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RESIDENT CENSUS AND CONDITIONS OF RESIDENTS THIS FORM IS TO BE COMPLETED BY THE FACILITY AND REPRESENTS THE CURRENT CONDITION OF RESIDENTS AT THE TIME OF COMPLETION There is not a federal requirement for automation of the 672 form. The facility may continue to complete the 672 with manual methods. The facility may use the MDS data to start the 672 form, but must verify all information, and in some cases, re-code the item responses to meet the intent of the 672 to represent current resident status according to the definitions of the 672. Since the census is designed to be representation of the facility during the survey, it does not directly correspond to the MDS in every item.
For the purpose of this form "the facility" equals certified beds (i.e., Medicare and/or Medicaid certified beds).
For the purpose of this form " residents" means residents in certified beds regardless of payor source.
Following the definition of each field, the related MDS 2.0 codes and instructions will be noted within square brackets Where coding refers to the admission assessment, use the first assessment done after the most recent admission or readmission event.
Complete each item by specifying the number of residents characterized by each category. If no residents fall into a category enter a “0”.
Provider No. - Enter the facility’s assigned provider Bathing F79 - F81 number. Leave blank for initial certifications.
The process of bathing the body (excluding back and shampooing hair). This includes a full-body bath/ Block F75 - Enter the number of facility residents, whose shower, sponge bath, and transfer into and out of tub or primary payer is Medicare. [code manually] shower. [F79: G2A = 0; F80: G2A = 1,2,3; F81: G2A Block F76 - Enter the number of facility residents, whose Many facilities routinely provide “setup” assistance to all primary payer is Medicaid. [code manually] residents such as drawing water for a tub bath or laying out bathing materials. If this is the case and the resident Block F77 - Enter the number of facility residents, whose requires no other assistance, count the resident as primary payer is neither Medicare nor Medicaid. [code Block F78 - Enter the number of total residents for whom How the resident puts on, fastens, and takes off all items of a bed is maintained, on the day the survey begins, street clothing, including donning or removing including those temporarily away in a hospital or on prostheses (e.g., braces and artificial limbs). [F82:G1Ag leave. [Total residents in nursing facility or on bedhold] Many facilities routinely set out clothes for all residents. If To determine resident status, unless otherwise noted, this is the case and this is the only assistance the resident consider the resident’s condition for the 7 days prior to receives, count the resident as independent. However, the survey. [Horizontal totals must equal the number in if a resident receives assistance with donning a brace, F78; Manually re-code all "8" responses.] elastic stocking, a prosthesis and so on, securing fasteners, or putting a garment on, count the resident as needing the assistance of 1 or 2 staff.
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS F97 - Occasionally or frequently incontinent of bowel How the resident moves between surfaces, such as to and - The number of residents who have a loss of bowel from the bed, chair, wheelchair or to and from a control two or more times per week. [H1a = 2,3 or 4] standing position. (EXCLUDE transfers to and from the bath or toilet). [F85; G1Ab = 0: F86; G1Ab = 1,2,3: F98 - On individually written bladder training program - The number of residents with a detailed plan of care Many facilities routinely provide “setup” assistance to all to assist the resident to gain and maintain bladder residents, such as handing the equipment (e.g., sliding control (e.g., pelvic floor exercises). Count all residents board) to the resident. If this is the case and is the only on training programs including those who are assistance required, count the resident as independent.
F99 - On individually written bowel training program How the resident uses the toilet room (or bedpan, bedside - The number of residents with a detailed plan of care commode, or urinal). How resident transfers on and off to assist the resident to gain and maintain bowel toilet, cleans self after elimination, changes sanitary control (e.g., use of diet, fluids, and regular schedule napkins, ostomy, external catheters, and adjusts clothing for bowel movements). Count all residents on training prior to and after using toilet. If all that is done for the programs including those who are incontinent. [code resident is to open a package (e.g., a clean sanitary pad), count the resident as independent. [F88; G1Ai = 0: F89; [Total for F100-F103 should = F78; Algorithm to force mutual exclusivity: Test for each resident. If F100 = How resident eats and drinks regardless of skill. Many 1 then add 1 to F100, and go to the next resident; If facilities routinely provide “setup” activities, such as F101 = 1 then add 1 to F101and go to the next resident; opening containers, buttering bread, and organizing If F103 = 1 then add 1 to F103 and go to the next the tray; if this is the case and is the extent of resident; If F102 = 1 then add 1 and go to the next assistance, count this resident as independent. [F91; G1Ah = 0: F92; G1Ah = 1,2,3: F93; G1Ah = 4] F100 - Bedfast all or most of time- The number of residents who were in bed or recliner 22 hours or more per day in the past 7 days. Includes bedfast with F94 - With an indwelling or an external catheter - The bathroom privileges. [G6a =check