11: Minimum Data Set

Minimum Data Set (MDS) 3.0 pages 1–28 (preview)

MDS 3.0 Nursing Home Comprehensive (NC) Item Set

Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

MINIMUM DATA SET (MDS) - Version 3.0RESIDENT ASSESSMENT AND CARE SCREENINGNursing Home Comprehensive (NC) Item Set

Section AIdentification Information

A0050. Type of Record

Enter Code Enter Code: 1 box

1.Add new record ➞then: Continue to A0100, Facility Provider Numbers 2. Modify existing record ➞then: Continue to A0100, Facility Provider Numbers 3. Inactivate existing record ➞then: Skip to X0150, Type of Provider

A0100. Facility Provider Numbers

A. National Provider Identifier (NPI): 10-character field

B. CMS Certification Number (CCN):

12-character field

C. State Provider Number:

15-character field

A0200. Type of Provider

Enter Code Enter Code: 1 box

Type of provider 1. Nursing home (SNF/NF) 2. Swing Bed

A0300. Optional State Assessment

Complete only if A0200 = 1

Enter Code Enter Code: 1 box

A. Is this assessment for state payment purposes only? 0. No 1. Yes

A0310. Type of Assessment

Enter Code Enter Code: 2 boxes

A. Federal OBRA Reason for Assessment B. PPS Assessment PPS Unscheduled Assessment for a Medicare Part A Stay Not PPS Assessment E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? F. Entry/discharge reporting A0310 continued on next page MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 1 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section AIdentification Information

A0310. Type of Assessment - Continued

Enter Code Enter Code: 1 box

G. Type of discharge - Complete only if A0310F = 10 or 11 G1. Is this a SNF Part A Interrupted Stay? H. Is this a SNF Part A PPS Discharge Assessment? 0. No 1. Yes

A0410. Unit Certification or Licensure Designation

Enter Code Enter Code: 1 box

1.Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State 2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State 3. Unit is Medicare and/or Medicaid certified

A0500. Legal Name of Resident

A. First name: 12-character field

B. Middle initial:

1-character field

C. Last name:

18-character field

D. Suffix:

3-character field

A0600. Social Security and Medicare Numbers

A. Social Security Number: 3-character field – 2-character field – 4-character field

B. Medicare number:

12-character field

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient

14-character field

A0800. Gender

Enter Code Enter Code: 1 box

1.Male 2. Female

A0900. Birth Date

MonthMonth–DayDay–YearYear

A1000. Race/Ethnicity

↓ Check all that apply

checkbox	A. American Indian or Alaska Native
checkbox	B. Asian
checkbox	C. Black or African American
checkbox	D. Hispanic or Latino
checkbox	E. Native Hawaiian or Other Pacific Islander
checkbox	F. White

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section AIdentification Information

A1100. Language

Enter Code Enter Code: 1 box

A. Does the resident need or want an interpreter to communicate with a doctor or health care staff? B. Preferred language:15-character field

A1200. Marital Status

Enter Code Enter Code: 1 box

1.Never married 2. Married 3. Widowed 4. Separated 5. Divorced

A1300. Optional Resident Items

A. Medical record number: 12-character field

B. Room number:

10-character field

C. Name by which resident prefers to be addressed:

23-character field

D. Lifetime occupation(s) - put "/" between two occupations:

23-character field

A1500. Preadmission Screening and Resident Review (PASRR)

Complete only if A0310A = 01, 03, 04, or 05

Enter Code Enter Code: 1 box

Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 0. No ➞then: Skip to A1550, Conditions Related to ID/DD Status 1. Yes ➞then: Continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions 9. Not a Medicaid-certified unit ➞then: Skip to A1550, Conditions Related to ID/DD Status

A1510. Level II Preadmission Screening and Resident Review (PASRR) Conditions

Complete only if A0310A = 01, 03, 04, or 05

↓ Check all that apply

checkbox	A. Serious mental illness
checkbox	B. Intellectual Disability
checkbox	C. Other related conditions

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section AIdentification Information

A1550. Conditions Related to ID/DD Status

If the resident is 22 years of age or older, complete only if A0310A = 01

If the resident is 21 years of age or younger, complete only if A0310A = 01, 03, 04, or 05

↓ Check all conditions that are related to ID/DD status that were manifested before age 22, and are likely to continue indefinitely

	ID/DD With Organic Condition
checkbox	A. Down syndrome
checkbox	B. Autism
checkbox	C. Epilepsy
checkbox	D. Other organic condition related to ID/DD
	ID/DD Without Organic Condition
checkbox	E. ID/DD with no organic condition
	No ID/DD
checkbox	Z. None of the above

