Bella Vita Health And Rehabilitation Center

by the provider, as this was the resident's first visit; and-Regarding the left medial lower leg wound, diabetic, no infection, dressing treatment used was honey alginate, mild serosanguinous exudate, no odor, two open wounds with intervening epithelium.

The wound progress was unable to be determined by the provider, as this was the resident's first visit.The July 14, 2025, surgical note included an assessment and plan of the wounds.

The assessment and plan revealed the wounds were stable and required continued topical wound dressing therapy; to obtain consent from family in case the resident has some improvement overall and would benefit from further debridement; offload; turn per facility protocol; LALM; foam boots; and a follow-up interval of every week. On the July 21, 2025 visit, the surgical note document revealed that the sacrococcyx wound, the left and right medial heel wounds, and the left medial lower leg wound, and all the wounds had all decreased in size. A review of the psychiatric progress note dated July 28, 2025 at 8:28 AM revealed a late entry note; the resident had not had any evidence of increased depression, no psychotic symptoms or major behavioral disturbances, maintaining a fair oral intake, and no evidence of worsening anorexia, and had been cooperative with his cares.A review of the nursing progress note dated August 11, 2025 at 12:56 PM revealed the resident was very lethargic, not opening eyes or responding to voice or touch in the morning, and was unable to answer any questions for the MDS quarterly.

The floor nurse and the ADON were aware of the resident's decline in health.A review of the Nutrition-Quarterly Evaluation assessment dated [DATE], revealed the resident had an order for regular mechanical soft diet, thin fluid consistency; resident's weight on August 11, 2025 using a wheelchair scale was 195.7 pounds, significant weight gain noted for August; have upper and lower dentition; total assist for dining; pressure and non-pressure wounds skin status; had a Body Mass Index (BMI) of 28.1, overweight; at risk of malnutrition per the Minimum Nutrition Assessment (MNA) due to decreased mobility and impaired cognition; has healing pressure and non-pressure wounds; meal intake of mechanical soft food and House supplement 4 ounces by mouth three times a day, meeting needs; and intake of Prostat 1 ounce at bedtime, exceeding needs.Review of Skin Wound progress note dated August 14, 2025 at 3:54 PM revealed the provider, ADON, and floor nurse were notified of a new foul odor from the resident's buttock wound. A wound culture and an infectious disease consult were ordered. A wound culture specimen was obtained and placed in the refrigerator.

The staff was unable to reach the resident's guardian for a debridement consent.Review of eMAR-Medic

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