CARING NURSES, INC.
SOC HHRG
Patient: KLUEVER , JAN- MR# 900010982
Chart: 1 Episode: 1
Patient Care Assistant: LIVE ALONE
Visit Date: 03/23/2026
Problems:
FALL WITH INJURY, SUBDURAL HEMATOMA WITHOUT COMA, ANTIPLATELET OR ANTITHROMBOTIC LONG TERM USE, FRICTION BURN, LEFT SHOULDER PAIN, HYPERTENSION, CLOSED TRAUMA WOUND HEAD

Tests
CLOX:
pass

03/23/2026
OASIS-D
Kira Irenze
Assessor
(M0030) Start of Care Date:
03/23/2026

(M1030) Therapies the patient receives at home: (Mark all that apply.)

(M1033) Therapies the patient receives at home: (Mark all that apply.).
1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months)
5 - Decline in mental, emotional, or behavioral status in the past 3 months
6 - Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
7 - Currently taking 5 or more medications
8 - Currently reports exhaustion

(M1200) Vision (with corrective lenses if the patient usually wears them):

(M1242) Frequency of Pain Interfering with patient's activity or movement:

(M1400) When is the patient dyspneic or noticeably Short of Breath?
2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)

(M1610) Urinary Incontinence or Urinary Catheter Presence:
1 - Patient is incontinent

(M1620) Bowel Incontinence Frequency:
0 - Very rarely or never has bowel incontinence

(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?
0 - Patient does not have an ostomy for bowel elimination.
(M1800). Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
2 - Someone must assist the patient to groom self.

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
2 - Someone must help the patient put on upper body clothing.

(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:
2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.

(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
2 - Able to bear weight and pivot during the transfer process but unable to transfer self.

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
3 - Able to walk only with the supervision or assistance of another person at all times.

(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.
NA - No injectable medications prescribed.

Home Health Certification and Plan of Care
03/23/2026
Skilled Nursing Kira Irenze
Added by: Veltra 03/23/26 03:33 PM
2Week1
03/23/26 - 03/27/26
2
1Week8
03/28/26 - 05/21/26
8
Physical Therapy
CONSULT SAFETY , TRANSFER AND HEP 1 WK 1 		Richard Scott Derringer
Added by: Veltra 03/23/26 04:30 PM
Primary Care Physician DR. ROBERT WHITE
PECOS Enrolled
Physician Scheduled Visit 04/13/2026: DR. ROBERT WHITE
03/18/2026: DR. STEPHANIE MARTINEZ
Reported to: Veltra 03/23/2026 03:33 PM
Printed By/Date/Time: 04/06/2026 09:05 AM