**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #4 - The facility failed to initiate a thorough investigation of an injury of unknown origin. A. Resident #4 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included systemic involvement of connective tissue (autoimmune disease), arthritis, edema, and history of stroke. The 6/3/25 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 14 out of 15. The resident required total assistance (fully dependent) from the staff for toileting, dressing, bed mobility (the ability to sit up or roll from side to side while lying), and all transfers. The resident required (two-person) extensive assistance from the staff for bathing and personal hygiene. Resident #4 had impairments to her lower extremities and a limited full range of motion. 2. Resident interview Resident #4 was interviewed on 6/25/25 at 4:00 p.m. She said she sustained an injury in the middle of May 2025 when a male CNA she did not know came into her room to transfer her from the wheelchair to the bed. She said he told her he was going to show her how to transfer without a mechanical device, then lifted her out of her chair and put her on the bed. Resident #4 said he was rough when picking her up, and she asked him to be gentle and that her bones were fragile, but he did not say anything except to put her down on her bed in a rough manner. She said her body twisted, but not her leg, and both she and the CNA heard a popping sound, then the CNA left her room and did not send anyone in to look at her leg. Resident #4 said she experienced constant aching pain in her right leg and right foot but did not want to tell the doctor because she thought it would heal itself, but it kept swelling instead. She said when the staff would come in to take care of her, they would comment to her that her ankle looked swollen, and if they tried to turn her ankle, it was very painful. Resident #4 said a male nurse came to look at it one evening, and she told CNAs about the injury, but could not recall staff names or exactly when she told them. She said that exactly four weeks after her injury, she told her community provider, who sent her to the hospital for Xrays, and the fractures were then discovered. Resident #4 said her transfer status had changed from a sit-to-stand lift to a Hoyer (mechanical lift) lift. She said she did not like the Hoyer lift because it made her feel nervous and unstable when she was lifted. 3. Record review a. The musculoskeletal care plan, revised on 6/20/25, revealed Resident #4 had an alteration in musculoskeletal status related to a right distal tibia and fibula fracture. Interventions, revised 6/20/25, included to keep the call light within reach, provide heat and/or cold applications as tolerated, and monitor for fall risks. b. The activities of daily living (ADL) care plan, revised 6/20/25, revealed Resident #4 had ADL deficits related to generalized weakness, chronic left lower extremity and right upper extremity, pain, osteoarthritis, and right tibia and fibula fracture. Interventions, revised 6/23/25, included providing two-person Hoyer lift assistance with transfers and providing one to two-person assistance with bathing. Interventions, revised 12/27/24, included providing one to two-person assistance with toileting, bed mobility, personal hygiene, and dressing. -The care plan failed to reveal that Resident #4's ADL focus had been updated to show the resident's physical decline in all areas. c. The 3/3/25 MDS assessment revealed the resident required total assistance from the staff for toileting and toilet transfers. The resident required extensive assistance from the staff for dressing, personal hygiene, bed mobility, and chair transfers. Resident #4 did not have any impairments to her lower extremities and had a full range of motion. -Between 3/3/25 and 6/3/25, Resident #4 had a decline in abilities to include dressing, all transfers, bed mobility, and her range of motion in her lower extremities (see 6/3/25 MDS assessment above). d. The June 2025 CPO revealed the following physician orders: Weight-bearing status: non-weight bearing to right ankle - ordered on 6/17/25. Monitor right lower extremity and notify the provider of any concerns related to circulation, motion, or sensation - ordered on 6/18/25. Float right lower extremity with pillows while in bed due to ankle fracture - ordered on 6/20/25. e. The facility-reported incident on 6/17/25 of physical abuse revealed Resident #4 had been sent to the hospital for Xrays on 6/17/25, directly from her community provider, who she saw twice weekly. Included in the facility-reported incident were ten staff member interviews. Out of ten staff members interviewed, one staff member replied they had observed redness and swelling to the resident's ankle as of 6/16/25, and