Most Recent Admission/Entry or Reentry into this Facility

A1600. Entry Date

MonthMonth–DayDay–YearYear

A1700. Type of Entry

Enter Code Enter Code: 1 box

1.Admission 2. Reentry

A1800. Entered From

Enter Code Enter Code: 2 boxes

01.Community (private home/apt., board/care, assisted living, group home) 02. Another nursing home or swing bed 03. Acute hospital 04. Psychiatric hospital 05. Inpatient rehabilitation facility 06. ID/DD facility 07. Hospice 09. Long Term Care Hospital (LTCH) 99. Other

A1900. Admission Date (Date this episode of care in this facility began)

MonthMonth–DayDay–YearYear

A2000. Discharge Date

Complete only if A0310F = 10, 11, or 12

MonthMonth–DayDay–YearYear

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section AIdentification Information

A2100. Discharge Status

Complete only if A0310F = 10, 11, or 12

Enter Code Enter Code: 2 boxes

01.Community (private home/apt., board/care, assisted living, group home) 02. Another nursing home or swing bed 03. Acute hospital 04. Psychiatric hospital 05. Inpatient rehabilitation facility 06. ID/DD facility 07. Hospice 08. Deceased 09. Long Term Care Hospital (LTCH) 99. Other

A2200. Previous Assessment Reference Date for Significant Correction

Complete only if A0310A = 05 or 06

MonthMonth–DayDay–YearYear

A2300. Assessment Reference Date

Observation end date: MonthMonth–DayDay–YearYear

A2400. Medicare Stay

Complete only if A0310G1 = 0

Enter Code Enter Code: 1 box

A. Has the resident had a Medicare-covered stay since the most recent entry? B. Start date of most recent Medicare stay:MonthMonth–DayDay–YearYear

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MonthMonth–DayDay–YearYear

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Look back period for all items is 7 days unless another time frame is indicated

Section BHearing, Speech, and Vision

B0100. Comatose

Enter Code Enter Code: 1 box

Persistent vegetative state/no discernible consciousness 0. No ➞then: Continue to B0200, Hearing 1. Yes ➞then: Skip to G0110, Activities of Daily Living (ADL) Assistance

B0200. Hearing

Enter Code Enter Code: 1 box

Ability to hear (with hearing aid or hearing appliances if normally used) 0. Adequate - no difficulty in normal conversation, social interaction, listening to TV 1. Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy) 2. Moderate difficulty - speaker has to increase volume and speak distinctly 3. Highly impaired - absence of useful hearing

B0300. Hearing Aid

Enter Code Enter Code: 1 box

Hearing aid or other hearing appliance used in completing B0200, Hearing 0. No 1. Yes

B0600. Speech Clarity

Enter Code Enter Code: 1 box

Select best description of speech pattern 0. Clear speech - distinct intelligible words 1. Unclear speech - slurred or mumbled words 2. No speech - absence of spoken words

B0700. Makes Self Understood

Enter Code Enter Code: 1 box

Ability to express ideas and wants, consider both verbal and non-verbal expression 0. Understood 1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time 2. Sometimes understood - ability is limited to making concrete requests 3. Rarely/never understood

B0800. Ability To Understand Others

Enter Code Enter Code: 1 box

Understanding verbal content, however able (with hearing aid or device if used) 0. Understands - clear comprehension 1. Usually understands - misses some part/intent of message but comprehends most conversation 2. Sometimes understands - responds adequately to simple, direct communication only 3. Rarely/never understands

B1000. Vision

Enter Code Enter Code: 1 box

Ability to see in adequate light (with glasses or other visual appliances) 0. Adequate - sees fine detail, such as regular print in newspapers/books 1. Impaired - sees large print, but not regular print in newspapers/books 2. Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects 3. Highly impaired - object identification in question, but eyes appear to follow objects 4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects

B1200. Corrective Lenses

Enter Code Enter Code: 1 box

Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 6 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section CCognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

Attempt to conduct interview with all residents

Enter Code Enter Code: 1 box

0.No (resident is rarely/never understood) ➞then: Skip to and complete C0700-C1000, Staff Assessment for Mental Status 1. Yes ➞then: Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)

C0200. Repetition of Three Words

Enter Code Enter Code: 1 box

Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.” Number of words repeated after first attempt After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (orientation to year, month, and day)

Enter Code Enter Code: 1 box

Ask resident: "Please tell me what year it is right now." A. Able to report correct year Ask resident: "What month are we in right now?" B. Able to report correct month Ask resident: "What day of the week is today?" C. Able to report correct day of the week 0. Incorrect or no answer 1. Correct

C0400. Recall

Enter Code Enter Code: 1 box

Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word. A. Able to recall "sock" B. Able to recall "blue" C. Able to recall "bed" 0. No - could not recall 1. Yes, after cueing ("a piece of furniture") 2. Yes, no cue required

C0500. BIMS Summary Score

Enter Score Enter Score: 2 boxes

Add scores for questions C0200-C0400 and fill in total score (00-15) Enter 99 if the resident was unable to complete the interview

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section CCognitive Patterns

C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?

