Form Cms-802s - Roster/sample Matrix Instruction For Surveyors Page 2
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214. Depressive Symptoms: residents with symptoms of
25. Vision/Hearing/Other Assistive Devices: residents with
depression with or without antidepressant therapy.
visual or hearing impairments to function at their highest
practicable level, including those residents who have glasses
15. Urinary Tract Infections (UTl): residents having a UTI.
or hearing aids. Include residents needing other special
devices to assist with eating or mobility.
16. Indwelling Urinary Catheter: residents with an indwelling
urinary catheter.
26. ROM/Contractures/Positioning: occurrence, prevention or
treatment of contractures, staff provision or lack of provision
17. Lo-Risk Residents Who Lose Bowel/Bladder Control–
of appropriate application/use of splints, ROM exercises, or
Incontinence/Toileting Programs: residents with bowel
positioning. Concerns about residents identified as having a
and/or bladder incontinence and/or on a toileting program.
decline in ROM.
18. Excessive Weight Loss/Gain: residents with an unintended
27. Special Care (Tube Feeding, Central Lines, Ventilators,
weight loss/gain of >5% in one month or >10% in six
O
, etc.): residents receiving nutrition via a feeding tube;
months, or is at nutritional risk.
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residents with tracheostomies or ventilators; residents
needing suctioning, and/or residents receiving oxygen, IPPB
19. Need for Increased ADL Help: concerns about residents
or other inhalation therapy, pulmonary toilet, humidifiers,
identified as having ADL decline.
etc., or have special care areas, (e.g., prosthesis, ostomy,
20. Hospice: residents who have elected or are receiving
injection, IV’s, including total parenteral nutrition, etc.).
hospice care.
28. Hydration/Swallowing/Oral Health: residents, who show
21. Dialysis: care and coordination of services for residents
signs or symptoms or have risk factors for dehydration.
receiving hemo- or peritoneal dialysis either within the
Residents with chewing or swallowing problems. Provision
facility or offsite.
or lack of provision for oral health care for residents.
22. Admission/Transfer/Discharge: care/treatment for residents
29. Infections: residents receiving antibiotics or have an
admitted within the past 30 days or is scheduled to be
infectious disease or residents under strict isolation
transferred or discharged within the next 30 days. Including
precautions.
but not limited to, resident preparation and procedures for
transfer or discharge, such as:
30. Specialized Rehabilitation: provision or lack of provision
of specialized rehabilitative services including, but not
•
Relevant clinical and psychosocial information provided
limited to:
to next care providers, (i.e., Home Health, Hospital,
Primary Care Provider, etc.) and,
•
Physical therapy
•
Appropriate arrangements for necessary services to meet
•
Speech/language pathology
resident needs upon transfer and/or discharge.
•
Occupational therapy
23. Mental Illness (MI) (Non-Dementia) or Intellectual
Disability (ID) and/or Developmental Disability (DD).
•
Nursing restorative programs
(Mental retardation as defined at 42 CFR 483.45(a)):
•
Health rehabilitative services for MI and/or ID/DD
care and treatment of residents with a diagnosis of MI, ID
and/or DD.
31–34. Note any other concerns; e.g., residents who are
24. Language/Communication: residents with communication
comatose, have delirium, have special skin care needs other
challenges to communicate at their highest practicable level,
than pressure ulcers, fecal impaction or observed to spend
or residents identified as speaking and/or understanding
most of their time in bed or a chair, such as a geriatric chair,
other than the dominant language of the facility, or using
recliner, etc. If during offsite preparation, concerns arise
non-oral communication such as, picture boards, computers,
about the accuracy of the MDS information, enter MDS
American Sign Language, etc.
accuracy as a concern.
Form CMS-802S (04/12)
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