Fill - RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Medicare & Medicaid)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

Provider No. Medicare

F75 F76

Medicaid

F77

Other

F78

Total Residents

ADL Independent Assist of One or Two Staff Dependent

Bathing

F79 F80 F81

Dressing

F82 F83 F84

Transferring

F85 F86 F87

eToilet Us

F88 F89 F90

Eating

F91 F92 F93

A. Bowel/Bladder Status

F94 ____ With indwelling or external catheter

F95 Of the total number of residents with catheters,

how many were present on admission ____?

F96 ____ Occasionally or frequently incontinent of

bladder

F97 ____ Occasionally or frequently incontinent of

bowel

F98 ____ On urinary toileting program

F99 ____ On bowel toileting program

B. Mobility

F100____ Bedfast all or most of time

F101____ In a chair all or most of time

F102____ Independently ambulatory

F103____ Ambulation with assistance or assistive device

F104____ Physically restrained

F105 Of the total number of residents with restraints,

how many were admitted or readmitted with orders for

restraints ____?

F106____ With contractures

F107 Of the total number of residents with contractures,

how many had a contracture(s) on admission ____?

C. Mental Status

F108-114 – indicate the number of residents with:

F108____ Intellectual and/or developmental disability

F109____ Documented signs and symptoms of depression

F110____ Documented psychiatric diagnosis

(exclude dementias and depression)

F111____ Dementia: (e.g., Lewy-Body, vascular or Multi-

infarct, mixed, frontotemporal such as Pick’s disease;

and dementia related to Parkinson’s or Creutzfeldt-

Jakob diseases), or Alzheimer’s Disease

F112____ Behavioral healthcare needs

F113 Of the total number of residents with

behavioral healthcare needs, how many have an

individualized care plan to support them ____?

F114____ Receiving health rehabilitative services

for MI and/or ID/DD

D. Skin Integrity

F115-118 – indicate the number of residents with:

F115____ Pressure ulcers (exclude Stage 1)

F116 Of the total number of residents with

pressure ulcers excluding Stage 1, how many

residents had pressure ulcers on admission ____?

F117____ Receiving preventive skin care

F118____ Rashes

Form CMS-672 (05/12) 1

Form CMS-672 (05/12)

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

E. Special Care

F119-132 – indicate the number of residents receiving:

Fl19 ____ Hospice care

F120____ Radiation therapy

F121____ Chemotherapy

F122____ Dialysis

F123____ Intravenous therapy, IV nutrition, and/or blood transfusion

F124____ Respiratory treatment

F125____ Tracheostomy care

F126____ Ostomy care

F127____ Suctioning

F128

____ Injections

(exclude

vitamin

B12 injections)

F129

____ Tube feedings

Fl30

____ Mechanically

altered

diets including

pureed and all

chopped food (not only meat)

F131____ Rehabilitative services (Physical therapy, speech-

language therapy, occupational therapy, etc.)

Exclude health rehabilitation for MI and/or ID/DD

F132____ Assistive devices with eating

F. Medications

F133-139 – indicate the number of residents receiving:

F133____ Any psychoactive medication

F134____ Antipsychotic medications

F135____ Antianxiety medications

F136____ Antidepressant medications

F137____ Hypnotic medications

F138____ Antibiotics

F139____ On pain management program

G. Other

F140____ With unplanned significant weight loss/gain

F141____ Who do not communicate in the dominant

language of the facility (include those who

use American sign language)

F142____ Who use non-oral communication devices

F143____ With advance directives

F144____ Received influenza immunization

F145____ Received pneumococcal vaccine

I certify that this information is accurate to the best of my knowledge.

TitleSignature of Person Completing the Form 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 _______%

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RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

(use with Form CMS-672)

GENERAL INSTRUCTIONS:

THIS FORM IS TO BE COMPLETED BY THE FACILITY AND REPRESENTS THE CURRENT CONDITION OF RESIDENTS AT

THE TIME OF COMPLETION

There is no federal requirement to automate the 672 form. A facility may use its MDS data to assist in completing the entry fields for the

672 form, however, facilities should ensure that the MDS information is not simply counted and copied over into the form. All conditions

noted on this form that are not identified on the MDS must be counted manually. This information is designed to be a representation

of the facility during survey; it does not directly correspond to the MDS data in every field. The information entered on this form must

be reflective of all residents as of the day of survey; therefore all information entered must be independently verified.