Enter Code Enter Code: 1 box

0.No (resident was able to complete Brief Interview for Mental Status) ➞then: Skip to C1310, Signs and Symptoms of Delirium 1. Yes (resident was unable to complete Brief Interview for Mental Status) ➞then: Continue to C0700, Short-term Memory OK

Staff Assessment for Mental Status

Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed

C0700. Short-term Memory OK

Enter Code Enter Code: 1 box

Seems or appears to recall after 5 minutes 0. Memory OK 1. Memory problem

C0800. Long-term Memory OK

Enter Code Enter Code: 1 box

Seems or appears to recall long past 0. Memory OK 1. Memory problem

C0900. Memory/Recall Ability

↓ Check all that the resident was normally able to recall

checkbox	A. Current season
checkbox	B. Location of own room
checkbox	C. Staff names and faces
checkbox	D. That he or she is in a nursing home/hospital swing bed
checkbox	Z. None of the above were recalled

C1000. Cognitive Skills for Daily Decision Making

Enter Code Enter Code: 1 box

Made decisions regarding tasks of daily life 0. Independent - decisions consistent/reasonable 1. Modified independence - some difficulty in new situations only 2. Moderately impaired - decisions poor; cues/supervision required 3. Severely impaired - never/rarely made decisions

Delirium

C1310. Signs and Symptoms of Delirium (from CAM©)

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record

A. Acute Onset Mental Status Change

Enter Code Enter Code: 1 box

Is there evidence of an acute change in mental status from the resident's baseline? Coding: 1.Behavior continuously present, does not fluctuate 2.Behavior present, fluctuates (comes and goes, changes in severity)

↓ Enter Codes in Boxes

Enter code: 1 box

B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

Enter code: 1 box

C. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

Enter code: 1 box

D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria?

• Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section DMood

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents

Enter Code Enter Code: 1 box

0.No (resident is rarely/never understood) ➞then: Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV) 1. Yes ➞then: Continue to D0200, Resident Mood Interview (PHQ-9©)

D0200. Resident Mood Interview (PHQ-9©)

Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.

1. Symptom Presence 0.No (enter 0 in column 2) 1.Yes (enter 0-3 in column 2) 9.No response (leave column 2 blank) 2. Symptom Frequency 0.Never or 1 day 1.2-6 days (several days) 2.7-11 days (half or more of the days) 3.12-14 days (nearly every day)

D0200 Resident Mood Interview (PHQ-9): enter scores in boxes Symptom 1. Symptom Presence 2. Symptom Frequency A. Little interest or pleasure in doing things code entry: 1 box code entry: 1 box B. Feeling down, depressed, or hopeless code entry: 1 box code entry: 1 box C. Trouble falling or staying asleep, or sleeping too much code entry: 1 box code entry: 1 box D. Feeling tired or having little energy code entry: 1 box code entry: 1 box E. Poor appetite or overeating code entry: 1 box code entry: 1 box F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down code entry: 1 box code entry: 1 box G. Trouble concentrating on things, such as reading the newspaper or watching television code entry: 1 box code entry: 1 box H. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual code entry: 1 box code entry: 1 box I. Thoughts that you would be better off dead, or of hurting yourself in some way code entry: 1 box code entry: 1 box

D0300. Total Severity Score

Enter Score Enter Score: 2 boxes

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section DMood

D0500. Staff Assessment of Resident Mood (PHQ-9-OV*)

Do not conduct if Resident Mood Interview (D0200-D0300) was completed

Over the last 2 weeks, did the resident have any of the following problems or behaviors?

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.

