Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph

Allergies No Known Allergies

Diet Nothing by Mouth (NPO) diet Nothing by Mouth (NPO) texture, NPO

ENCEPHALOPATHY, UNSPECIFIED(G93.40), TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED(E11.40), GASTROSTOMY STATUS(Z93.1), ANEMIA DUE TO ENZYME DISORDER, UNSPECIFIED
(D55.9), FUNCTIONAL QUADRIPLEGIA(R53.2), ESSENTIAL (PRIMARY) HYPERTENSION(I10), MUSCLE WEAKNESS (GENERALIZED)(M62.81), DYSPHAGIA, UNSPECIFIED(R13.10), HYPERLIPIDEMIA, UNSPECIFIED(E78.5),
Medical Conditions ACQUIRED ABSENCE OF RIGHT LEG ABOVE KNEE(Z89.611), ACQUIRED ABSENCE OF LEFT LEG ABOVE KNEE(Z89.612), UNSPECIFIED GLAUCOMA(H40.9), GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT
ESOPHAGITIS(K21.9), MODERATE PROTEIN-CALORIE MALNUTRITION(E44.0), COVID-19(U07.1), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12), COGNITIVE COMMUNICATION DEFICIT(R41.841)

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

amLODIPine Besylate Oral 122/ 130/ 130/ 150/ 123/ 121/ 138/ 137/ 132/ 133/
BP X X X X X X X X X X X X X X X X X X X X
Tablet 5 MG (Amlodipine 64 70 77 69 70 65 68 77 67 72
Besylate) √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
Give 1 tablet via G-Tube GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
one time a day for
Hypertension hold if
SBP<100
-Start Date-
04/21/2023 0900
Atorvastatin Calcium Oral √ √ √ √ √ √ √ √ √ √
2100 X X X X X X X X X X X X X X X X X X X X
Tablet 10 MG (Atorvastatin LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
Calcium)
Give 1 tablet via G-Tube at
bedtime for Hyperlipidemia
-Start Date-
04/21/2023 2100

ENTERAL: Change √ √ √ √ √ √ √ √ √ √ √
Night X X X X X X X X X X X X X X X X X X X
syringe daily CEM CEM CEM jej jej jej CEM CEM CW CEM jej
every night shift
-Start Date-
04/20/2023 2300

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 1 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Latanoprost Ophthalmic √ √ √ √ √ √ √ √ √ √
2100 X X X X X X X X X X X X X X X X X X X X
Solution 0.005 % LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
(Latanoprost)
Instill 1 drop in both eyes
at bedtime for Glaucoma
-Start Date-
04/21/2023 2100
MiraLax Oral Powder 17 √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
GM/SCOOP (Polyethylene GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
Glycol 3350)
Give 17 gram via G-Tube
one time a day for Bowel
Management hold for loose
stools
-Start Date-
04/21/2023 0900

Multivitamin Oral Tablet √ √ √ √ √ √ √ √ √ √

0900 X X X X X X X X X X X X X X X X X X X X
(Multiple Vitamin) GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
Give 1 tablet via G-Tube
one time a day for
Supplement
-Start Date-
04/21/2023 0900
Omega-3 Oral Capsule √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
500 MG (Krill Oil) GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
Give 1 capsule via G-Tube
one time a day for
Supplement
-Start Date-
04/21/2023 0900

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 2 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Pantoprazole Sodium Oral

0630 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Packet 40 MG
(Pantoprazole Sodium)
Give 1 packet by mouth
one time a day for GERD
give before breakfast
-Start Date-
04/21/2023 0630
-D/C Date-
04/20/2023 1747
Pro-Stat Sugar Free Oral
0900 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Liquid (Amino Acids-
Protein Hydrolysate)
Give 30 ml by mouth one
time a day for supplement
-Start Date-
04/27/2023 0900
-D/C Date-
04/26/2023 1510

Pro-Stat Sugar Free Oral √ √ √ √

0900 X X X X X X X X X X X X X X X X X X X X X X X X X X
Liquid (Amino Acids- W.O. GLBA W.O. W.O.
Protein Hydrolysate)
Give 30 ml via G-Tube one
time a day for supplement
-Start Date-
04/27/2023 0900

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 3 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Vitamin C Oral Tablet

0900 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
(Ascorbic Acid)
Give 500 mg by mouth one
time a day for supplement
-Start Date-
04/27/2023 0900
-D/C Date-
04/26/2023 1509