Following certain entry fields, the related MDS 3.0 item(s) is noted. Remember, that although MDS items are noted for some fields, the

field itself may need to be completed differently to reflect the current status of all residents as of the day of survey. The MDS items

are provided only as a reference point, the form is to be completed using the time frames and other specific instructions as noted below.

Where a field refers to the “admission assessment,” use only the counts from the first assessment since the most recent admission/entry

or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each resident).

For the purpose of completing this form the terms: “facility” means certified beds (i.e., Medicare and/or Medicaid certified beds) and

“residents” means residents in certified beds regardless of payer source.

INSTRUCTIONS AND DEFINITIONS:

Complete each field by specifying the number of residents in

each category. If no residents fall into a category enter a “0”.

Provider Number: Facility CMS certification provider number.

A0100B; leave blank for initial certifications.

Block F75: Residents whose primary payer is Medicare.

Block F76: Residents whose primary payer is Medicaid.

Block F77: Residents whose primary payer is neither Medicare

nor Medicaid.

Block F78: Residents for whom a bed is maintained on the day

the survey begins, including those temporarily away in a hospital

or on leave. This should be representative of residents in the

nursing facility or those who have a bed-hold.

ADLS (F79 – F93): To determine resident status, unless otherwise

noted, consider the resident’s condition for the 7 days prior to the

survey. Horizontal totals across the three columns (Independent,

Assist of One or Two Staff, and Dependent) must equal the number

in Block F78, Total Residents, for each of the ADL categories

(Bathing, Dressing, Transferring, Toilet Use and Eating).

Bathing (F79 – F81): This includes a full-body bath/shower,

sponge bath, and transfer into and out of tub or shower.

G0120A = 0 for F79, G0120A = 1, 2, OR 3 for F80. OR

G0120A = 4 for F81.

Facilities may provide “setup” assistance to residents such as

drawing water for a tub bath or laying out clothes, bathing

supplies/toiletries, etc. Also, a resident may only need assistance

with washing their back or shampooing their hair. If either of

these are the case, and the resident requires no other assistance,

count the resident as independent.

Dressing (F82 – F84): How the resident puts on, and takes off all

items of clothing, including donning/removing prostheses (e.g.,

braces and artificial limbs) or elastic stockings. G0110G1 = 0 for

F82 OR G0110G1 = 1, 2, OR 3 for F83 OR G0110G1 = 4 for F84.

Facilities may set out clothes for residents. If this is the case

and this is the only assistance the resident receives, count

the resident as independent. However, if a resident receives

assistance, such as with dressing, donning a brace, elastic

stocking, a prosthesis , or securing fasteners, etc. count the

resident as needing the assistance of 1 or 2 staff, as appropriate.

Transferring (F85 – F87): How the resident moves between

surfaces, including, to or from bed, chair, wheelchair, or

standing position. (EXCLUDES transfers to/from the bath/

toilet). G0110B1 = 0 for F85 OR G0110B1 = 1, 2, or 3 for F86

OR G0110B1 = 4 for F87.

Facilities may provide “setup” assistance to residents, such as

handing equipment (e.g., quad cane) to the resident. If this is the

case and is the only assistance required, count the resident as

independent.

Toilet Use (F88 – F90): How the resident uses the toilet, commode,

bedpan, or urinal; transfers on/off toilet; cleanses self after elimination;

changes pad(s); manages ostomy or catheter, and adjusts clothing.

If all that is done for the resident is to open a package (e.g., a clean

incontinence pad), count the resident as independent. G0110I1 = 0 for

F88 OR G0110I1 = 1, 2, or 3 for F89 OR G0110I1 = 4 for F90.

Eating (F91 – F93): How a resident eats and drinks, regardless

of skill. Do not include eating/drinking during medication pass.

