Day 12 nursing progress note. Mr. Kowalski continues to participate in PT, OT, and SLP per schedule. Vitals this morning: BP 138/82, HR 70, RR 16, O2 sat 97% on room air. Sertraline initiated on 2/6 — no adverse effects noted to date; mood per nursing observation marginally improved; less tearful at morning care today. Oral intake has been approximately 75% of meals on modified diet consistency per dietary log. Coccyx wound assessed: Stage 2 pressure injury, approximately 2 cm x 1.5 cm, wound bed pink with no signs of infection; dressings changed per wound care team orders. Resident continues to require total assist with bathing, dressing, and toileting. Daughter visited this afternoon and participated in care; verbalized updated questions regarding long-term placement options — social work notified for follow-up.
MDS 3.0 · Section I — Active Diagnoses · target 2026-02-14
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 2026-02-14
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···☐ NOT CODED