Vitamin C Oral Tablet √ √ √ √

0900 X X X X X X X X X X X X X X X X X X X X X X X X X X
(Ascorbic Acid) W.O. GLBA W.O. W.O.
Give 500 mg via G-Tube
one time a day for
supplement
-Start Date-
04/27/2023 0900
Vitamin D3 Oral Tablet √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
(Cholecalciferol) GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
Give 1000 tsp via G-Tube
one time a day for
Supplement
-Start Date-
04/21/2023 0900
Zinc-220 Oral Capsule
0900 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
(Zinc Sulfate)
Give 1 capsule by mouth
one time a day for wound
management
-Start Date-
04/27/2023 0900
-D/C Date-
04/26/2023 1508

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 4 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Zinc-220 Oral Capsule √ √ √ √

0900 X X X X X X X X X X X X X X X X X X X X X X X X X X
(Zinc Sulfate) W.O. GLBA W.O. W.O.
Give 1 capsule via G-Tube
one time a day for wound
management
-Start Date-
04/27/2023 0900
Brimonidine Tartrate √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
Ophthalmic Solution 0.15 GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
% (Brimonidine Tartrate) √ √ √ √ √ √ √ √ √ √
1700 X X X X X X X X X X X X X X X X X X X X
Instill 1 dose in both eyes LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
two times a day for
Glaucoma
-Start Date-
04/21/2023 0900
Docusate Sodium Oral √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
Tablet 100 MG (Docusate GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
Sodium) √ √ √ √ √ √ √ √ √ √
1700 X X X X X X X X X X X X X X X X X X X X
Give 1 tablet via G-Tube LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
two times a day for Bowel
Management hold for loose
stools
-Start Date-
04/21/2023 0900

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 5 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Esomeprazole Magnesium √
0630 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Oral Packet 40 MG CEM
(Esomeprazole
1630 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Magnesium)
Give 1 packet via G-Tube
two times a day for GERD
-Start Date-
04/21/2023 0630
-D/C Date-
04/21/2023 1557

Metoprolol Tartrate Oral 122/ 130/ 130/ 150/ 123/ 121/ 138/ 137/ 132/ 133/
BP X X X X X X X X X X X X X X X X X X X X
Tablet 25 MG (Metoprolol 64 70 77 69 70 65 68 77 67 72
Tartrate)
Pulse X X X X X X X X X X X X X X X X X X X X 74 79 79 80 63 81 70 79 74 70
Give 0.5 tablet via G-Tube
two times a day for √ √ √ √ √ √ √ √ √ √
Hypertension hold if 0900 X X X X X X X X X X X X X X X X X X X X
GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
SBP<100 or Pulse<55 125/ 132/ 136/ 127/ 128/ 123/ 148/ 139/ 133/ 126/
-Start Date- BP X X X X X X X X X X X X X X X X X X X X
60 72 78 68 72 62 73 87 67 74
04/21/2023 0900
Pulse X X X X X X X X X X X X X X X X X X X X 90 76 79 68 74 73 76 87 70 72

√ √ √ √ √ √ √ √ √ √
1700 X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
Protonix Oral Packet 40 √ √ √ √ √ √ √ √ √
0630 X X X X X X X X X X X X X X X X X X X X X
MG (Pantoprazole Sodium) CEM CEM jej jej jej CEM CEM CW CEM
Give 40 mg via G-Tube √ √ √ √ √ √ √ √ √
1630 X X X X X X X X X X X X X X X X X X X X X
two times a day for GERD W.O. GEO W.O. GEO LGF CW CW W.O. GEO
-Start Date-
04/22/2023 0630

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 6 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Acknowledge diet as √ √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
followed GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
every shift NPO √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
-Start Date- LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
04/20/2023 2300 √ √ √ √ √ √ √ √ √ √ √
Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
Assess for pain every shift
NPI X X X X X X X X X X X X X X X X X X X X NA NA NA NA NA 0 0 NA 0 0
and chart intensity of pain
using 1-10 numeric pain Pain
X X X X X X X X X X X X X X X X X X X X 0 0 0 0 0 0 0 0 0 0
scale. 0= no pain, 1-4= Level
mild pain, 5-7= moderate √ √ √ √ √ √ √ √ √ √
pain, 8-9=severe pain, 10= Day ( X X X X X X X X X X X X X X X X X X X X
GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
excruciating pain.
every shift Non- NPI X X X X X X X X X X X X X X X X X X X X 0 0 0 0 0 0 NA NA 0 4
Pharmacological
Pain
Interventions: A-Heat, B- X X X X X X X X X X X X X X X X X X X X 0 0 0 0 0 0 0 0 0 0
Level
Re-positioning, C-
Relaxation Breathing, D- √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
Food/Fluids, E-Massage, LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
F-Exercise, G-
NPI X X X X X X X X X X X X X X X X X X X NA NA NA -- -- -- NA NA NA NA --
Immobilization of Joints, H-
Other (Document in Pain
X X X X X X X X X X X X X X X X X X X 0 0 0 0 0 0 0 0 0 0 0
Nurses note) N-Not Level
Needed √ √ √ √ √ √ √ √ √ √ √
-Start Date- Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
04/20/2023 2300

