**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide the necessary care and services to recognize and treat changes in condition, follow physician's orders for medication parameters, document medication administration, and provide food in the correct form.Resident #93 suffered actual harm after the facility failed to identify and timely treat a change in condition resulting in the resident being hospitalized with Respiratory Failure, Urinary Tract Infection , and Aspiration Pneumonia. Resident #110 suffered actual harm at the facility when she died of a food bolus when she was given hamburger at the facility despite having an order for nothing by mouth. Even though the facility did not serve the resident the meal they failed to protect the resident from others providing her with food. This deficient practice was identified for 10 of 30 sampled residents (Residents #93, #109, #8, #9, #110, #107, #17, #112, #1, and #85). Facility Census: 102 a) Resident #85 A review of Resident #85's medical record on 08/18/25 found the following physician orders: -- ANTIPSYCHOTIC side effect monitoring list #2 not limited to: insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity. --MOOD STABILIZER Side effect monitoring: Hives, a rash, fever, or swollen glands. Signs of [NAME]-[NAME] syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids. Confusion. Slurred speech. Nausea, vomiting, and diarrhea. Trembling. Increased thirst and increased need to urinate. Weight gain in the first few months of use. Drowsiness. --ANTIPSYCHOTIC side effect monitoring list #1: Dystonia: torticollis(stiffness of neck), Anticholinegic symptoms:Dry Mouth, blurred vision, constipation, urinary retention. Hypotension, Sedation/drowsiness, increased falls/dizziness, Cardiac abnormalities(tachycardia, bradycardia, irregular H.R; NMS). Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy,pseudoparkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. --ANTIDEPRESSANT side effect monitoring not limited to: Dystonia: torticollis(stiffness of neck),Anticholinegic symptoms: Dry Mouth, blurred vision,constipation, urinary retention.Hypotension, Sedation/drowsiness,increased falls/dizziness,Cardiac abnormalities(tachycardia, bradycardia, irregular H.R; NMS).Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy, weakness,tremors,appetite change/weight change,insomnia,confusion,tardive dyskinesia, suicidal ideations --ANTIANXIETY side effect monitoring but not limited to: Dystonia: torticollis(stiffness of neck), Anticholinegic symptoms: Dry Mouth, blurred vision, constipation, urinary retention. Hypotension, Sedation/drowsiness, increased falls/dizziness, Cardiac abnormalities (tachycardia, bradycardia, irregular H.R; NMS). Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy. Weakness, hangover effect. -- Lantus Subcutaneous Solution 100 Units /ML In ject 10 ML subcutaneously in the morning. -- Fasting blood sugar every day in the morning. Further review of the Medication Administration Record for the months of 06/2025, 07/2025, and 08/2025 found the following occasions when the aforementioned physician orders were not followed: On the following dates and times the side effect monitoring was not completed: 05/05/25, 05/06/25, 05/11/25 Day shift 06/26/25 day shift. 07/15/25 on day shift. 07/18/25, 07/19/25, 07/20/25 evening shift. On 06/23/25 the fasting blood sugar was not obtained nor was his insulin administered according to the MAR. On 08/18/25 the residents blood sugar was obtained and was 94. The nurse held the residents insulin despite not having a physician's order to do so. An interview with the Director of Nursing (DON) at 12:30 pm on 08/18/25 confirmed the above findings and no further information was provided. b) Resident #107 Resident #107 had diagnoses of a recent myocardial infarction, atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, hypertensive heart disease, and chronic obstructive heart disease. On 08/16/25 at 11:48 AM, the on-call telemedicine physician service assessed Resident #107 due to the nurse's report that the resident had swelling of the face and legs. The resident was not experiencing shortness of breath or chest pain. The resident's vital signs and oxygen saturation were within normal limits. The nurse reported the resident's lung sounds were clear bilaterally. The on-call physician's plan was as follows: - Order a comprehensive metabolic panel (CMP), complete blood count (CBC) with differential, and a B-type natriuretic peptide (BNP) to assess for heart failure. - Elevate lower extremities to manage edema.- Monitor fluid status carefully to avoid dehydration.