another staff member replied Resident #4 had expressed pain in her ankle as of 6/16/25. There were no staff names mentioned or follow-up questions reported in the incident. f. The community provider notes revealed that on 6/10/25, an Xray was ordered for 6/12/25 (but not completed until 6/17/25) due to Resident #4 complaining of ankle pain after an injury. During the visit on 6/10/25, the nurse observed pain, redness, bruising, swelling, tenderness, and changes in range of motion. g. A review of skin assessments from 5/1/25 to 6/16/25 failed to reveal observations of redness, bruising, or swelling to the right ankle. h. Progress notes were reviewed from 5/1/25 to 6/16/25 and failed to reveal any injury to the resident had been documented. C. Staff interviews 1. CNA #5 was interviewed on 6/26/25 at 10:33 a.m. She said Resident #4 used to complain to her about her foot hurting, but CNA #5 was not aware of the injury and did not ask the resident what had happened. She said she told RN #3 on 6/15/25 when she noticed bruising on Resident #4's mid calf going down her leg to her foot. 2. CNA #6 was interviewed on 6/26/25 at 10:41 a.m. She said Resident #4 used to use a sit-to-stand lift before the injury, but now required total assistance in a Hoyer lift. CNA #6 said on 6/16/25, she noticed redness to Resident #4's ankle, and the resident complained to her about pain and tenderness. She said there was no place in the CNA charting to document new injuries; the CNAs had to report it to the nurse, but she said she had not reported it. 3. RN #3 was interviewed on 6/26/25 at 12:34 p.m. He said a change of condition would constitute any change in a resident's physical or emotional baseline. He said that when a change of condition was determined, as a nurse, he would assess the change, report it to the physician and family, and make a note in the chart. -RN #3 said that a CNA brought it to his attention on the evening shift on 6/15/25 that while laying Resident #4 down, the resident had complained of pain in her ankle, and the CNA had observed swelling and bruising. RN #3 said he looked at the ankle and observed it was swollen and bruised. He said Resident #4 told him she was waiting for the Xrays to be completed by her community provider; therefore, RN #3 said he did not do a skin assessment or a pain assessment, or contact the resident's family or physician because he assumed all parties were aware since the resident was waiting for Xrays. -He said he did not ask the resident how and when the injury occurred. RN #3 said the following day was the weekly meeting between Resident #4's community provider and the facility and RN #3 advised the DON to ask the community provider if an Xray was scheduled, but he said he did not follow up any time later with the DON regarding the Xrays that the resident mentioned. He said before the injury, Resident #4 was able to propel herself in her wheelchair and participate in sit-to-stand lift transfers. 4. LPN #2 was interviewed on 6/26/25 at 12:55 p.m. She said any changes from a resident's normal baseline would be considered a change of condition. She said a swollen ankle would be considered a change of condition, and if reported to her, she would do a full body assessment to see if any other injuries were present, check vital signs, and ask the resident when and how the injury occurred. LPN #2 said it was important to gain as much information as possible to rule out a potential abuse situation, and when an injury occurred during a transfer, it had to be reported to the NHA and the DON to rule out the abuse. She said nursing documentation would include an assessment of the change of condition and a progress note. 5. LPN #1 was interviewed on 6/26/25 at 12:55. She said a swollen ankle would be considered a change of condition, and if a resident was able to answer questions, she would ask when and how it occurred. LPN #1 said it was important to ask these questions to rule out the abuse, and if injury occurred during the transfer, it must be reported to the NHA and the DON as well for investigation of potential abuse. LPN #1 said a full body assessment and vital signs were taken when a resident experienced a change of condition, and all findings should be documented under progress notes and the change of condition form. She said after assessment, the physician and the family must be notified about findings. 6. The assistant director of nursing (ADON) was interviewed on 6/26/25 at 1:08 p.m. She said any unexpected changes in a resident's physical or mental condition was a change of condition, and upon a change of condition, the nurses were expected to complete a full assessment, vital signs when necessary, ask the resident about the origin and timing of the injury, and assess for pain. 7. The MDS coordinator (MDSC) was interviewed on 6/26/25 at 5:25 p.m. She said a change of condition could be exhibited by health status, physical, psychosocial, or behavioral changes. She said she expected that if a CNA observed something that appeared different about a resident, they were to report to the nurse, and then the nurse was expected to do a visual assessment of the resident to determine if further actions needed to be taken. She said if a change of condition had been determined, an assessment was completed, and the resident's provider was notified. She said if the change of condition was determined on the night shift, it needed to be passed on in report to the oncoming nurse the next morning. Based on observations, record review and interviews, the facility failed to investigate thoroughly allegations of staff-to-resident verbal abuse and failed to initiate a thorough investigation of an injury of an unknown origin. The facility failure affected two (#24 and #4) of five residents out of 37 total sample residents. 1. The facility failed to recognize, address, and thoroughly investigate allegations of staff-to-resident abuse. Interview with Resident #24, who was visibly tearful during three interviews, one on 6/23/25, and two on 6/24/25, revealed she felt mentally and verbally abused. On 6/23/25, Resident #24 said she had reported to the social services director (SSD) and other staff in leadership that registered nurse (RN) #2 accused her of medication-seeking behavior and retaliated against her by not administering her medications on time. She also reported to the SSD and other staff in leadership that certified nurse aide (CNA) #4 yelled at her when she provided her care. Resident #24 said that since she made her report to the SSD and other staff in leadership, nurses and CNAs had argued with her and made her feel bad. Resident #24 said no one followed up with her, both RN #2 and CNA #4 continued to work with her, and she had no other option but to cope with it. Interviews with the director of nursing (DON) on 6/23/25 at 4:26 p.m. and the SSD on 6/23/25 at 4:33 p.m. revealed they were aware of the incident involving Resident #24 and RN #2, and followed up with the resident unofficially, removing RN #2 from Resident #24's care for a while. The SSD said the resident told her that RN #2 ignored her on purpose and CNA #4 was brisk and not friendly, and in response, she had informally educated staff on customer service. The facility's failure to recognize Resident #24's report of her interactions with RN #2 and CNA #4 as potential allegations of staff-to-resident abuse and thoroughly investigate them created a situation that was likely to result in serious harm. 2. The facility failed to initiate a thorough investigation of an injury of unknown origin. Interview with Resident #4, who was alert and oriented and required total assistance from staff for all transfers, revealed she sustained right lower extremity injuries in the middle of May 2025 when a CNA picked her up without a mechanical lift device and put her down in bed in a rough manner. She said she experienced constant aching pain and swelling in her right leg and ankle. Record review revealed Resident #4 was seen by a community provider on 6/10/25, and Xrays completed on 6/17/25 revealed right distal tibia and fibula fractures (lower leg bones). The facility reported the incident on 6/17/25 and interviewed ten staff members, two of whom reported observing injury (redness, swelling, pain) as of 6/16/25. Yet, there were no follow-up questions in the report, and a review of skin assessments and progress notes from 5/1/25 to 6/16/25 failed to reveal observations of bruising or swelling or documentation of the resident's pain. In an interview with RN #3 on 6/26/25 at 12:34 p.m., he said he looked at the resident's ankle on 6/15/25 and observed it was swollen and bruised, but when the resident told him that she was waiting for Xrays to be completed, he did not conduct an assessment or contact family or the physician because he assumed all parties were aware of the situation given the order for Xrays. In an interview with licensed practical nurse (LPN) #2 on 6/26/25 at 12:55 p.m., she said it was important to gain as much information as possible when there was a change in condition to rule out a potential abuse situation. And, when it occurred during a transfer, it had to be reported to the the nursing home administrator (NHA) to rule out abuse. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Interview with Resident #24, who was visibly tearful, on 6/23/25, revealed she felt mentally and verbally abused. She said she had reported to the social services director (SSD) and other staff in leadership that registered nurse (RN) #2 accused her of medication-seeking behavior and retaliated against her by not administering her medications on time. She also reported to the SSD and other staff in leadership that certified nurse aide (CNA) #4 yelled at her when she provided her care. She said that since she made her report to the SSD and other staff in leadership, nurses and CNAs had argued with her and made her feel bad. Resident #24 said no one followed up with her, both RN #2 and CNA #4 continued to work with her, and she had no other option but to cope with it. Staffing records documented CNA #4 continued to be scheduled to work with Resident #24, and RN #2 was taken off from Resident #24's hall but was put back on soon after. The DON was interviewed on 6/23/25 at 4:26 p.m., and the SSD was interviewed on 6/23/25 at 4:33 p.m. Their interviews revealed that the DON and the SSD were aware of the incident involving RN #2. The DON said she had followed up with the resident unofficially, and the resident was satisfied with the outcome. She also said she removed RN #2 from Resident #24's care for a while; she was unsure of the length of time. The SSD said the resident told her that RN #2 ignored her on purpose, and CNA #4 was brisk and not friendly, and in response, she had informally educated staff on customer service. The SSD said that the nursing home administrator (NHA), as well as the other managers, knew about both incidents because she said she had discussed them in their morning meeting. On 6/24/25, Resident #24, visibly tearful, said that on the previous day, the NHA came into her room and drilled her on what she had said during her interview on 6/23/25 with the state. She said she found the exchange intimidating, and she had been up since midnight with anxiety and perseverating about the interaction. On 6/24/25 at 5:02 p.m., the NHA was interviewed. He said he was not aware of the verbal abuse situations involving RN #2 and CNA #4. He said he became aware of the situation on 6/23/25 when he spoke to Resident #24. On 6/23/25 at 2:25 p.m. and 6/24/25 at 10:17 a.m. and 3:51 p.m., Resident #24 was visibly tearful. She expressed feelings of harm, including retaliation, intimidation, anxiety, and mental and verbal abuse as a result of her interactions with RN #2, CNA #4, and the NHA. The facility's failure to recognize, address, and thoroughly investigate her allegations of potential abuse by staff was likely to result in serious harm if not immediately corrected. B. Facility plan to remove immediate jeopardy On 6/25/25 at 2:54 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: Immediate actions: Resident #24 was interviewed by clinical resource (CR) #1 and the corporate licensed clinical social worker on 6/24/25, at which time they provided psychosocial support and offered additional mental health support. The NHA and RN #2 were suspended on 6/24/25 at 5:30 p.m. and CNA #4 was suspended on 6/23/25 at 5:00 p.m. Education with the NHA, the SSD, and the DON were conducted on 6/25/25 and included how to identify instances and allegations of abuse and to understand the difference between a concern and forms of abuse. Competencies for understanding of education were completed on 6/25/25, and education was given by a clinical nurse resource. Education provided to RN #2 and CNA #4 in regards to understanding the differences of concerns and forms of abuse and how to report appropriately. Education given by the clinical nurse resource to RN #2 on 6/25/25. CNA #4 will not return to work until education and return demonstration is provided in person. Identification of other residents at risk: Starting on 6/25/25, initiate interviews with all residents who can participate in interviews to ensure all allegations of abuse are identified and thoroughly investigated. Any residents who are not interviewable, the facility will reach out to emergency contact or resident representative to discuss concerns. If an interview is unable to be completed, social services will complete an observation to identify any signs of psychosocial distress or change in mood. All interviews or observations to be completed by 6/25/25. Systemic changes: All staff will be educated on the identification of allegations of abuse versus customer service and abuse reporting. Education to include differentiating potential abuse allegations from concerns or customer service-related issues from residents. Staff education to be provided by social services, clinical nurse resource, or a licensed nurse. Education was initiated via video chat on 6/24/25. All education to be completed by 6/26/25. Any employee who cannot complete education in person will be educated prior to their next scheduled shift. Monitoring: The social services or designee will complete audits on five random residents weekly for 12 weeks. The audit will include identification through a resident interview: have any staff members, resident, visitor