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 7 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Dorzolamide HCl √ √ √ √ √ √ √ √ √ √
0900 X X X X X X X X X X X X X X X X X X X X
Ophthalmic Solution 2 % GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
(Dorzolamide HCl) √ √ √ √ √ √ √ √ √ √
1200 X X X X X X X X X X X X X X X X X X X X
Instill 1 drop in both eyes GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
three times a day for √ √ √ √ √ √ √ √ √ √
Glaucoma 1700 X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
-Start Date-
04/21/2023 0900
Enteral Feed Order √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X X X X X
every shift Glucerna 1.2 @ GLBA GLBA GLBA GLBA GLBA bakh
60 ml/hr x 20 hours (1200 √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X X X X X X
ml/day; 1440 kcal/day);and LGF W.O. GEO W.O. GEO
flush with water at 45 ml/hr √ √ √ √ √ √
x 20 hours on at 1300 and Night X X X X X X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej
off at 0900 or until
volumetric dose is
completed
-Start Date-
04/20/2023 2300
-D/C Date-
04/26/2023 1455

Enteral Feed Order √ √ √ √

Day ( X X X X X X X X X X X X X X X X X X X X X X X X X X
every shift Glucerna 1.2 @ W.O. GLBA W.O. W.O.
65 ml/hr x 20 hours (1300 √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X X X X X X X
ml/day; 1560 kcal/day);and CW CW W.O. GEO
flush with water at 45 ml/hr √ √ √ √ √
x 20 hours on at 1300 and Night X X X X X X X X X X X X X X X X X X X X X X X X X
CEM CEM CW CEM jej
off at 0900 or until
volumetric dose is
completed
-Start Date-
04/26/2023 2300

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 8 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

ENTERAL: Check and

ml X X X X X X X X X X X X X X X X X X X X 5 5 5 0 0 5 0 5 0 0
record residual Qshift. Hold
feeding for 1 hour for √ √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
residual > 100 ml GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
every shift
-Start Date- ml X X X X X X X X X X X X X X X X X X X X 0 0 0 0 0 0 0 0 0 0
04/20/2023 2300 √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO

ml X X X X X X X X X X X X X X X X X X X 0 0 0 0 0 0 0 0 0 0 0

√ √ √ √ √ √ √ √ √ √ √
Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
ENTERAL: Check tube √ √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
placement Qshift GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
every shift √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
-Start Date- LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
04/20/2023 2300 √ √ √ √ √ √ √ √ √ √ √
Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
ENTERAL: Elevate HOB at √ √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
least 40 degrees at all GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
times during feeding √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
every shift LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
-Start Date- √ √ √ √ √ √ √ √ √ √ √
04/20/2023 2300 Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 9 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

ENTERAL: Evaluate I&O

I X X X X X X X X X X X X X X X X X X X X 360 480 420 420 2400 650 380 660 660
weekly x 4 weeks
every shift for 4 Weeks
O X X X X X X X X X X X X X X X X X X X X 600 x3 x3 x3 750 3x x3 3x 3x
-Start Date-
04/20/2023 2300 √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.

I X X X X X X X X X X X X X X X X X X X X 600 840 350 840 350 880 NA NA 880 350

O X X X X X X X X X X X X X X X X X X X X 550 3x 3 3x 3 2x NA NA 3X 3x

√ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO

I X X X X X X X X X X X X X X X X X X X 520 650 400 100 100 100 520 580 NA 560 100

O X X X X X X X X X X X X X X X X X X X 3x 560 2x 50 50 50 450 3x NA 3x 50

√ √ √ √ √ √ √ √ √ √ √
Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
ENTERAL: Flush feeding √ √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
tube with 30 ml water GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
before and after √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
medication administration LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
every shift √ √ √ √ √ √ √ √ √ √ √
-Start Date- Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
04/20/2023 2300

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 10 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

O2 via nasal cannula at

O2 Sats X X X X X X X X X X X X X X X X X X X X 97 97 99 98 97 97 95 97 96 96
2Liter/minute, may
administer with humidifier √ √ √ √ √ √ √ √ √ √
Day ( X X X X X X X X X X X X X X X X X X X X
every shift for Shortness of GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
breath
-Start Date- O2 Sats X X X X X X X X X X X X X X X X X X X X 97 96 98 96 98 96 97 97 97 97
04/20/2023 2300 √ √ √ √ √ √ √ √ √ √
Eveni X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO

O2 Sats X X X X X X X X X X X X X X X X X X X 95 95 95 98 98 99 95 95 97 97 99

√ √ √ √ √ √ √ √ √ √ √
Night X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM jej
hydrALAZINE HCl Oral 122/ 132/ 130/ 150/ 123/ 121/ 138/ 137/ 132/ 133/
BP X X X X X X X X X X X X X X X X X X X X
Tablet 50 MG (Hydralazine 64 73 77 69 70 65 68 77 67 72
HCl) √ √ √ √ √ √ √ √ √ √
0800 X X X X X X X X X X X X X X X X X X X X
Give 1 tablet via G-Tube GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
four times a day for 118/ 123/ 123/ 136/ 119/ 113/ 132/ 129/ 127/ 127/
Hypertension hold if BP X X X X X X X X X X X X X X X X X X X X
61 66 72 63 61 71 76 74 70 75
SBP<110 √ √ √ √ √ √ √ √ √ √
-Start Date- 1200 X X X X X X X X X X X X X X X X X X X X
GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.
04/21/2023 0800
125/ 127/ 136/ 127/ 128/ 123/ 136/ 139/ 133/ 121/
BP X X X X X X X X X X X X X X X X X X X X
60 72 78 68 72 62 78 87 67 71
√ √ √ √ √ √ √ √ √ √
1600 X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO
130/ 125/ 122/ 133/ 128/ 122/ 144/ 136/ 142/ 126/
BP X X X X X X X X X X X X X X X X X X X X
70 71 74 72 72 64 60 60 68 74
√ √ √ √ √ √ √ √ √ √
2000 X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 11 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Monitor Blood Sugar and

BS X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
record
every 6 hours
0000 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
-Start Date-
04/20/2023 1800
-D/C Date- BS X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
04/20/2023 1729
0600 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

BS X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

1200 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

BS X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

1800 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Monitor Blood Sugar and

BS X X X X X X X X X X X X X X X X X X X X 135 166 197 150 121 100 134 154 211 142
record
every 6 hours √ √ √ √ √ √ √ √ √ √
0000 X X X X X X X X X X X X X X X X X X X X
-Start Date- CEM CEM CEM jej jej jej CEM CEM CW CEM
04/21/2023 0000
BS X X X X X X X X X X X X X X X X X X X X 198 175 104 116 135 120 164 175 134 153

√ √ √ √ √ √ √ √ √ √
0600 X X X X X X X X X X X X X X X X X X X X
CEM CEM CEM jej jej jej CEM CEM CW CEM

BS X X X X X X X X X X X X X X X X X X X X 147 159 140 131 118 133 143 142 135 134

√ √ √ √ √ √ √ √ √ √
1200 X X X X X X X X X X X X X X X X X X X X
GLBA GLBA GLBA GLBA GLBA bakh W.O. GLBA W.O. W.O.

BS X X X X X X X X X X X X X X X X X X X X 148 152 147 152 126 142 214 165 142 121

√ √ √ √ √ √ √ √ √ √
1800 X X X X X X X X X X X X X X X X X X X X
LGF W.O. GEO W.O. GEO LGF CW CW W.O. GEO

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 12 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Acetaminophen Oral Pain

X X X X X X X X X X X X X X X X X X X
Tablet 325 MG Level
(Acetaminophen)
PRN X X X X X X X X X X X X X X X X X X X
Give 2 tablet via G-Tube
every 4 hours as needed
for Mild Pain (1-4 Pain
Scale) NTE 3 grams of
acetaminophen per 24
hours from all sources.
-Start Date-
04/20/2023 1700
Bowel Regimen: (1.) MOM
PRN X X X X X X X X X X X X X X X X X X X
30 cc Gtube Q24H PRN
Constipation
as needed for 14 Days
-Start Date-
04/20/2023 1700
Bowel Regimen: (2.)
PRN X X X X X X X X X X X X X X X X X X X
Dulcolax Suppository 10
mg per Rectum QD PRN
for constipation if MOM is
ineffective.
as needed for 14 Days
-Start Date-
04/20/2023 1700

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 13 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Bowel regimen: (3.) Fleets