- Order a chest X-ray to assess for pulmonary congestion.The patient was to remain in the facility for continued monitoring and management of her fluid status and renal function. Nursing staff were to continue elevating the resident's legs and monitoring for any changes in condition. On 08/16/25 at 6:43 PM, the on-call provider evaluated the resident's laboratory testing results and determined the patient is stable with improved laboratory results and no significant change in symptoms that would necessitate altering the current treatment plan. The provider noted the chest x-ray was pending. The resident was described as having faint wheezing upon expiration. The plan was as follows: - Continue current medications, including Lasix 20 milligrams (mg) twice daily - Daily weights to monitor for fluid retention, with notification if weight gain exceeds two (2) pounds (lbs) - Schedule chest x-ray for Monday - Inpatient provider to evaluate the patient on Monday - Monitor and report and worsening symptoms The x-ray was obtained on Sunday, 08/17/25. The report at 12:48 PM showed bilateral lower lobe infiltrates. A handwritten note on the report stated, Calling [on-call service] 08/17/25 at 1:14 PM. The report was signed by the facility's medical director on 08/18/25. A nursing note written on 8/17/2025 at 12:54 PM stated the chest x-ray results showed bilateral lower lobe infiltrates. The note stated the on-call service would be notified. A nursing note written on 8/17/2025 at 1:41 PM stated the resident's medical power of attorney (MPOA) was notified regarding the resident's x-ray results and that the on-call service planned to order antibiotics for pneumonia. A nursing note written on 08/17/25 at 2:59 PM stated the facility was waiting for an order for antibiotics to be placed. A nursing note written on 08/17/25 at 7:02 PM stated the on-call service was messaged. The note also stated there were no new orders as of yet and the facility was awaiting an antibiotic order for the resident. Nursing notes showed the on-call service had been re-called on 08/17/25 at 7:14 PM and nursing was waiting for a response. A follow-up progress note was written by the on-call service on 08/19/25 at 11:52 PM. The resident's chest x-ray was not mentioned in the progress note. The plan was as follows: - Reinforce importance of Thrombo-Embolic Deterrent (TED) hose - Monitor daily weights and report any rapid increases - Continue Lasix as prescribed, but review with nephrology due to end-stage renal disease (ESRD) status - Monitor for symptoms of decompensation (shortness of breath, orthopnea, chest pain, rapid weight gain) - Continue close monitoring due to elevated BNP - Monitor labs and electrolytes as indicated for chronic kidney disease and ESRD - Avoid nephrotoxic medications - Encourage mobility as tolerated to reduce risk of further edema - Monitor for skin breakdown in edematous areas A nursing note written 8/20/2025 at 7:00 AM stated, Resident dyspneic, audible wheeze, O2 sats < 50%. Placed on NRB [non-rebreather oxygen]. Call to [on-call service] waiting in queue. [MPOA's name] aware and requested resident sent to [hospital]. On 08/20/2025 at 10:46 AM, the Director of Nursing stated the facility's physician does not see acutely-ill residents and did not see Resident #107. She stated nursing staff had reached out to the on-call service to inquire about treatment for the lung infiltrates identified on the chest x-ray. However, the on-call service did not respond. The DON stated the resident was receiving a broad spectrum antibiotic for Clostridium difficile (C. Diff) infection. The resident's physician's orders showed she was receiving the antibiotic Vancomycin orally. According an on-line article published by the National Institutes of Health titled Vancomycin, although oral Vancomycin is effective to treat C. Diff infections, Vancomycin has poor oral bioavailability and is typically administered intravenously to treat most infections. No futher information was provided through the completion of the survey process. c) Resident #112 Review of Resident #112's physician's orders showed an order written on 08/04/25 for Midodrine, 5 milligrams (mg) by mouth, three (3) times a day for hypotension. The medication was to be held for blood pressure readings greater than 110. Review of Resident #112's Medication Administration Record (MAR) for August 2025 showed Midodrine had been administered on three (3) occasions when the resident's blood pressure was greater than 110. These occasions were as follows: - 08/05/25 at 12:00 PM, when the resident's blood pressure was126/74. - 08/05/25 at 4:00 PM, when the resident's blood pressure was 118/64. - 08/12/25 at 12:00 PM, when the resident's blood pressure was 112/65. On 08/13/2025 at 2:00 PM, the Director of