/11/2024, 05/17/2024, 05/22/2024, 06/04/2024, 06/14/2024, 07/18/2024, 08/01/2024, 08/26/2024, 09/20/2024, 10/27/2024, 11/04/2024, 11/11/2024, 12/16/2024, 01/12/2025, 01/19/2025, 01/25/2025, 02/02/2025, 02/14/2025, 02/16/2025, 03/04/2025, 03/07/2025, 03/25/2025, 03/26/2025, 03/26/2025, 04/03/2025, 04/19/2025, 04/24/2025, twice on 05/03/2025, 05/05/2025, 05/14/2025, and 05/17/2025) from 04/05/2024 to 05/17/2025. Review of the electronic medical record from 04/05/2024 to 05/17/2025 showed Resident 50 experienced injuries of varying severity related to 36 falls that included abrasions (05/09/2025, 05/11/2024, 06/14/2024, 07/18/2024, 08/01/2024, 11/11/2024), contusions (an injury to soft tissue that causes bleeding beneath the skin, usually without breaking the skin itself, 08/01/2024, 08/26/2024, 11/11/2024, 03/27/2025), lacerations (08/01/2024, 08/26/2024, 02/02/2025) closed head injuries (08/01/2024, 03/27/2025), swelling to right side of forehead (10/27/2024), skin tears (03/04/2027, 03/07/2025, 04/20/2025), and multiple transfers to the Emergency Department (08/01/2024, 02/02/2025, 05/07/2025). Review of progress notes and investigative review documents associated with the falls showed no documentation the facility evaluated why previous interventions were ineffective and revised or developed interventions accordingly or developed effective interventions to compensate for Resident 50's forgetfulness and impulsiveness, like increased supervision or monitoring of the resident to intercept self-transfers to complete their ADLs. Facility reviews of the falls showed the staff continued to ask of Resident 50 to request assistance by using the call light and ultimately to call out for help, both repeatedly failed interventions. The facility investigations of the falls failed to show the facility considered what actually prompted the resident to self-transfer and effectively address the root-cause of the falls which precluded the staff from anticipating the resident's needs differently. The investigative reviews repeated interventions already established on Resident 50's day of admission and shortly thereafter to address the continued falls and did not determine how the interventions failed to prevent falls and their associated injuries. The investigations and their conclusions did not define for the staff what frequent checks or rounding of the resident entailed or show how staff supervision of the resident changed. Record review showed 10 of the 36 falls were related to Resident 50's toileting needs. The care plan showed no revision of the toileting program to effectively anticipate this ADL which required staff assistance. No documentation was located to show the facility requested a review by the pharmacist as instructed in the care plan. Investigative reviews associated with the 09/20/2024, 10/27/2024, 11/04/2024, 11/11/2024 falls showed the facility concluded the resident desires to fall and maintain their independence even if that means [they are] going to fall. Resident 50 fell another 20 times after 11/11/2024. In an interview on 05/20/2025 at 9:58 AM, Staff R, Nursing Assistant - Registered, stated they were formally re-assigned to Resident 50 for the first time on 05/20/2025 after their shift had already started but had assisted another aide with the resident on a previous occasion during training. Staff R stated they obtained information on resident care by getting report from the nurse and shift to shift report from another aide. When asked if Resident 50 had any falls, Staff R stated, Not that I'm aware of. Staff R stated they thought Resident 50 transferred in or out of bed or wheelchair because they needed to, use the rest room and they transferred, Either before or after lunch. Staff R stated that a resident who was cognitively impaired, impulsive, and showed they were not receptive to reminders or signage would require supervision of, every 15 minutes checks. In an interview on 05/20/2025 at 8:10 AM, Staff M, Licensed Practical Nurse (LPN), stated Resident 50 experienced several falls, doesn't call for help, will self-transfer, eyesight is very poor. Staff M stated the resident, can't seem to get his feet situated, sometimes [they] will step on one foot with the other and loses balance and flops back, does not sit down, rarely calls for help. Staff M indicated the resident's poor balance, impaired vision, poor body mechanics, and no safety awareness placed them at risk for falls. Staff M stated Resident 50 had no pattern when they self-transferred out of bed or wheelchair but that the staff, try to get in there before breakfast, before meals, because [the resident] likes to sit up for [their] meals. Staff M said that even though they parked their medication cart by Resident 50's room so they could hear the resident when they moved around, and staff made frequent checks and placed the wheelchair by the bed to prevent the resident from falling, it did not help decrease or prevent Resident 50's falls. Staff M stated they felt there was not enough staff to monitor the resident to make sure they did not fall when trying to transfer out of bed or the