Includes intake of nourishment by other means (e.g., tube feeding,

total parenteral nutrition, includes IV fluids administered for

nutrition or hydration). Facilities may provide “setup” activities,

such as opening containers, buttering bread, and organizing the

tray; if this is the case and is the only assistance a resident needs,

count this resident as independent. G0110H1 = 0 for F91 OR

G0110H1 = 1, 2, or 3 for F92 OR G0110H1 = 4 for F93.

Form CMS-672 (05/12) 3

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

(use with Form CMS-672)

A. BOWEL/BLADDER STATUS (F94 – F99) -

RESIDENTS

F94: With an indwelling or an external catheter:

Whose urinary bladder is constantly drained by a catheter (e.g.,

an indwelling catheter, a suprapubic catheter or nephrostomy

tube) or who wears an appliance that is applied over the penis and

connected to a drainage bag to collect urine from the bladder (e.g.,

condom catheter or similar appliance). H0100A or B = checked.

F95: Of the total number of residents with catheters:

Who had a catheter present on admission/entry or reentry.

H0100A or B = checked. To complete this field use only the

counts from the first assessment since the most recent admission/

entry or reentry (OBRA or Scheduled PPS, i.e., A0310A = 01

OR A0310B = 01 or 06 OR A0310E = 1 for each resident).

F96: Occasionally or frequently incontinent of bladder:

Who have an incontinent episode two or more times per week.

Do not include residents with an indwelling or external catheter.

H0100A and B = not checked AND H0300 =1, 2, or 3.

F97: Occasionally or frequently incontinent of bowel:

Who have a loss of bowel control two or more times per week.

H0400 = 2 or 3.

F98: On urinary toileting program: With a systematically

implemented, individualized urinary toileting program

(i.e. bladder rehabilitation/retraining, prompted voiding,

habit training/scheduled voiding) to decrease or prevent

urinary incontinence or minimizing or avoiding the negative

consequences of incontinence (e.g., pelvic floor exercises).

Count all residents on urinary training programs including those

who are incontinent. H0200A = 1 OR H200C = 1 OR H0300 =

1, 2 or 3.

F99: On bowel toileting program: With a systematically

implemented, individualized bowel toileting program to decrease

or prevent bowel incontinence or minimizing or avoiding the

negative consequences of incontinence (e.g., use of adequate

fluid intake, fiber in the diet, exercise, and scheduled times

to attempt bowel movement). Count all residents on toileting

programs including those who are incontinent. H0400 = 2 or 3

OR H0500 OR H0600 = 1.

B. MOBILITY (F100 – F107) - RESIDENTS

Total for F100 – F103 should = the number in Block F78,

Total Residents. Algorithm to force mutual exclusivity: Test

for each resident. If F100 = 1 then add 1 to F100, and go to

the next resident; If F101 = 1 then add 1 to F101 and go to the

next resident; If F103 = 1 then add 1 to F103 and go to the next

resident; If F102 = 1 then add 1 and go to the next resident.

F100: Bedfast all or most of time: Who are bedfast all or most

of the time (e.g., in bed or geriatric chair/recliner) includes

bedfast with bathroom privileges.

F101: In a chair all or most of time: Who depend on a chair for

mobility includes those residents who can stand with assistance to

pivot from bed to wheelchair or to otherwise transfer. The resident

cannot take steps without extensive or constant weight-bearing

support from others and is not bedfast all or most of the time.

G0300A or E = 2 OR G0600C = checked.

F102: Independently ambulatory: Who require no help or

oversight; or help or oversight was provided only 1 or 2 times

during the past 7 days. Do not include residents who use a cane,

walker or crutch. G0110C1 or G0110D1 = 0 or 7 and G0110C2 or

G0110D2 = 0 or 1 AND G0600A and G0600B = not checked.

F103: Ambulation with assistance or assistive devices:

Who require oversight, cueing, physical assistance or who use a

cane, walker, or crutch. Count the use of lower leg splints, orthotics,

and braces as assistive devices. G0110C1 or G0110D1 = 1, 2, or

3 AND G0110C2 or G0110D2 = 1, 2 or 3 OR G0600A and/or

G0600B = checked.

