Latest acuity assessment
Level 5 — Memory care
$8,200 / month base rate
annual renewal · target 2026-06-14
ADL score
7
0–28; higher = more independent
Falls / 90d
2
Cognition
severe
Behavioral risk
moderate
Medications
11
Mobility aid
walker
Diet
mechanical_soft
Wandering risk
Yes
Diagnoses
G30.9Alzheimer's disease, unspecified
Moved in 2023-07-12
Care notes
At approximately 1910, Mr. Nguyen was found seated on the floor beside his bed by CNA during evening rounds. Resident stated he got up to use the restroom without calling for help. No loss of consciousness reported. Head-to-toe assessment completed: no lacerations, no swelling, no c/o pain. Vitals stable — BP 132/80, HR 76, SpO2 98%. MD notified and acknowledged. Daughter Lan contacted and updated. Resident reminded of fall risk related to his primary diagnosis and importance of using call light. Bed alarm re-enabled and non-slip socks applied. Incident report filed per facility policy.
Met with Mr. Nguyen and his daughter Lan during scheduled family check-in. Discussed ongoing fall-prevention plan given his diagnosis of recurrent falls and the family's expressed concerns. Lan was updated on PT progress and current assist levels. Mr. Nguyen stated he sometimes feels frustrated about needing help but acknowledged the importance of safety. Encouraged him to participate in the afternoon balance exercise group. Family expressed satisfaction with current care. No new psychosocial concerns identified at this time.
Skilled PT session completed in hallway and room. Mr. Nguyen performed 10 minutes of gait training with standard walker, demonstrating improved step symmetry compared to last week. Balance activities including tandem standing at countertop completed x3 sets with minimal cueing. Addressed fall risk reduction strategies with resident; he was receptive and verbalized two safety strategies back correctly. Recommend continued two-person assist on stairs until strength improves. Will reassess in one week.
Met with Mr. Nguyen and his daughter, Linh, for a brief check-in. Mr. Nguyen reports feeling more comfortable in the community but mentioned some anxiety about falling when walking alone in common areas. Linh expressed appreciation for the fall prevention measures in place. Discussed the option of supervised group walks and encouraged participation in structured activities to build confidence. Referral to activities staff made to explore engagement opportunities. Care conference scheduled for next month.
Visited Mr. Nguyen at lunch to review nutritional intake. Weight stable this month. He expressed preference for Vietnamese-style dishes and noted the current menu feels unfamiliar at times. Discussed options available through dietary to better accommodate his preferences and support adequate caloric intake. Calcium and Vitamin D intake noted as important given fall risk history; current supplementation appears appropriate. Will follow up with kitchen staff regarding cultural food options.
Afternoon med pass completed. Mr. Nguyen received all scheduled medications without refusal. Blood pressure checked per fall-prevention protocol — 128/76, heart rate 72, no orthostatic symptoms reported. Resident verbalized understanding of call-light use and agreed to call for assistance before getting up from the recliner. Room environment checked: pathway clear, bed in low position, call light within reach. No skin concerns observed on bilateral lower extremities. Plan to continue fall-risk precautions given primary diagnosis of recurrent falls.
Worked with Mr. Nguyen on lower extremity strengthening and balance exercises in the hallway for approximately 25 minutes. He tolerated the session well with only mild fatigue reported near the end. Gait observed with rolling walker — steady with occasional lateral sway. Given his recurrent fall history, reinforcing proper walker technique and sit-to-stand sequencing remains a priority. Plan to continue sessions three times per week. Family updated via staff communication log.
Mr. Nguyen was up and dressed by 0800 with standby assist. Gait appeared steady this morning and he used his walker throughout the hallway without prompting. No complaints of dizziness or pain. Skin check completed — no redness or breakdown noted on heels or coccyx. Given his history of recurrent falls, non-slip footwear was confirmed on prior to ambulation. Breakfast tray accepted and eaten in dining room without incident. Mood pleasant and cooperative.
Completed monthly fall risk reassessment for Mr. Nguyen per care plan. Score remains elevated, consistent with his primary diagnosis of recurrent falls (R29.6). Bed and chair alarms are in place and functioning. Reviewed medication list with attention to any sedating agents; no new concerns identified. Mr. Nguyen verbalized understanding of the importance of asking for assistance before getting up. Environment checked — pathway to bathroom clear, nightlight operational. Will continue current fall precaution interventions.
Assisted Mr. Nguyen with morning ADLs including bathing, dressing, and oral care. He was cooperative and in good spirits today. Given his history of recurrent falls, reminded him to use call light before standing and confirmed his non-slip footwear was on prior to ambulation. No falls or near-misses this shift. Skin intact, no new areas of concern noted. Appetite appeared good at breakfast.