wheelchair. Staff M stated they did not think an increase in supervision was attempted by the facility to prevent Resident 50 from falling and that even with frequent checks Resident 50 fell. Staff M stated, It's hard to be there when you don't have enough staff. In an interview on 05/20/2025 at 8:40 AM, Staff S, Occupational Therapist, stated they wanted to be notified immediately if fall interventions were not effective, If that's what we are working on. Staff S stated they were unaware Resident 50 fell 36 times but knew the resident fell, a lot of times because they did not listen, was forgetful and impulsive. Staff S stated that impulsivity and decreased safety awareness were the main reasons for Resident 50's fall occurrences. When asked if increased supervision was attempted to help decrease falls or prevent Resident 50 from falling, Staff S stated, I know the aides were checking on [the resident] regularly. We haven't done that before. Staff S stated that staff could try 10-minute interval checks on the resident and concluded the signage on the wall was ineffective in preventing Resident 50 from falling. In an interview on 05/20/2025 at 8:20 AM, Staff T, Therapy Director, stated that they wanted to be notified when a resident fell at the time of occurrence or anytime there is a problem. Staff T stated they identified when interventions were suitable for a resident at risk for falls, Through the assessment process. Sometimes it's trial and error. Staff T explained that because of Resident 50's progressing palsy, they were going to lose the ability to sequence events, experience vision loss, and become increasingly dizzy. Staff T said Resident 50 did not want to wait for help to go to the bathroom because they were afraid of experiencing incontinence. When asked at what point was a recommendation made to increase and define the type of supervision required to help prevent falls and associated injuries, Staff T stated, We have discussed that and talked about if a different room would help but right now [the resident] is close to the door and we all pass by. Staff T stated to prevent falls for a resident who was cognitively impaired, impulsive, and not receptive to reminders or signage, the resident required, more frequent checks, asking every two hours if they need to go to the bathroom. Staff T stated, With somebody like [Resident 50], I would almost like to go back to the sensor pad pressure alarm because it will sound off when the resident is moving, and staff can be there to help [the resident]. To have a 1:1 on [Resident 50] would be super costly. Staff T stated, I don't think there's a trend to Resident 50's falls. The above findings were shared in a joint interview on 05/20/2025 at 10:21 AM with Staff B Director of Nursing, and Staff C, Clinical Resource Nurse. Both staff acknowledged the ineffective fall prevention interventions in Resident 50's care plan. Staff C acknowledged the consistently inadequate reviews of the falls that failed to determine what truly prompted Resident 50 to self-transfer, along with staff misperception of the resident's ability to recall or process information. When asked if the facility effectively supervised Resident 50 to prevent falls and their associated injuries, Staff B answered, No. When asked if the facility attempted to increase supervision of the resident Staff C answered, No and that doing so could have possibly prevented Resident 50 from falling. On 05/22/25 at 12:23 PM, Staff M (the nurse assigned to Resident 50) was observed walking past the resident's room with another staff. Resident 50 was observed by the surveyor standing up from the wheelchair next to their bed and transfer to the bed holding on to the grab bar to the left side, placing themselves on the bed, with the call light underneath them. Resident 50 admitted they self-transferred and said, No, I don't want to fall, then pulled the bed linens over themselves. Observation directly outside of Resident 50's room showed a clipboard on the handrail with a form titled Resident Monitoring Tool. The form showed Resident 50 was on 15-minute checks but no documentation the staff checked on the resident on or around 11:30 AM, 11:45 AM, 12:00 PM, or 12:15 PM. Review of progress notes between 05/21/2025 and 05/22/2025 showed that despite the 15 minute checks, the staff continued to identify Resident 50 self-transferred to the bathroom both with assist and unattended, does not call for help nor has called out loud for help, found several times already up in [their] wheel chair, Nurse is alerted outside of room doorway, when the bathroom door bangs into the room door that this resident is on the move . able to sit up and get out of bed & into wheel chair very quietly without being heard . TV volume up relatively high that also hinders the sounds of [their] movement. Another 05/21/2025 note showed, Continues to self-transfer quietly without staff noticing despite being moved closer to nurses station. Attempt to redirect and instruct on use of call light without effect. Cart nurse unable to stand at doorway or next to doorway for long periods of time to monitor resident as