F104: Physically restrained: For whom restraints were used.

Restraints include any manual or physical method or mechanical

device, material or equipment attached or adjacent to the

resident’s body in such a way that the individual cannot remove

easily and it restricts freedom of movement or normal access

to one’s body. Do not include devices such as braces which are

used for medical/clinical reasons. P0100A through H = 1 or 2.

F105: Of total number of restrained residents: On admission/

entry or reentry with an order for restraint(s). P0100A through

H = 1 or 2. To complete this field use only the counts from the

first assessment since the most recent admission/entry or reentry

(OBRA or Scheduled PPS, i.e., A0310A = 01 OR A0310B = 01

or 06 OR A0310E = 1 for each resident).

F106: With contractures: With a restriction of full passive

range of motion of any joint due to deformity, disuse, pain, etc.,

includes loss of range of motion in neck, fingers, wrists, elbows,

shoulders, hips, knees and ankles. G0400A and/or B = 1 or 2.

F107: Of the total number with contractures, those who

had a contracture(s) on admission: To complete this field use

only the counts from the first assessment since the most recent

admission/entry or reentry (OBRA or Scheduled PPS, i.e.,

A0310A = 01 OR A0310B = 01 or 06 OR A0310E = 1 for each

resident). (neck contractures not included in MDS data).

Form CMS-672 (05/12) 4

RESIDENT 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

as defined at 483.45(a)) or Developmental Disability (DD):

In all of the categories of intellectual or developmental disability

regardless of severity, as determined by the State Mental Health

or State Mental Retardation Authorities. A1550A, B through

E = checked.

F109: With documented signs and symptoms of depression:

With documented signs and symptoms of depression. D0200A1

through D1 = 1 for any indicator present OR D0200I1 = 1OR

D0200A2 through D2 = 2 or 3 for symptom frequency OR

D0300 = 05 - 27 OR D0500A1 through D1 = 1 for any indicator

present OR D0500I1 = 1 OR D0500A2 through D2 = 2 or 3 for

symptom frequency OR D0600 = 05 - 30.

F110: With documented psychiatric diagnosis (exclude

dementias and depression): With primary or secondary

psychiatric diagnosis including:

• Schizophrenia

• Schizo-affective disorder

• Schizophreniform disorder

• Delusional disorder

• Anxiety disorder

• Psychotic mood disorders (including mania and depression

with psychotic features, acute psychotic episodes, brief

reactive psychosis and atypical psychosis). I5700, I5900,

I5950, I6000 or I6100 = checked.

F111: Dementia: Non-Alzheimer’s Dementia (e.g., Lewy-

Body, vascular or Multi-infarct, mixed, frontotemporal such

as Pick’s disease; and dementia related to Parkinson’s or

Creutzfeldt-Jakob diseases), or Alzheimer’s Disease: With a

primary or secondary diagnosis of dementia or organic mental

syndrome including, Non-Alzheimer’s Dementia (e.g., Lewy-

Body, vascular or Multi-infarct, mixed, frontotemporal such as

Pick’s disease; and dementia related to Parkinson’s or Creutzfeldt-

Jakob diseases). I4200 or I4800 = checked

F112: With behavioral health care needs: With one or more

of the following indicator(s): wandering, verbally abusive,

physically abusive, socially inappropriate/disruptive, and

resistive to care. E0200A, B, or C = 1, 2, or 3 OR E0300 = 1 OR

E0500A, B, or C = 1 OR E0600A, B, or C = 1 OR E0800 = 1, 2,

or 3 OR E0900 = 1, 2, or 3 OR E1000A or B = 1.

F113: Of the total number with behavioral healthcare needs,

those having an individualized care plan to support them:

With behavior symptoms who are receiving an individualized

care plan/program designed to support and manage behavioral

needs (as noted in F112).

F114: Receiving health rehabilitative services for Mental

Illness (MI) and/or ID/DD: Receiving health rehabilitative

services for MI and/or ID/DD.

