Form Cms-672 - Resident Census And Conditions Of Residents Page 5
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7RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
C. MENTAL STATUS (F108 – F114) - RESIDENTS
D. SKIN INTEGRITY (F115 – F118) - RESIDENTS
F108: With Intellectual Disability (ID) (Mental retardation
F115: With pressure ulcers: With localized injury to the skin
as defined at 483.45(a)) or Developmental Disability (DD):
and/or underlying tissue, usually over a bony prominence, as a
In all of the categories of intellectual or developmental disability
result of pressure, or pressure in combination with shear and/
regardless of severity, as determined by the State Mental Health
or friction (exclude Stage I). M0300B1, M0300C1, M0300D1,
or State Mental Retardation Authorities. A1550A, B through
M0300E1, M0300F1and/or M0300G1 > 0.
E = checked.
F116: Of the total number of residents with pressure ulcers
F109: With documented signs and symptoms of depression:
(excluding Stage 1), those who had pressure ulcers on
admission/entry or reentry: M0300B2, M0300C2, M0300D2,
With documented signs and symptoms of depression. D0200A1
through D1 = 1 for any indicator present OR D0200I1 = 1OR
M0300E2, M0300F2 and/or M0300G2 > 0. To complete this
D0200A2 through D2 = 2 or 3 for symptom frequency OR
field, use only the counts from the first assessment since the
D0300 = 05 - 27 OR D0500A1 through D1 = 1 for any indicator
most recent admission/entry or reentry. (OBRA or Scheduled
present OR D0500I1 = 1 OR D0500A2 through D2 = 2 or 3 for
PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E =
symptom frequency OR D0600 = 05 - 30.
1 for each resident.)
F110: With documented psychiatric diagnosis (exclude
F117: Receiving preventive skin care: Receiving non-
dementias and depression): With primary or secondary
routine skin care ordered by a physician, and/or included in
psychiatric diagnosis including:
the resident’s comprehensive plan of care (e.g., hydrocortisone
•
Schizophrenia
ointment to areas of dermatitis three times a day, granulex
•
Schizo-affective disorder
sprays, etc.). M1200A through I = checked.
•
Schizophreniform disorder
•
Delusional disorder
Fl18: With rashes: Who have rashes which may or may not
•
Anxiety disorder
be treated with any medication or special baths, etc. (e.g.,
•
Psychotic mood disorders (including mania and depression
may include but are not limited to antifungals, corticosteroids,
with psychotic features, acute psychotic episodes, brief
emollients, diphenhydramines or scabicides).
reactive psychosis and atypical psychosis). I5700, I5900,
I5950, I6000 or I6100 = checked.
E. SPECIAL CARE (F119 – F132) - RESIDENTS
F119: Receiving hospice care: Who have elected or are
F111: Dementia: Non-Alzheimer’s Dementia (e.g., Lewy-
currently receiving the hospice benefit. O0100K2 = checked.
Body, vascular or Multi-infarct, mixed, frontotemporal such
as Pick’s disease; and dementia related to Parkinson’s or
F120: Receiving radiation therapy: Who are under a treatment
Creutzfeldt-Jakob diseases), or Alzheimer’s Disease: With a
plan involving radiation therapy. O0100B1 or O0100B2 =
primary or secondary diagnosis of dementia or organic mental
checked.
syndrome including, Non-Alzheimer’s Dementia (e.g., Lewy-
Body, vascular or Multi-infarct, mixed, frontotemporal such as
F121: Receiving chemotherapy: Who are under a treatment
Pick’s disease; and dementia related to Parkinson’s or Creutzfeldt-
plan involving chemotherapy. O0100A1 or O0100A2 = checked.
Jakob diseases). I4200 or I4800 = checked
F122: Receiving dialysis: Receiving hemodialysis or
F112: With behavioral health care needs: With one or more
peritoneal dialysis either within the facility or offsite. O0100J1
of the following indicator(s): wandering, verbally abusive,
or O0100J2 = checked.
physically abusive, socially inappropriate/disruptive, and
resistive to care. E0200A, B, or C = 1, 2, or 3 OR E0300 = 1 OR
F123: Receiving intravenous therapy, IV nutrition and/
E0500A, B, or C = 1 OR E0600A, B, or C = 1 OR E0800 = 1, 2,
or blood transfusion: Receiving fluids, medications, all or
or 3 OR E0900 = 1, 2, or 3 OR E1000A or B = 1.
most of their nutritional requirements and/or blood and blood
products administered intravenously. K0510A2, O0100H2, or
F113: Of the total number with behavioral healthcare needs,
O0100I2 = checked.
those having an individualized care plan to support them:
With behavior symptoms who are receiving an individualized
F124: Receiving respiratory treatment: Resceiving treatment
care plan/program designed to support and manage behavioral
by the use of respirators/ventilators, oxygen, IPPB or other
needs (as noted in F112).
inhalation therapy, pulmonary toilet, humidifiers, and other
methods to treat conditions of the respiratory tract. This does
F114: Receiving health rehabilitative services for Mental
not include residents receiving tracheostomy care or respiratory
Illness (MI) and/or ID/DD: Receiving health rehabilitative
suctioning. O0100C2, O0100F2, or O0100G2 = checked.
services for MI and/or ID/DD.
Form CMS-672 (05/12)
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