other residents need meds [medications]/cares as well. Another 05/21/2025 note showed, Resident was up again at this time, while this nurse was documenting previous note, noises/crashes were heard from [their] room and resident again was found seated in [their] wheelchair not 7 minutes from prior use of bathroom and was assisted to bed at that time . Another 05/21/2025 note showed, Resident is impulsive and transfers without use of call light. Sometimes will yell help when [they are] about to fall or needs help. Requires frequent reminders and observation. Resident has limited safety awareness and poor vision. Stiff/rigid body mechanics makes transfers difficult as well as bending at the hips/low back to sit . often times flops backwards into wheelchair. In an interview on 05/22/2025 at 12:35 PM, Staff M stated Resident 50 self-transferred, Last night, even with the 15-minute checks. Staff M stated they felt the 15-minute checks were ineffective as the resident did not call for help, I could be standing right here and will not always hear [them]. Staff M stated they did not tell anybody about the failed 15-minute checks, that they should have reported the failed intervention, Right away. I'll do it right now. The above findings were shared with Staff A (Administrator), Staff B, Staff C, and Staff Q (Director of Clinical Services) on 05/22/2025 at 1:12 PM. Staff C said they ensured interventions were effective by making observations of the staff and resident and reviewing the progress notes. Staff B stated they expected the staff to alert them of failed fall prevention interventions, As soon as they know it's not working. <Resident 60> Review of a 05/01/2025 admission assessment showed Resident 60 admitted to the facility on [DATE] with a diagnosis of a stroke, orthostatic hypotension (when the blood pressure drops when you sit or stand up), and diabetes. This assessment showed the resident had intact cognition, was dependent on the staff for toileting hygiene, required partial to substantial assistance for transfers, and used a wheelchair for mobility. The staff assessed Resident 60 was frequently incontinent of urine and always continent of bowel and had no toileting program. The assessment showed Resident 60 had no falls prior to admission but fell since admission to the facility. Review of a 04/25/2025 progress note showed the staff identified Resident 60 required extensive assistance with transfers and ADLs, Left sided weakness secondary to CVA [cerebrovascular accident, a stroke]. A 04/26/2025 note showed the resident, Has left sided weakness. Requires 2 person assist for transfers, bed mobility and toileting. Review of Resident 60's care plan showed 04/25/2025 instructions to the staff to provide assistance of 1 or more person for toilet transfers going to the right side with the use of the grab bar, that Resident 60 required constant verbal cues for sequencing and left sided neglect. The interventions also asked the staff to, Stay with patient when on toilet to decrease risk of falls, and Respond to resident requests timely. Anticipate needs. Keep call light and bedside table items within reach. Review of a 04/27/2025 progress note showed when the nurses walked down the hallway to administer medication to another resident, they heard Resident 60 yelling for help. The resident was found lying on their left side with their upper body under the edge of the bed. No injuries were sustained from this fall. The progress notes showed, Interventions placed were to encourage resident to use call light for assistance, frequent bathroom checks and bed to remain in lowest position. Review of 04/28/2025 care plan intervention showed the resident was totally dependent on staff when transferred by two or more staff in a mechanical lift and used the bed pan for toileting. Review of 04/29/2025 care plan intervention showed the staff placed a Call don't fall sign in Resident 60's room and the staff was asked to Monitor resident position in bed or wheelchair for safety upon entry and exit from room and with rounding. Anticipate resident needs. Review of a 05/03/2025 progress note showed a staff member assisted Resident 60 to the toilet per resident request and that the resident asked the aide to step out for privacy. The aide stepped out and was standing outside the door when the resident reached for wipes on their wheelchair and because of left sided weakness fell on [their] left side hitting [their] left orbital [eye socket] area. The note showed the nurse applied an ice pack to Resident 60's face, educated staff not to leave the resident unattended, and called the provider who gave orders to transfer Resident 60 to the hospital. Review of a 05/03/2025 Incident Note showed the fall resulted in a left orbital fracture (a break in one or more of the bones surrounding the eye socket). Nursing interventions included, Educated staff not to leave [resident] unattended, an intervention which was in place on 04/25/2025 (Stay with patient when on toilet to decrease risk of falls), two days prior to the fall. Review of investigative documents associated with the fall of 05/03/2025 