PRN X X X X X X X X X X X X X X X X X X X
enema 133 ml per rectum
Q 3 Day PRN for
constipation if Dulcolax is
ineffective.
as needed for Constipation
for 14 Days if dulcolax
ineffective
-Start Date-
04/20/2023 1651
PPD STEP 1 Reading:
mm X X X X X X X X X X X X X X X X X X X X X X 0 X X X X X X X
Reading in 72 hours.
Document N for Negative
N/P X X X X X X X X X X X X X X X X X X X X X X n X X X X X X X
& P for Positive, including
Induration in (mm). √
One
Reminder: Document PPD X X X X X X X X X X X X X X X X X X X X X X GEO X X X X X X X
Time 2130
Reading under
IMMUNIZATION Tab.
one time only until
04/23/2023 23:59
-Start Date-
04/23/2023 2000
PPD STEP 1: PPD 0.1 ml
site X X X X X X X X X X X X X X X X X X X LA X X X X X X X X X X
Intradermal. Reminder:
Document PPD under √
One
IMMUNIZATION tab. X X X X X X X X X X X X X X X X X X X LGF X X X X X X X X X X
Time 2329
one time only until
04/20/2023 23:59
-Start Date-
04/20/2023 2000

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 14 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

PPD STEP 2 Reading:

mm X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 0
Reading in 72 hours.
Document N for Negative
N/P X X X X X X X X X X X X X X X X X X X X X X X X X X X X X -
& P for Positive, including
Induration in (mm). √
One
Reminder: Document PPD X X X X X X X X X X X X X X X X X X X X X X X X X X X X X GEO
Time 2151
Reading under
IMMUNIZATION Tab.
one time only until
04/30/2023 23:59
-Start Date-
04/30/2023 2000
PPD STEP 2: PPD 0.1 ml
site X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Intradermal, 7 days after
Initial PPD. Reminder: One
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Document under Time
IMMUNIZATION Tab.
one time only until
04/27/2023 23:59
-Start Date-
04/27/2023 2000
Senna Oral Tablet 8.6 MG
PRN X X X X X X X X X X X X X X X X X X X
(Sennosides)
Give 1 tablet via G-Tube
every 12 hours as needed
for Constipation for 14
Days
-Start Date-
04/20/2023 1715

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 15 of 16
Facility Country Villa Westwood Nursing Center Pharmacy Premier Pharmacy Services Physician Pack, John Joseph
Allergies No Known Allergies

Advance Directive DNR

Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun
Schedule for
Hours
Apr 2023 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Custom Prompt Legend

1. Anticonvulsant Drug level (ACDL) 5. Digoxin Level (Dig) 9. Potassium (K) 13. TSH (TSH)
2. BUN (BUN) 6. Glucose (Glu) 10. PT/INR (PTINR) 14. Urine pH (Ur.pH)
3. CBC (CBC) 7. Hematocrit (Hct) 11. PTT (PTT)
4. Creatinine (Creat) 8. Hemoglobin (Hgb) 12. Theophylline Level (Theo)

Chart Codes
OBA=Group Observed - All OBI=Observed Individual OBP=Group Observed - Partial
1=Absent from facility without meds 1=Absent from home without meds 2=Drug Refused
3=Absent from facility with meds 3=Absent from home with meds 4=Vitals Outside of Parameters for
Administration
5=Hold/See Progress Notes 6=Hospitalized 7=Sleeping
8=Nauseated / Vomiting 9=Other / See Progress Notes 10=Partial Administration

Chart Codes / Follow Up Codes Init Name Signature Init Name Signature Name Signature
----- Follow Up Codes ----- OBI=Observed Individual
OBP=Group Observed -
Checked By 1st
√=Administered
I=Ineffective Partial
E=Effective 1=Absent from facility Checked By 2nd
U=Unknown without meds
H=On Hold By Physician 1=Absent from home Checked By 3rd
without meds
------- Chart Codes ------- 2=Drug Refused
MEDICATION ADMINISTRATION
(Refer to the last page of 4/1/2023 - 4/30/2023 BALLARD,
Resident ADLAY (173121317)
the report for a complete
RECORD:
Photo date: 04/25/2023
list of chart codes)
OBA=Group Observed - All Admit Date 04/20/2023 DOB 04/27/1925 Unit West Station Room 120 Location A

Printed on: May 1, 2023 at 23:15:10 PDT BALLARD, ADLAY (173121317) - Page: 16 of 16
Facility #: --- Country Villa Westwood Nursing Center Facility Code: 1520
Date: May 1, 2023 Location of Administration Report User: Anne Panganiban
Time: 02:15:09 PT 4/1/2023 thru 4/30/2023 Page 1 of 1

Resident: Ballard, Adlay (173121317)

Administration Record: MEDICATION ADMINISTRATION RECORD: Sort Residents By: Location Sort Orders By: Schedule Type
No site of administration data found for MEDICATION ADMINISTRATION RECORD: