Day 8 of SNF stay. Mr. Okafor continues to progress with recovery from pneumonia (J18.9). SpO2 now 96% on 1L NC at rest; MD notified of improvement and order received to trial room air with SpO2 monitoring. Oral levofloxacin course completed yesterday without reported adverse effects. Appetite improving per resident report; consuming approximately 60–70% of meals. Coccygeal redness previously noted on admission remains present, approximately 2 cm x 1.5 cm, non-blanchable; skin surrounding area intact. Resident repositioned and reminded to shift weight when in chair. Mood noted as slightly improved — resident smiled and engaged in brief conversation with this nurse and a visiting neighbor. Therapy reports resident is making functional gains. Family daughter called for update and expressed satisfaction with care. Continue current plan of care.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-24
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 2026-04-24
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···✓
Gap detection · grounded
claude-opus-4-7 · 847ms · 2.1k tok
DEPRESSIONmedium
Notes describe depressive symptoms. Score a PHQ-9 (D0150) or staff assessment (D0500) at next MDS to capture for nursing classification.
Field: pdpmDepression
Evidence: "[MD] ...dered. Nursing has flagged resident for depressed mood — resident endorses low energy, poor sleep, and diminished interest in act..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...s with recovery from pneumonia (J18.9). SpO2 now 96% on 1L NC at rest; MD notified of improvement and order received to tria...", "[LPN] ... VS: T 98.4°F, BP 126/80, HR 88, RR 18, SpO2 94% on 2L NC. Physician and charge nurse notified. Daughter Amara notified by p..."