showed Resident 60 was sent to the hospital secondary to being on an anticoagulant (a blood thinner) and acknowledged the fall resulted in a fracture of the left orbital area. The investigation concluded Resident 60 did not use the call light to request assistance and attempted to use their affected side to reach for an item within the reach of their unaffected side, which caused the resident to fall off the toilet. The investigation documented staff followed the care plan at the time of the incident. The facility made a change to the care plan to have therapy assess for safe toileting techniques. The above findings were shared with Staff B and C on 05/22/2025 at 9:03 AM. Staff B acknowledged the staff did not follow the 04/25/2025 care plan instruction to, Stay with patient when on toilet to decrease risk of falls and did not determine why the intervention failed to be implemented. When asked if staff not following the care plan placed Resident 60 at risk of a fall and a fracture, Staff B said, Yes. Staff C stated their expectation was to have the nursing assistant speak with the resident and let them know it is for their safety they must stay with the resident and if the encouragement is not successful, to get assistance from the nurse, not leave the resident alone. Review of 05/08/2025 care plan interventions showed to make a referral for therapy to screen the resident for safe toileting technique. Review of a 05/14/2025 progress note showed that staff reported they had run over the resident's leg when transporting resident down the hallway. The incident was described as the resident's left foot came off the wheelchair footrest (for the user's foot to rest on), the aide did not notice and rolled the wheelchair over Resident 60's left foot. The nurse then completed an assessment and found Resident 60's left leg with visible swelling, complaints of pain to the knee, calf and thigh, and a bruised area to a swollen ankle. A small and dry abrasion was also assessed to the left calf,. The progress note showed the resident denied being hurt and told the nurse, My leg hurts all the time. Review of a 05/15/2025 progress note showed the staff assessed Resident 60 to be in uncontrollable pain, swelling to left ankle, a bruise with a superficial scratch to the back of resident's left calf. Resident 60 stated repeatedly, I want to go to the hospital. The staff transferred Resident 60 to the local emergency department. Review of another 05/15/2025 progress note showed the staff notified Staff B in the morning that an aide, ran over resident's foot yesterday at 4pm and resident is now complaining of pain, swelling, and bruising. Review of a 05/17/2025 and 05/18/2025 progress notes showed, Resident has a new distal end of left fibula [calf bone] fracture with a boot in place. The note showed that Resident 60 previously managed pain with Tylenol (a pain killer used to treat mild to moderate pain) but due to the increase in pain, resident received an oxycodone [a pain killer used to treat severe pain] which has helped with [their] pain. A 05/18/2025 care plan intervention showed, Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. [etcetera]. Review of a 05/20/2025 Provider Note showed Resident 60, was supposed to discharge on [DATE] [sic] however patient ended up getting [their] right ankle fractured a day before [their] discharge. The provider stated the fracture was due to an accident when the nursing assistant tried to roll the resident out and thought that the resident's wheelchair was just stuck on the floor mat that they use for patient protection for falls before realizing it was the resident's foot. In an interview on 05/21/2025 at 3:07 PM, Staff V (NA) stated Resident 60 was not known to refuse staff presence when they used the bathroom. Staff V recalled Resident 60's, left side was really weak. The staff stated the wheelchair had a footrest for the left foot and an arm rest for left arm placement. Staff V said the footrest properly supported the left leg, did not observe issues with the left leg falling off the footrest, and the resident used the right leg to propel themselves in the wheelchair. Review of investigative documents associated with the 05/14/2025 wheelchair incident showed the facility determined Resident 60's left foot fell off the foot pedal during transport unbeknownst to the aide. It showed that when the aide and resident were going through the resident room's doorway, the residents foot became lodged between the door and the wheelchair, the aide did not know the foot was caught, pushed three times due to the resistance, and ran over the left foot. The investigation concluded it was an accident. Review of the investigation showed no documentation the facility ascertained why Resident 60's leg fell off the footrest meant to support the resident's leg during wheelchair use. Additionally, the investigation showed no documentation the facility asked why the 04/29/2025 intervention to, Monitor resident position in bed or wheelchair for safety upon entry and exit from room and with rounding failed. The above findings were shared with Staff B and C on 