F115: With pressure ulcers: With localized injury to the skin

and/or underlying tissue, usually over a bony prominence, as a

result of pressure, or pressure in combination with shear and/

or friction (exclude Stage I). M0300B1, M0300C1, M0300D1,

M0300E1, M0300F1and/or M0300G1 > 0.

F116: Of the total number of residents with pressure ulcers

(excluding Stage 1), those who had pressure ulcers on

admission/entry or reentry: M0300B2, M0300C2, M0300D2,

M0300E2, M0300F2 and/or M0300G2 > 0. To complete this

field, use only the counts from the first assessment since the

most recent admission/entry or reentry. (OBRA or Scheduled

PPS, i.e., A0310A = 01 OR A0310B = 01 or 06 OR A0310E =

1 for each resident.)

F117: Receiving preventive skin care: Receiving non-

routine skin care ordered by a physician, and/or included in

the resident’s comprehensive plan of care (e.g., hydrocortisone

ointment to areas of dermatitis three times a day, granulex

sprays, etc.). M1200A through I = checked.

Fl18: With rashes: Who have rashes which may or may not

be treated with any medication or special baths, etc. (e.g.,

may include but are not limited to antifungals, corticosteroids,

emollients, diphenhydramines or scabicides).

E. SPECIAL CARE (F119 – F132) - RESIDENTS

F119: Receiving hospice care: Who have elected or are

currently receiving the hospice benefit. O0100K2 = checked.

F120: Receiving radiation therapy: Who are under a treatment

plan involving radiation therapy. O0100B1 or O0100B2 =

checked.

F121: Receiving chemotherapy: Who are under a treatment

plan involving chemotherapy. O0100A1 or O0100A2 = checked.

F122: Receiving dialysis: Receiving hemodialysis or

peritoneal dialysis either within the facility or offsite. O0100J1

or O0100J2 = checked.

F123: Receiving intravenous therapy, IV nutrition and/

or blood transfusion: Receiving fluids, medications, all or

most of their nutritional requirements and/or blood and blood

products administered intravenously. K0510A2, O0100H2, or

O0100I2 = checked.

F124: Receiving respiratory treatment: Resceiving treatment

by the use of respirators/ventilators, oxygen, IPPB or other

inhalation therapy, pulmonary toilet, humidifiers, and other

methods to treat conditions of the respiratory tract. This does

not include residents receiving tracheostomy care or respiratory

suctioning. O0100C2, O0100F2, or O0100G2 = checked.

Form CMS-672 (05/12) 5

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

(use with Form CMS-672)

F125: Receiving tracheostomy care: Receiving care involved

in maintenance of the airway, the stoma and surrounding skin,

and dressings/coverings for the stoma. O0100E2 = checked.

F126: Receiving ostomy care: Receiving care for a colostomy,

ileostomy, uretrostomy, or other ostomy of the intestinal and/or

urinary tract. DO NOT include tracheostomy. H0100C = checked.

F127: Receiving suctioning: That require use of a mechanical

device which provides suction to remove secretions from

the respiratory tract via the oral cavity, nasal passage, or

tracheostomy. O0100D2 = checked. (Note: O0100D2 does not

include oral suctioning, so residents who receive oral suctioning

will have to be counted separately.)

F128: Receiving injections: That have received one or more

injections within the past 7 days. (Exclude injections of Vitamin

B 12.) Review residents where N0300 > 0. Omit from the count

any resident whose only injection currently is B12.

F129: Receiving tube feeding: Who receive all or most of

their nutritional requirements via a feeding tube that delivers

food/nutritional substances directly into the GI system (e.g.,

nasogastric tube, gastrostomy tube). K0510B2 = checked.

F130: Receiving mechanically altered diets: Receiving a

mechanically altered diet including pureed and/or chopped foods

(not only meat). K0510C2 = checked.

F131: Receiving rehabilitative services: Receiving care

designed to improve functional ability provided by, or under

the direction of a rehabilitation professional (physical therapist,

occupational therapist, speech-language pathologist). Exclude

health rehabilitation for MI and/or ID/DD. Any minutes > 0

entered in O0400.