and G5d is not = number of residents whose urinary bladder is constantly drained by a catheter (e.g., a Foley catheter, a suprapubic catheter) or who wears an appliance that is applied over F101 - In chair all or most of time - The number of the penis and connected to a drainage bag to collect residents who depend on a chair for mobility. Includes urine from the bladder (e.g., a Texas catheter). [H3c or 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 F95 - Of the total number of residents with catheters - weight-bearing support from others and is not bedfast The number of residents who had a catheter present on admission. For a resident readmitted from a hospital with a catheter, count this resident as admitted with a F102 - Independently ambulatory - The number of catheter. [H3c or d = check and A8a=1 or A8b=1 or 5] residents who require no help or oversight; or help or oversight was provided only 1 or 2 times during the F96 - Occasionally or frequently incontinent of bladder past 7 days. Do not include residents who use a cane, - The number of residents who have an incontinent walker or crutch. [G1ac = 0 and G1Ad = 0 and G5a is episode two or more times per week. Do not include residents with an indwelling or external catheter. [H1b = 2,3 or 4 and H3c and d are not = check] RESIDENT CENSUS AND CONDITIONS OF RESIDENTS F103 - Ambulation with assistance or assistive devices - The number of residents who required oversight, cueing, physical assistance or who used a cane, walker, l Psychotic mood disorders (including mania and crutch. Count the use of lower leg splints, orthotics, and depression with psychotic features, acute psychotic braces as assistive devices. [G1Ac or d = 1,2 or 3 or G5a episodes, brief reactive psychosis, and atypical psychosis). [I1dd,ff, or gg = check. Code manually for F104 - Physically restrained - The number of residents whose freedom of movement and/or normal access to F111 - Dementia: Multi-infarct, senile, Alzheimer's his/her body is restricted by any manual method or type, or other than Alzheimer's type - The number of physical or mechanical device, material or equipment residents with a primary or secondary diagnosis of that is attached or adjacent to his/her body and cannot dementia or organic mental syndrome including multi- be easily removed by the resident. [Any P4c,d or e = 1 infarct, senile type, Alzheimer’s type, or other than F105 - Of total number of restrained residents, number F112 - With behavioral symptoms - The number of admitted or readmitted with an order for restraint.
residents with one or more of the following symptoms: [Code manually when criteria for F104 is met and P4c,d wandering, verbally abusive, physically abusive, socially inappropriate/disruptive, resistive to care. (See MDS Section (Mood and Behavioral Patterns)). [Any F106 - With contractures - The number of residents that have a restriction of full passive range of motion of any joint due to deformity, disuse, pain, etc. Includes loss F113 - Of the total number with behavioral symptoms, of range of motion in fingers, wrists, elbows, shoulders, the number receiving a behavior management program.
hips, knees and ankles. [Any G4Aa,b,c,d,e or f = 1 or 2] The number of residents with behavior symptoms who are receiving an individualized care plan/program F107 - Of total of residents with contractures, the designed to address behavioral symptoms (as listed number who had a contracture(s) on admission.
above). [Manually code when criteria for F112 is met [Code when criteria for F106 is met on admission or re- admission assessment and A8a=1 or A8b=1 or 5.] F114 - Receiving health rehabilitative services for MI/ MR- The number of residents for whom the facility is providing health rehabilitative services for MI/MR as F108 - With mental retardation - Identify the total defined at 483.45(a). [Use item for Residents who meet number of residents in all of the categories of developmental disability regardless of severity, as determined by the State Mental Health or State Mental D. SKIN INTEGRITY (F115 - F118) Retardation Authorities. [Any AB10b,c,e or f = check] F115 - With pressure sores - The number of residents with F109 - With documented signs and symptoms of ischemic ulcerations and/or necrosis of tissues overlying depression - The total number of residents with a bony prominence (exclude Stage I). [Any M1b,c or d documented signs and symptoms of depression as defined > 0 or M2a > 1 Code for first assessment after latest by MDS (Mood and Behavior Section). [I1ee = check or F116 - Of the total number of residents with pressure F110 - With documented psychiatric diagnosis (exclude sores excluding Stage I, the number who had pressure dementias and depression) - The number of residents sores on admission or who were readmitted with a new with primary or secondary psychiatric diagnosis pressure sore (exclude Stage I). [Code when criteria for field 115 are met and A8a=1 or A8b=1 or 5.] l Schizophrenial Schizo-affective disorder RESIDENT CENSUS AND CONDITIONS OF RESIDENTS F117 - Receiving preventive skin care - The number of F125 - Receiving tracheotomy care - The number of residents receiving non-routine skin care provided residents receiving care involved in maintenance of the according to a physician’s order, and/or included in the airway, the stoma and surrounding skin, and dressings/ resident’s comprehensive plan of care (e.g., hydrocortisone ointment to areas of dermatitis three times a day, granulex sprays, etc.) [Any M5a,b,c,d,e,f,g,h, F126 - Receiving ostomy care - The number of residentsor i = check] receiving care for a colostomy, ileostomy, uretrostomy, or other ostomy of the intestinal and/or urinary tract.