05/22/2025 at 9:14 AM. Staff C stated the investigation did not show the facility considered or determined how Resident 60's leg fell off the footrest to prevent recurrence or additional injury and should have. Staff B answered No when asked if the facility provided education to the staff on how to keep residents limbs safe when propelling them in their wheelchair after the incident happened. Staff B acknowledged the facility did not but should have determined how the intervention that directed the staff to monitor the resident position in wheelchair for safety upon entry and exit from the room failed. SUBSTANCE USE DISORDER <Resident 49> According to the 04/22/2025 quarterly assessment, Resident 49 admitted to the facility on [DATE] with diagnoses including medically complex conditions and nicotine dependence. Resident 49 had moderate cognitive impairment and was able to clearly verbalize their needs. Review of the 03/21/2024 hospital and physical showed Resident 49 had a substance use disorder to include alcohol, methamphetamine (meth, powerful addictive illegal substance), and opioids (medications used to treat moderate to severe pain). The notes further showed Resident 49 reported using meth a week prior, alcohol two weeks prior to their hospitalization and voiced interest in substance use treatment. Review of the 04/03/2024 psychosocial evaluation showed Resident 49 was identified as having a substance use disorder, comments documented as smoking meth. The assessment further showed Resident 49 had been had been clean from drugs for 3 weeks. No documentation was found to show Resident 49 was assessed for potential risks associated with the SUD. Review of the 04/19/2024 behavioral care plan showed Resident 49 had the potential to exhibit disruptive, risky, self-destructive behaviors and instructed staff to allow Resident 49 time to adjust, divert attention, and assist with finances. The care plan identified Resident 49 as having had a drug and alcohol addiction in the past. No documentation was found that addressed potential risks associated with the SUD such as brining substances into the facility. Review of Staff Z, Medical Doctor, provider progress notes showed the following: - 10/22/2024 Resident 49 was persistently requesting a shot or 2 of whiskey. The note documented Resident 49 suffered from alcoholism, whiskey was not a good idea, and Resident 49 was advised against alcohol use. - 12/04/2024 Resident 49 wanted Scotch. The note further showed I told [Resident 49] I would allow 1.5 [ounces] of scotch daily. The provider ordered scotch at night as needed. Review of January 2025 through May 2025 nursing progress notes showed: - 02/09/2025 Resident 49 was up all night, did not sleep all night. - 02/10/2025 Resident 49 received a delivery, staff observed a bottle of [NAME] in the bag. Resident 49 was reminded the provider ordered an allotment of [NAME] once daily at bedtime. Resident 49 hesitantly gave staff a bottle of Crown Royal. - 02/12/2025 Resident 49 becoming more and more forgetful. - 02/20/2025 Resident 49 was again awake all night. - 02/26/2025 Resident 49 was obsessed with wanting their as needed liquor allotment, boundaries established for liquor consumption. - 02/28/2025 Resident 49 was observed smoking behind the facility dumpster. Resident 49 became belligerent when redirected by staff. - 03/04/2025 Resident 49 returned from to the facility with the feeling of bugs crawling on their skin and altered mentation. Meth use is suspected. - 03/05/2025 Resident 49 refused to cooperate with a urine drug screen. - 03/09/2025 Resident 49 was observed to have uncontrollable movements similar to a tic with their hand moving above their head in a repetitive motion along with the lower extremities, unable to be still. - 03/27/2025 Resident 49 opiates were stopped related to worries of surreptitious drug use. - 04/16/2025 Resident 49 continues to occasionally try to sneak some alcohol. - 05/11/2025 an empty bottle of [NAME] Vodka was found hidden in Resident 49's wheelchair after they were assisted to bed. Addition review of Staff Z, Medical Doctor, provider notes showed the following: - 02/15/2025 Resident 49 had a bottle of scotch delivered and was drinking it through the night. The note further showed Resident 49 experienced insomnia partly due to drinking alcohol. - 03/04/2025 Resident 49 returned to the facility from an outing with reports of bugs crawling on them and an altered mental status. Resident 49 refused to cooperate with a urine drug screen. Meth use is suspected. - 03/27/2025 Resident 49's opiates were stopped related to uncertainty of drug use and delay with cooperating with a urine drug screen. We are worried about surreptitious drug use. In an interview on 05/21/2025 at 1:59 PM, Staff K, NA, was unsure what a SUD was but nurses would assess residents for potential risks associated with SUDs as a nursing assistant they just monitored the residents. In an interview on 05/21/2025 at 2:44 PM, Staff M, LPN, explained what a SUD was and potential signs and/or symptoms of substance abuse. Staff M was unsure of the facility process for deal[TRUNCATED]