Nursing confirmed Resident #112's Midodrine had been administered when the blood pressure was greater than 110. d) Resident #17 Review of Resident #17's physician's orders showed an order written on 07/28/25 for Midodrine, 5 milligrams (mg) by mouth, three (3) times a day for hypotension. The medication was to be held for systolic blood pressure readings greater than 110. Review of Resident #17''s Medication Administration Record (MAR) for July 2025 showed Midodrine had been administered on two (2) occasions when the resident's blood pressure was greater than 110. These occasions were as follows: - 07/28/25 at 5:00 PM, when the resident's blood pressure was112/70. - 07/29/25 at 8:00 AM, when the resident's blood pressure was114/72. Review of Resident #17''s Medication Administration Record (MAR) for August 2025 showed Midodrine had been administered on three (3) occasions when the resident's blood pressure was greater than 110. These occasions were as follows: - 08/05/25 at 8:00 AM, when the resident's blood pressure was113/68. - 08/05/25 at 5:00 PM, when the resident's blood pressure was129/74. - 08/12/25 at 12:00 PM, when the resident's blood pressure was114/75 On 08/13/2025 at 2:00 PM, the DON Director of Nursing confirmed Resident #17's Midodrine had been administered when the systolic blood pressure was greater than 110. e) Resident #17 Review of Resident #17's physician's orders showed an order written on 01/24/25 for gabapentin (Neurontin) 600 mg, three (3) times a day for pain. Review of Resident #17's controlled substance administration record for January 2025 showed two (2) occasions when gabapentin had been dispensed four (4) times instead of the three (3) times ordered by the physician. On 01/26/25, gabapentin was dispensed at 5:20 AM, 9:44 AM, 12:10 PM, and 8:30 PM. The Medication Administration Record (MAR) showed the resident received gabapentin three (3) times a day as ordered. On 01/29/25, gabapentin was dispensed at 5:30 AM, 9:31 AM, 12:04 PM, and 9:04 PM. The Medication Administration Record (MAR) showed the resident received gabapentin three (3) times a day as ordered. On 08/19/2025 at 5:28 PM, the Director of Nursing (DON) confirmed the gabapentin discrepancies. She stated the resident received four (4) doses of gabapentin on those days but had no explanation as to why this occurred. f) Resident #1 Review of Resident #1's physician's orders showed an order written on 10/17/24 for gabapentin (Neurontin) 300 mg, three (3) times a day for neuropathy. Review of Resident #1's controlled substance administration record for January 2025 showed one (1) occasion when gabapentin had been dispensed four (4) times instead of the three (3) times ordered by the physician. On 01/07/25, gabapentin was dispensed at 6:05 AM, 8:36AM, 2:00 PM, and 9:20 PM. The Medication Administration Record (MAR) showed the resident received gabapentin three (3) times a day as ordered. On 08/19/2025 at 5:28 PM, the Director of Nursing (DON) confirmed the gabapentin discrepancy. She stated the resident received four (4) doses of gabapentin on those days but had no explanation as to why this occurred. g) Resident #93 Record review completed on 08/19/25 revealed the following notes a nursing note dated 08/01/25 at 05:58 AM showed staff documented the resident’s urine output from the Foley catheter was thick, mucous-like, and dark golden in color. No evidence of physician notification or further assessment was documented. A behavior note dated 08/04/25 at 06:01 AM showed the resident was screaming out during the shift. The resident was repositioned and provided fluids; however, no additional assessment or physician notification was documented. A behavior note dated 08/08/25 at 05:46 AM showed the resident yelled aloud for the majority of the shift. The documentation reflected “all needs were met” with redirection, snacks, and fluids offered, but no assessment for pain, infection, or other medical issues was documented. On 08/09/25 at 10:05 AM, the resident was noted to have labored shallow respirations, decreased alertness, and oxygen saturation of 68% with oxygen in place. A PRN Duoneb treatment was given without improvement. The nurse practitioner was notified, and an order was received to send the resident to the ER. On 08/09/25 at 14:43 PM, hospital staff reported the resident was on a ventilator and diagnosed with respiratory failure, urinary tract infection, and aspiration pneumonia. Interview 08/18/2025 10:47 AM during an interview the Director of nursing stated she could not find where the doctor was notified The facility’s failure to assess and notify the physician when the resident presented with abnormal urinary output and repeated episodes of yelling and distress delayed treatment and resulted in the resident requiring hospitalization for respiratory failure, UTI, and aspiration pneumonia h) Resident #9 Record review completed on 08/14/29 revealed the following blood sugar 7/10/2025 17:22401.0 mg/dL An interview was conducted with Unit Manager #41 on 08/14/25 at 10:00 AM regarding notifying the Doctor for blood sugars, she stated if below 60 or above 400. On 08/18/2025 at 10:47 AM an interview with the director of nursing was completed, when asked to provide more information of what was done for Resident #9 having a blood sugar of 401 the DON stated I find where the doctor was notified, i can only look back f16 days in the secure messaging system, the nurse should have completed a progress note after contacting the doctor, i can't find anything else. i) Resident #8 08/19/2025 5:30 PM resident #48 states he's had no medication for hemorrhoids for the past two months AN interview on 08/20/25 at 9:30 AM with Licensed Practical Nurse (LPN)#16 stated (I offer him the cream I think he gets every six (6) hours, and showed this surveyor the tube of cream with Resident #8's name on it. Record review completed on 08/20/25 of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of July and August revealed no documentation that Resident #8 had got had any hemorrhoid cream Interview with the director of nursing was completed on 08/20/25 at 11:00AM when asked to provide more supporting documentation that resident#8 did get the hemorrhoid cream for rectum, she stated I can not provide that, it was not documented on the MAR or TAR. j) Resident #110 On 06/13/25 at 10:40 PM, an initial reporting of allegations was reported to the Office of Health Facility Licensure and Certification. The description of the allegation was as follows: Resident [#110] was coded by facility staff. CPR [cardiopulmonary resuscitation] and AED [automated external defibrillator] administered. EMS [emergency medical services] arrived at 8:45 PM to transport resident while still performing CPR. Call back from facility by paramedic at 9:18 PM to inform facility that resident has 2 quarter [NAME] [size] pieces of hamburger extracted from throat. The steps taken immediately to ensure the alleged victim was protected was to place the alleged perpetrator on 1:1 observation by staff. The five (5) day follow up investigation as follows: Resident [#110] was coded by staff. CPR and AED was administered. EMS arrived to transport resident to the hospital. Alleged perpetrator [#61] was immediately placed on 1:1 observation by staff. A statement was obtained from [Resident #61] (alleged perpetrator). PTSD [post traumatic stress disorder] screening has been completed with alleged perpetrator, with no adverse outcomes reported at this time. Nursing assignment sheets have been reviewed. PCC [point click care] documentation has been reviewed to ensure that residents dietary order for NPO was in and correct. Dietary tickets were reviewed and confirmed to ensure resident did not receive a ticket. Statements obtained from all nursing staff on shift at the time of the incident occurred. Interviews verified no tray was observed with [Resident #110]. Statements were obtained from the dietary staff that was bringing the trays to the floors. Interviews verified that no tray was prepared. Statements have been collected from all staff that have been completing 1:1 observation with alleged perpetrator following this incident. A statement was obtained from resident [#35] who is alert and oriented x 3, that was in the room speaking with the alleged perpetrator when this incident occurred. Resident [#35] stated that she did not witness anyone feed [#110] . After a complete investigation, this incident has been found to not be verified. After reviewing statements obtained from staff, no one observed any staff, resident's roommate, or visitors feeding or attempting to feed Resident [#110]. Alleged perpetrator adamantly denies that she attempted to feed the alleged victim at anytime. Resident [#35] also reports that they did not witness anyone attempt to feed the alleged victim prior to this incident. All witness statements support [Resident #61] and [Resident #35] statements of no one was seen feeding [Resident #110]. Due to the incident being found to be not verified, no further actions will be taken by the facility. According to the death certificate, the death injury occurred on 06/13/25 at 8:28 PM. The cause of death was choked on food bolus. Resident #110 had experienced a stroke and had an order to receive nothing by mouth (NPO). She received all her nutrition via enteral feeding. A speech therapy evaluation completed on 06/13/2025, documented the resident had