F132: Assistive devices with eating: Who are using devices to

maintain independence and to provide comfort when eating (i.e.,

plates with guards, large handled flatware, large handle mugs,

extend hand flatware, etc.). O0500C or H > 0.

F. MEDICATIONS (F133 – F139) - RESIDENTS

F133: Receiving psychoactive medications: That receive

medications classified as antipsychotics, anxiolytics,

antidepressants, and/or hypnotics. Days entered > 0 for N0410A,

B, C or D.

Use the following lists to assist you in determining the number

of residents receiving psychoactive medications. These lists are

not meant to be all inclusive; therefore, a resident receiving

a psychoactive medication not on this list, should be counted

under F133 and any other medication category that applies:

F134, F135, F136, and/or F137.

F134: Antipsychotic medications: Days entered for N0410A > 0

• Clozapine

• Haloperidol

• Haloperiodal Deconate

• Droperidol

• Loxapine

• Thioridazine

• Molindone

• Theothixene

• Zyprexa

• Pimozide

• Fluphenazine Deconate

• Fluphenazine

• Quetiapine

• Risperidone

• Mesoridazine

• Promazine

• Trifluoperazine

• Chlorprothixene

• Chlorpromazine

• Acetophenazine

• Perphenazine

F135: Antianxiety medications (anxiolytics): Days entered for

N0410B > 0

• Lorazepam

• Oxazepam

• Prazepam

• Diazepam

• Clonazepam

• Hydroxyzine

• Chlordiazepoxide

• Halazepam

• Alprazolam

F136: Antidepressant medications: Days entered for N0410C > 0

• Aripiprazole

• Amoxapine

• Nortriptyline

• Wellbutrin

• Trazodone

• Venlafaxine

• Amtriptyline

• Lithium

• Maprotiline

• Isocarboxazid

• Phenelzine

• Serzone

• Desipramine

• Tranylcypromine Paroxetine

• Fluoxetine

• Sertraline

• Doxepin

• Imipramine

• Protriptyline

Form CMS-672 (05/12) 6

RESIDENT CENSUS AND CONDITIONS OF RESIDENTS

(use with Form CMS-672)

F137: Hypnotic medications: Days entered for N0410D > 0

• Flurazepam

• Quazepam

• Estazolam

• Temazepam

• Triazolam

• Zolpidem

F138: Receiving antibiotics: Receiving antibacterial

sulfonamides, antibiotics, etc., either for prophylaxis or

treatment. Days entered for N0410F > 0.

F139: On a pain management program: With a specific plan

for control of difficult to manage or intractable pain, which

may include self medication pumps or regularly scheduled

administration of medication alone or in combination with non-

medication interventions (e.g., massages heat/cold, biofeedback,

etc.). J0100A, B, or C = 1.

G. OTHER RESIDENT CHARACTERISTICS

(F140 – F145)

F140: With unplanned significant weight loss/gain: Who have

experienced unplanned weight loss/gain of > 5% in one month

or > 10% over six months. K0300 or K0310 = 2.

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.

F142: Who use non-oral communication: Who communicate

via non-oral methods, including, picture boards, computers, etc.

A1100B, Preferred Language (e.g. American Sign Language).

F143: Who have advance directives: Who have advance

directives, such as Physician’s Orders for Life-Sustaining

Treatment (POLST), a living will or durable power of attorney

for health care, recognized under state law and relating to the

provisions of care when the individual is incapacitated.

F144: Received influenza immunization: Who received the

influenza immunization within the last 12 months. O0250A = 1.

F145: Received pneumococcal vaccine: Who received the

pneumococcal vaccine. O0300A = 1.

LEAVE BLANK (F146-F148) – To Be Completed By

Survey Team

F146: Ombudsman notice: Indicate whether or not the State

Ombudsman was notified prior to the survey.

F147: Ombudsman presence: Indicate whether or not the State

Ombudsman was present at any time during the survey.

F148: Medication error rate: Calculate and enter the

medication error percentage of the facility.

Form CMS-672 (05/12) 7

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