Form Cms-672 - Resident Census And Conditions Of Residents Page 7
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7RESIDENT CENSUS AND CONDITIONS OF RESIDENTS
(use with Form CMS-672)
F137: Hypnotic medications: Days entered for N0410D > 0
F142: Who use non-oral communication: Who communicate
•
Flurazepam
via non-oral methods, including, picture boards, computers, etc.
•
Quazepam
A1100B, Preferred Language (e.g. American Sign Language).
•
Estazolam
F143: Who have advance directives: Who have advance
•
Temazepam
•
Triazolam
directives, such as Physician’s Orders for Life-Sustaining
•
Zolpidem
Treatment (POLST), a living will or durable power of attorney
for health care, recognized under state law and relating to the
F138: Receiving antibiotics: Receiving antibacterial
provisions of care when the individual is incapacitated.
sulfonamides, antibiotics, etc., either for prophylaxis or
treatment. Days entered for N0410F > 0.
F144: Received influenza immunization: Who received the
influenza immunization within the last 12 months. O0250A = 1.
F139: On a pain management program: With a specific plan
for control of difficult to manage or intractable pain, which
F145: Received pneumococcal vaccine: Who received the
may include self medication pumps or regularly scheduled
pneumococcal vaccine. O0300A = 1.
administration of medication alone or in combination with non-
LEAVE BLANK (F146-F148) – To Be Completed By
medication interventions (e.g., massages heat/cold, biofeedback,
etc.). J0100A, B, or C = 1.
Survey Team
F146: Ombudsman notice: Indicate whether or not the State
G. OTHER RESIDENT CHARACTERISTICS
Ombudsman was notified prior to the survey.
(F140 – F145)
F147: Ombudsman presence: Indicate whether or not the State
F140: With unplanned significant weight loss/gain: Who have
Ombudsman was present at any time during the survey.
experienced unplanned weight loss/gain of > 5% in one month
or > 10% over six months. K0300 or K0310 = 2.
F148: Medication error rate: Calculate and enter the
medication error percentage of the facility.
F141: Who do not communicate in the dominant language
at the facility: Who do not speak or understand the dominant
language spoken in the facility and need or want an interpreter to
communicate. A1100A = 1.
Form CMS-672 (05/12)
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