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:
• 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 =
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