abused you? Have you observed any other resident being abused? Record review: if yes, abuse coordinator notified per regulations, thorough investigation completed with new intervention implemented to prevent reoccurrence, completion of state occurrence reporting site and police reporting completed. For identified concerns, corrective action completed. The audits will be recorded on an audit form. Discrepancies will be promptly reported to the administrator. Results will be reported monthly to the quality assurance committee. The director of nursing services or designee will interview five employees weekly for comprehension about types of abuse and signs of mental abuse, the difference between customer service concerns and allegations and reporting immediately. Social service resource or clinical nurse resource will complete oversight weekly to review investigations and audit if managers have an understanding between customer service and allegations. C. Removal of immediate jeopardy On 6/25/25 at 3:50 p.m., the interim nursing home administrator (INHA) was notified that the facility's plan to remove the immediate jeopardy was accepted based on the facility's plan and evidence of implementation of the measures outlined in the plan. However, the deficient practice remained at a G level, isolated, actual harm. Interviews conducted on 6/25/25 verified that staff had been educated on identifying abuse and the difference between an allegation and a customer service concern. -CNA #7 was interviewed on 6/25/25 at 3:35 p.m. She said staff had been getting a lot of training on abuse. She said she attended an in-service that day before her shift started. She said it was about abuse and interventions and the proper steps to take when staff saw it or heard it, who to report it to, and who to report it to if the abuse coordinator was not available. -LPN #2 was interviewed on 6/2525 at 3:28 p.m. She said she had been getting a lot of abuse training within the last week. She said she had received training that day on the difference between a complaint and abuse. She said abuse would be yelling at a resident, and a complaint would be if a resident complained when staff forgot to knock when entering their room. The maintenance director (MTD) was interviewed on 6/25/25 at 4:58 p.m. He said they were trained on the difference between abuse allegations and customer service. The MTD said abuse was purposely not answering a call light, and customer service was not being pleasant while providing care. II. Facility abuse policy The Abuse: Prevention of and Prohibition Against Policy and Procedure, revised January 2024, was received from the NHA on 6/24/25 at 2:39 p.m. It read in pertinent part: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. The facility will engage in training and orienting its new and existing nursing staff on topics which relate to the delivery of care in the post-acute setting. Topics of such training will include, but not be limited to: - Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; - Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The investigation, and the results of the investigation, will be documented. III. Resident #24 - The facility failed to recognize, address, and thoroughly investigate allegations of potential staff-to-resident abuse. A. Resident #24 1. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included emphysema, major depressive disorder, and anxiety. The 3/21/25 minimum data set (MDS) assessment revealed Resident #24 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment revealed that Resident #24 was independent or needed supervision for the majority of her activities of daily living (ADL). 2. Resident interview and observations on 6/23/25 Resident #24 was interviewed on 6/23/25 at 2:25 p.m. She said she did not feel comfortable in the facility anymore because the staff did not like it when she stood up for herself. -She said she had gone to RN #2 and asked for her medication, and RN #2 did not put her scheduled pain medication and her scheduled antianxiety medication into her medication cup. She said when she asked about it, RN #2 told her that she had already given them to her and argued with her, which caused her to feel like she was being accused of medication seeking. She said RN #2 checked her medication card and saw that she had, in fact, not given her the medications and put them in her cup without apologizing to her. She said that since that incident, she had felt that the staff and facility had been picking on her. -She said nurses and CNAs would argue with her and make her feel bad. She said that she felt like staff were mentally abusing her. She said that CNAs would become really rude. She said CNA #4 yelled at her when she asked where the lid to her water jug was. She said CNA #4 yelled, Because there wasn't any! when she was assisting her roommate. During the interview, Resident #24 was very tearful when she was speaking about RN #2 and CNA #4. A few minutes later, the NHA was observed entering Resident #24's room. 3. Resident interviews on 6/24/25 Resident #24 was interviewed on 6/24/25 at 10:17 a.m. She said she wanted to share that the NHA had come into her room the day before and drilled her on everything that was said during her interview with the state. She said she remembered another thing that CNA #4 had done. She said she asked CNA #4 to change the oxygen tubing because it was all twisted and she could not get any oxygen out of it, but CNA #4 refused to get it for her. Resident #24 was interviewed again on 6/24/25 at 3:51 p.m. She said the NHA did not ask her if she wanted to continue to work with CNA #4, whom she said she felt was abusive. She said she felt like the NHA was out of line to come and drill her. She said she felt like he was intimidating. -She said the SSD did not discuss the incident involving CNA #4 with her but did discuss a new counselor who would be able to spend more time with her. She said she would like someone outside of the facility to talk to because she felt like the people connected to the facility were vindictive, and she felt like she did not have anyone she could talk to. -She said she had told staff that she did not want to work with RN #2 and CNA #4. She said RN #2 was not on her hall for maybe two weeks, but then she was on her hall again. She said she felt like the management did not care, and they are going to do what they are going to do. -She said she felt like the NHA was the only one she could talk to, but after what he did the day before, she was no longer sure she can talk to him. During the interview, Resident #24 became very tearful when she spoke of RN #2, CNA #4, and the NHA. B. Facility response On 6/23/25, around 3:30 p.m., the NHA submitted a paper file stating that Resident #24 had just reported to him a situation of potential abuse, and he wanted to be proactive and show the investigation. 1. Facility investigation The facility investigation revealed that the NHA interviewed Resident #24, and she reported that several months ago, CNA #4 yelled at her without provocation. When asked what triggered the incident, Resident #24 stated that CNA #4 responded to her by yelling at her. Resident #24 expressed that she felt the interaction had been rude. The report read that Resident #24 said she did not report it to anyone because she did not want to bother anyone or cause any trouble. The investigation further revealed that the NHA interviewed CNA #4 about the allegation. CNA #4 reported she rarely provided cares for Resident #24 since she was mostly independent. She said she delivered iced tea to Resident #24's bedside while she was out of the room, and when she returned, Resident #24 questioned why there was not a lid on the tea. CNA #4 stated she told her that the kitchen was temporarily out of lids. Resident #24 then responded by saying, You don't have to yell at me, and then Resident #24 left the room. CNA #4 reported she did not raise her voice. The investigation further revealed that the nurse who conducted Resident #24's victim assessment was RN #2. CNA #4 received training on customer service and nonverbal/verbal communication. The allegation was unsubstantiated due to not having any witnesses. 2. Failure to thoroughly investigate Resident #24's allegations of potential abuse Staffing records documented CNA #4 continued to be scheduled to work with Resident #24, and RN #2 was taken off from Resident #24's hall but was put back on soon after. -The investigation submitted by the NHA did not include any interviews with other residents who received care from CNA #4, nor any feedback from Resident #24 to see if the resolution (see above) was satisfactory. -The investigation the NHA provided did not include concerns that Resident #24 shared about RN #2. -The investigation did not include observations of interactions between Resident #24, as well as other residents cared for by RN #2 and CNA #4, and the two staff members. -The investigation did not include interviews with staff and residents who worked with or were cared for by RN #2 and CNA #4 about their interactions with the RN or CNA. -The investigation did not include documentation from the unofficial investigation by the DON or any grievances or concerns involving Resident #24, RN #2, and CNA #4. C. Staff interviews 1. RN #2 was interviewed on 6/24/25 at 4:26 p.m. She said her relationship with Resident #24 was good. -She said that Resident #24 was upset with her in the past because of the timing of her medications. She said that Resident #24's pain medication was scheduled at 4 p.m., but she wanted it at 3 p.m. S[TRUNCATED]