1. Symptom Presence 0.No (enter 0 in column 2) 1.Yes (enter 0-3 in column 2) 2. Symptom Frequency 0.Never or 1 day 1.2-6 days (several days) 2.7-11 days (half or more of the days) 3.12-14 days (nearly every day)

D0500 Staff Assessment of Resident Mood (PHQ-9-OV): enter scores in boxes Symptom 1. Symptom Presence 2. Symptom Frequency A. Little interest or pleasure in doing things code entry: 1 box code entry: 1 box B. Feeling or appearing down, depressed, or hopeless code entry: 1 box code entry: 1 box C. Trouble falling or staying asleep, or sleeping too much code entry: 1 box code entry: 1 box D. Feeling tired or having little energy code entry: 1 box code entry: 1 box E. Poor appetite or overeating code entry: 1 box code entry: 1 box F. Indicating that s/he feels bad about self, is a failure, or has let self or family down code entry: 1 box code entry: 1 box G. Trouble concentrating on things, such as reading the newspaper or watching television code entry: 1 box code entry: 1 box H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that s/he has been moving around a lot more than usual code entry: 1 box code entry: 1 box I. States that life isn't worth living, wishes for death, or attempts to harm self code entry: 1 box code entry: 1 box J. Being short-tempered, easily annoyed code entry: 1 box code entry: 1 box

D0600. Total Severity Score

Enter Score Enter Score: 2 boxes

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.

* Copyright © Pfizer Inc. All rights reserved.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section EBehavior

E0100. Potential Indicators of Psychosis

↓ Check all that apply

checkbox	A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli)
checkbox	B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality)
checkbox	Z. None of the above

Behavioral Symptoms

E0200. Behavioral Symptom - Presence & Frequency

Note presence of symptoms and their frequency

Coding: 0.Behavior not exhibited 1.Behavior of this type occurred 1 to 3 days 2.Behavior of this type occurred 4 to 6 days, but less than daily 3.Behavior of this type occurred daily ↓ Enter Codes in Boxes Enter code: 1 box A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) Enter code: 1 box B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) Enter code: 1 box C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)

E0300. Overall Presence of Behavioral Symptoms

Enter Code Enter Code: 1 box

Were any behavioral symptoms in questions E0200 coded 1, 2, or 3? 0. No ➞then: Skip to E0800, Rejection of Care 1. Yes ➞then: Considering all of E0200, Behavioral Symptoms, answer E0500 and E0600 below

E0500. Impact on Resident

Enter Code Enter Code: 1 box

Did any of the identified symptom(s): A. Put the resident at significant risk for physical illness or injury? B. Significantly interfere with the resident's care? C. Significantly interfere with the resident's participation in activities or social interactions? 0. No 1. Yes

E0600. Impact on Others

Enter Code Enter Code: 1 box

Did any of the identified symptom(s): A. Put others at significant risk for physical injury? B. Significantly intrude on the privacy or activity of others? C. Significantly disrupt care or living environment? 0. No 1. Yes

E0800. Rejection of Care - Presence & Frequency

Enter Code Enter Code: 1 box

Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals. MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 11 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section EBehavior

E0900. Wandering - Presence & Frequency

Enter Code Enter Code: 1 box

Has the resident wandered? 0. Behavior not exhibited ➞then: Skip to E1100, Change in Behavior or Other Symptoms 1. Behavior of this type occurred 1 to 3 days 2. Behavior of this type occurred 4 to 6 days, but less than daily 3. Behavior of this type occurred daily

E1000. Wandering - Impact

Enter Code Enter Code: 1 box

A. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? B. Does the wandering significantly intrude on the privacy or activities of others? 0. No 1. Yes

E1100. Change in Behavior or Other Symptoms

Consider all of the symptoms assessed in items E0100 through E1000

Enter Code Enter Code: 1 box

How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or Scheduled PPS)? MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 12 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section FPreferences for Customary Routine and Activities

F0300. Should Interview for Daily and Activity Preferences be Conducted? - Attempt to interview all residents able to communicate.

If resident is unable to complete, attempt to complete interview with family member or significant other

Enter Code Enter Code: 1 box

0.No (resident is rarely/never understood and family/significant other not available) ➞then: Skip to and complete F0800, Staff Assessment of Daily and Activity Preferences 1. Yes ➞then: Continue to F0400, Interview for Daily Preferences

F0400. Interview for Daily Preferences

Show resident the response options and say: "While you are in this facility..."

Coding: 1.Very important 2.Somewhat important 3.Not very important 4.Not important at all 5.Important, but can't do or no choice 9.No response or non-responsive ↓ Enter Codes in Boxes Enter code: 1 box A. how important is it to you to choose what clothes to wear? Enter code: 1 box B. how important is it to you to take care of your personal belongings or things? Enter code: 1 box C. how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Enter code: 1 box D. how important is it to you to have snacks available between meals? Enter code: 1 box E. how important is it to you to choose your own bedtime? Enter code: 1 box F. how important is it to you to have your family or a close friend involved in discussions about your care? Enter code: 1 box G. how important is it to you to be able to use the phone in private? Enter code: 1 box H. how important is it to you to have a place to lock your things to keep them safe?

F0500. Interview for Activity Preferences

Show resident the response options and say: "While you are in this facility..."

