Form Cms-672 - Resident Census And Conditions Of Residents Page 2
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7RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
E. Special Care
F119-132 – indicate the number of residents receiving:
F127____ Suctioning
Fl19 ____ Hospice care
F128____ Injections (exclude vitamin B12 injections)
F120____ Radiation therapy
F129____ Tube feedings
F121____ Chemotherapy
Fl30____ Mechanically altered diets including pureed and all
chopped food (not only meat)
F122____ Dialysis
F131____ Rehabilitative services (Physical therapy, speech-
F123____ Intravenous therapy, IV nutrition, and/or blood transfusion
language therapy, occupational therapy, etc.)
Exclude health rehabilitation for MI and/or ID/DD
F124____ Respiratory treatment
F132____ Assistive devices with eating
F125____ Tracheostomy care
F126____ Ostomy care
F. Medications
G. Other
F133-139 – indicate the number of residents receiving:
F140____ With unplanned significant weight loss/gain
F133____ Any psychoactive medication
F141____ Who do not communicate in the dominant
language of the facility (include those who
F134____ Antipsychotic medications
use American sign language)
F135____ Antianxiety medications
F142____ Who use non-oral communication devices
F136____ Antidepressant medications
F143____ With advance directives
F137____ Hypnotic medications
F144____ Received influenza immunization
F138____ Antibiotics
F145____ Received pneumococcal vaccine
F139____ On pain management program
I certify that this information is accurate to the best of my knowledge.
Signature of Person Completing the Form
Title
Date
TO BE COMPLETED BY SURVEY TEAM
F146
Was ombudsman office notified prior to survey?
___ Yes
___ No
F147
Was ombudsman present during any portion of the survey?
___ Yes
___ No
F148
Medication error rate _______%
Form CMS-672 (05/12)
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Parent category: Medical