profound/absent swallowing abilities, with little to no attempts to initiate/participate and profound global aphasia with no verbalizations or voicing noted during the assessment. A physical therapy evaluation completed on 06/13/2026, documented Clinical Impression stated, Patient is very weak, is bed bound, unable to sit or stand, needs a lot of assistance with bed mobility, is at risk for falls and is very limited with her mobility and independence. Resident #61's meal ticket was reviewed. She had received meatloaf the evening of 06/13/2025. This information was not included in the facility's investigation of the matter. Resident #35's statement was as follows: I was in the room talking to [Resident #61] when [Resident #110] was having trouble breathing. The nurses and aides started working on her and I left the room at that time. I did not try to feed [Resident #110] anything and I did not see [Resident #61] try to feed her anything. I was not in or near her room at dinner time. I did not see a food tray in the room when I was in there. Resident #61 stated on 06/13/25, I did not help her eat dinner but she was hungry. No one helped her eat dinner. Is she dead? She is dead, isn't she? She died, didn't she? Resident #61 stated on 06/17/25, She did not tell me that she was hungry. She had not ate anything in two days. No one tried to feed her, so she had to be hungry. I did not try to feed her. No one told me she was NPO. Resident #61 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) and was determined to not have capacity. On 08/12/2025 at approximately 03:00 PM, the Administrator and Director of Nursing were interviewed by the State Surveyor concerning a Facility Reported Incident concerning Resident #110 and #61 on 06/13/2025. The Administrator reported the resident’s oxygen saturations decreased and she was sent to the hospital. The Director of Nursing (DON) reported, generally they contact physician when oxygen saturations decrease. Following the report from the hospital, the Administrator reported Resident #61 was placed on 1:1 observation because we weren’t 100% sure she didn’t provide any food by mouth. The Administrator stated, the investigation led to the conclusion a meal was not served and that they could not solidly conclude Resident #61 did it. The Administrator reported the was no follow-up education for other NPO residents. The Administrator reported she was unsure of the follow-up for the incident until she looked at the Facility Reported Incident. On 08/12/2025 at 04:25 PM, the Administrator reported they brought before the Quality Assurance and Performance Improvement (QAPI) committee review of NPO residents to be with like residents (NPO) or residents that take their meals in the dining room. There was no education outlined for residents with modified diets in the QAPI plan.

Based on record review, staff interview and resident interview the facility failed to assess, monitor and treat pain in accordance with professional standards of treatment. For Resident #85 this resulted in actual harm because the nurse assessed him as having pain but failed to treat the residents pain with non pharmacological or pharmacological interventions both of which he had physician orders for. The nurse further failed to assess the pain for location or duration and never notified the physician or the residents increased pain. For Resident #104 the resident an increase in pain upon movement and transfers. Though the facility treated her pain and increased her pain medications they failed to assess the cause of the pain which was later identified at two (2) fractures. For Resident #73 the resident reported to the nurse he was experiencing numbness and tingling in his toe amputation site the physician was notified and indicated he would address the next day but failed to do so and the resident continued to suffer tingling and pain in the site. These failures affected three (3) of eight (8) sampled residents reviewed for the care area of pain during the long term care survey process. Resident Identifiers: #85, #104 and #73. Facility census: 102. Findings Include: a) Resident #85 A review of Resident #85's medical record found the following physician orders related to pain: -- Non Pharmacological Interventions: 1. Attempt Repositioning. 2. Encourage Rest Periods. 3. Dim lighting in the room. 4. Check for well fitting clothing and shoes as needed. Order effective date 04/20/25 and current at the time of this review. -- Pain level q (every shift) (1-3 mild) (4-7 moderate) (8-10 severe) pain 1-3 with no PRN (As needed): contact practitioner, greater than or equal to 4 with no PRN or PRN not effective or new onset pain contact practitioner. Document non-pharmacological pain intervention prior to PRN pain medication administration. Order effective date 04/21/25 and current at the time of this review. -- Tylenol Oral Tablet 325 MG give 650 MG by mouth every 6 hours as needed for pain. This order had an effective date of 01/30/25 and was discontinues on 05/16/25 when an new Tylenol order was entered. -- Acetaminophen Extra strength oral tablet 500 mg Give 2 tablets by mouth every eight (8) hours as needed for pain. Order effective date 05/16/25 and current at the time of this review. A review of the medication administration records for the months of 05/2025, 06/2025, 07/2025 and 08/2025 found the following occasions when Registered Nurse (RN) #44 documented the resident was experiencing pain but provided no interventions to treat the pain nor did she contact the practitioner about the resident experiencing pain. Day Shift: --05/05/25 pain score of 5. -- 05/06/25 pain score of 5. -- 05/11/25 pain score of 10. -- 05/14/25 pain score of 8. -- 05/23/25 pain score of 2. -- 05/29/25 pain score of 2. -- 06/07/25 pain score of 2. -- 06/16/24 pain score of 3. -- 06/17/24 pain score of 3. --06/23/25 pain score of 2. -- 07/04/25 pain score of 1. -- 07/05/25 pain score of 8. -- 07/10/25 pain score of 2. -- 07/20/25 pain score of 3. -- 07/21/25 pain score of 2. -- 07/28/25 pain score of 8. -- 07/29/25 pain score of 3. -- 08/01/25 pain score of 3. -- 08/06/25 pain score of 3. -- 08/07/25 pain score of 3. Nigh Shift: -- 07/29/25 pain score of 3. Further review of the MAR's for this time period found the non- pharmacological interventions nor the PRN pain medications was never provided by RN #44. A review of the progress notes found no indication the physician was notified of the residents reports of pain. During an interview with the Director of Nursing (DON) in the afternoon of 08/20/25 she confirmed there was no further information she could provide related to Resident #85's complaints of pain. b) Resident #104 On 08/18/25 at 9:00 AM, a review of Resident #104’s medical record revealed: 07/25/25 1:32 PM: Resident received Oxycodone-acetaminophen 5-325 mg tablet PRN for pain. Documentation reflected the medication was effective. 07/25/25 5:18 PM: Physician ordered Oxycodone HCL oral solution 5 mg/5ml, 7.5 mL four times daily for pain. Documentation noted the medication was awaiting arrival from the pharmacy. 07/25/25 8:00 PM: Nursing note documented resident was nonresponsive to verbal/tactile stimuli and unable to take medications. 07/25/25 10:00 PM: CNA found resident without respirations or pulse. Resident pronounced deceased at 10:00 PM. The last documented effective pain medication was at 1:32 PM on 07/25/25, approximately 8.5 hours before the resident’s death. Interview with LPN #78 (08/18/25 at 3:00 PM):LPN stated “we don’t have liquid Oxycodone in the e-box for pain, we do have liquid morphine available.” Interview with Director of Nursing (08/19/25 at 11:20 AM): The DON confirmed the physician should have been notified that the ordered Oxycodone solution was not available in the emergency box. The DON stated the physician could have given an order for morphine, which was available in the emergency box. The facility failed to notify the physician when the ordered Oxycodone solution was unavailable and failed to obtain an alternative pain management order despite the availability of liquid morphine. c) Resident #73 During an interview on 08/11/2025 at 2:38 PM, Resident #73 stated that he received pain medications every six (6) hours for pain at the site of a left great toe amputation. He stated the pain medication was effective but sometimes he had pain in between pain medication administration. He stated he believed he was having phantom pain at the amputation site. A nursing note written on 8/17/2025 at 2:13 PM stated, Resident approached this nurse and stated he is having some numbness and tingling in his left foot. He also states he has been getting strangled on food and drink during meals. He states that it does not happen during every meal, but it is becoming more of an issue for him. [Physician] notified of these new issues. Orders obtained: ST [speech therapy] eval [evaluation] and treat. He stated he will address the numbness and tingling tomorrow when he comes in. Orders noted. Resident has capacity and is aware. On 08/18/25 at 4:36 PM, Resident #73 confirmed he was having numbness and tingling at his amputation site. He stated he had not been seen by the physician today. On 08/20/2025 at 10:55 AM, the Director of Nursing (DON) stated there was no documentation the physician had evaluated or prescribed treatment for the resident's numbness and tingling after the resident had reported it on 08/17/25.