Weekly nursing progress note, day 10 of skilled stay. Resident continues to require maximal assistance for all ADLs secondary to persistent right hemiparesis and cognitive deficits following CVA. Appetite has been fair to poor; consuming approximately 50-60% of meals per CNA observation; dietary notified. Mood remains flat; resident intermittently tearful during morning care. Sleeping approximately 9-10 hours per night per night shift staff. Coccyx wound noted on admission reassessed today: wound remains open, approximately 1.8 cm x 1.4 cm, shallow, pink wound bed, no signs of infection. Current turning and repositioning schedule in place per nursing staff. Vitals this shift: BP 138/84, HR 76, Temp 98.6°F, SpO2 97%. Resident participated in PT and OT sessions today without complaint. Family visited this afternoon; daughter engaged and supportive. Continue current plan of care.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-04
I0900Peripheral Vascular Disease···☐ NOT CODED
I2000Pneumonia···☐ NOT CODED
I2500Wound Infection···☐ NOT CODED
I3500Pressure Ulcer Stage 3···☐ NOT CODED
I4500Diabetes Mellitus···☐ NOT CODED
MDS · Section O — Special Treatments · target 2026-04-04
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···☐ NOT CODED