F118 - With rashes - Enter the number of residents who DO NOT include tracheotomy. [P1af = check] have rashes which may or may not be treated with any medication or special baths, etc. (e.g., but not limited to F127 - Receiving suctioning - The number of residents antifungals, cortisteroids, emollients, dipherydramines that require use of a mechanical device which provides suction to remove secretions from the respiratory tract via the mouth, nasal passage, or tracheotomy stoma.
F119 - Receiving hospice care- Number of residents who F128 - Receiving injections - The number of residents that have elected or are currently receiving the hospice have received one or more injections within the past 7 days. (Exclude injections of Vitamin B12.) [Review residents for whom O3 = 1,2,3,4,5,6 or 7. Omit from F120 - Receiving radiation therapy - The number of count any resident whose only injection currently is residents who are under a treatment plan involving F129 - Receiving tube feeding - The number of residents F121 - Receiving chemotherapy - The number of residents who receive all or most of their nutritional requirements under a specific treatment plan involving chemotherapy.
via a feeding tube that delivers food/nutritional substances directly into the GI system (e.g., naso- gastric tube, gastrostomy tube). [K5b = check] F122 - Receiving dialysis - The number of residents receiving hemodialysis or peritoneal dialysis either F130 - Receiving mechanically altered diets - The within the facility or offsite. [P1ab = check] number of residents receiving a mechanically altered diet including pureed and/or chopped foods (not only F123 - Receiving intravenous therapy, IV nutritional feedings and/or blood transfusion - The number of residents receiving fluids, medications, all or most of F131 - Receiving rehabilitative services - The number of their nutritional requirements and/or blood and blood residents receiving care designed to improve functional products administered intravenously. [K5a = check or ability provided by, or under the direction of a rehabilitation professional (physical therapist, occupational therapist, speech-language pathologist.
F124 - Receiving respiratory treatment - The number of (Exclude health rehab. for MI/MR.) [P1baA or P1bbA residents receiving treatment by the use of respirators/ ventilators, oxygen, IPPB or other inhalation therapy, F132 - Assistive devices with eating - The number of pulmonary toilet, humidifiers, and other methods to residents who are using devices to maintain treat conditions of the respiratory tract. This does not independence and to provide comfort when eating (i.e., include residents receiving tracheotomy care or plates with guards, large handled flatware, large handle respiratory suctioning. [P1ag = check or P1al = check or mugs, extend hand flatware, etc.). [K5g = check] RESIDENT CENSUS AND CONDITIONS OF RESIDENTS F133 - Receiving psychoactive drugs - The number of residents that receive drugs classified as anti-depressants, anti-anxiety, sedative and hypnotics, and anti- psychotics. [Any O4a,b,c or d = 1,2,3,4,5,6 or 7] Use the following lists to assist you in determining the number of residents receiving psychoactive drugs. These lists are not meant to be all inclusive, therefore, a resident receiving a psychoactive drug not on this list, should be counted under F133 and any other drug category that applies - F134, F135, F136, and/or F137.
F134 - Receiving Antipsychotic medications [O4a = F137 - Receiving Hypnotic medications [O4d = 1,2,3,4,5,6 F138 - Receiving antibiotics - The number of residents Prolixin, Deconoate (Fluphenazine Deconate) receiving sulfonamides, antibiotics etc. either for prophylaxis or treatment. [Code manually] F139 - On a pain management program - The number of residents 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 alternative approaches (e.g., massages, heat, etc.). [Code manually when any J3a,b,c,d,e,f,g,h,i or j = check] G. OTHER RESIDENT CHARACTERISTICS (F140 - F135 - Receiving Antianxiety medications [O4b = F140 - With unplanned or significant weight loss/gain - The number of residents who have experienced gain or loss of 5% in one month or 10% over six months.
F141 - Who do not communicate in the dominant language at the facility - The number of residents who F136 - Receiving Antidepressant medications [O4c = only express themselves in a language not dominant at the facility (e.g., this would include residents who speak only Spanish, but the majority of staff that care for the residents speak only English). [code manually] RESIDENT CENSUS AND CONDITIONS OF RESIDENTS F142 - Who use non-oral communication devices (e.g., F145 - Received pneumococcal vaccine - The number of picture board, computers, sign-language). [Any residents known to have received the pneumococcal F143 - Who have advanced directives (living will/ F146 - Ombudsman notice - LEAVE BLANK. This will durable power of attorney). The number of residents be completed by survey team. Indicate yes or no whether who have advanced directives, such as a living will or Ombudsman office was notified prior to survey.
durable power of attorney for health care, recognized under state law and relating to the provisions of care F147 - LEAVE BLANK. This will be completed by the when the individual is incapacitated. [Any survey team. Indicate whether Ombudsman was present at any time during the survey, 1 (yes) or 2 (no).
F144 - Received influenza immunization - The number F148 - Medication error rate - LEAVE BLANK. This of residents known to have received the influenza will be completed by the survey team.
immunization within the last 12 months. [code


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