Coding: 1.Very important 2.Somewhat important 3.Not very important 4.Not important at all 5.Important, but can't do or no choice 9.No response or non-responsive ↓ Enter Codes in Boxes Enter code: 1 box A. how important is it to you to have books, newspapers, and magazines to read? Enter code: 1 box B. how important is it to you to listen to music you like? Enter code: 1 box C. how important is it to you to be around animals such as pets? Enter code: 1 box D. how important is it to you to keep up with the news? Enter code: 1 box E. how important is it to you to do things with groups of people? Enter code: 1 box F. how important is it to you to do your favorite activities? Enter code: 1 box G. how important is it to you to go outside to get fresh air when the weather is good? Enter code: 1 box H. how important is it to you to participate in religious services or practices?

F0600. Daily and Activity Preferences Primary Respondent

Enter Code Enter Code: 1 box

Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500) MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 13 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section FPreferences for Customary Routine and Activities

F0700. Should the Staff Assessment of Daily and Activity Preferences be Conducted?

Enter Code Enter Code: 1 box

0.No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant other) ➞then: Skip to and complete G0110, Activities of Daily Living (ADL) Assistance 1. Yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other) ➞then: Continue to F0800, Staff Assessment of Daily and Activity Preferences

F0800. Staff Assessment of Daily and Activity Preferences

Do not conduct if Interview for Daily and Activity Preferences (F0400-F0500) was completed

Resident Prefers:

↓ Check all that apply

checkbox	A. Choosing clothes to wear
checkbox	B. Caring for personal belongings
checkbox	C. Receiving tub bath
checkbox	D. Receiving shower
checkbox	E. Receiving bed bath
checkbox	F. Receiving sponge bath
checkbox	G. Snacks between meals
checkbox	H. Staying up past 8:00 p.m.
checkbox	I. Family or significant other involvement in care discussions
checkbox	J. Use of phone in private
checkbox	K. Place to lock personal belongings
checkbox	L. Reading books, newspapers, or magazines
checkbox	M. Listening to music
checkbox	N. Being around animals such as pets
checkbox	O. Keeping up with the news
checkbox	P. Doing things with groups of people
checkbox	Q. Participating in favorite activities
checkbox	R. Spending time away from the nursing home
checkbox	S. Spending time outdoors
checkbox	T. Participating in religious activities or practices
checkbox	Z. None of the above

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GFunctional Status

G0110. Activities of Daily Living (ADL) Assistance

Refer to the ADL flow chart in the RAI manual to facilitate accurate coding

Instructions for Rule of 3 If none of the above are met, code supervision.

Code for resident's performance over all shifts - not including setup. If the ADL activity occurred 3 or more times at various levels of assistance, code the most dependent - except for total dependence, which requires full staff performance every time Coding: Activity Occurred 3 or More Times 0.Independent - no help or staff oversight at any time 1.Supervision - oversight, encouragement or cueing 2.Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance 3.Extensive assistance - resident involved in activity, staff provide weight-bearing support 4.Total dependence - full staff performance every time during entire 7-day period Activity Occurred 2 or Fewer Times 7.Activity occurred only once or twice - activity did occur but only once or twice 8.Activity did not occur - activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period 2. ADL Support Provided Code for most support provided over all shifts; code regardless of resident's self-performance classification Coding: 0.No setup or physical help from staff 1.Setup help only 2.One person physical assist 3.Two+ persons physical assist 8.ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period

G0110 Activities of Daily Living (ADL) Assistance: enter codes in boxes Activity 1. Self-Performance 2. Support A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture code entry: 1 box code entry: 1 box B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) code entry: 1 box code entry: 1 box C. Walk in room - how resident walks between locations in his/her room code entry: 1 box code entry: 1 box D. Walk in corridor - how resident walks in corridor on unit code entry: 1 box code entry: 1 box E. Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair code entry: 1 box code entry: 1 box F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities or treatments). If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair code entry: 1 box code entry: 1 box G. Dressing - how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses code entry: 1 box code entry: 1 box H. Eating - how 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, IV fluids administered for nutrition or hydration) code entry: 1 box code entry: 1 box I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag code entry: 1 box code entry: 1 box J. Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) code entry: 1 box code entry: 1 box

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GFunctional Status

G0120. Bathing

How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most dependent in self-performance and support

Enter Code Enter Code: 1 box

A. Self-performance B. Support provided

G0300. Balance During Transitions and Walking

After observing the resident, code the following walking and transition items for most dependent

Coding: 0.Steady at all times 1.Not steady, but able to stabilize without staff assistance 2.Not steady, only able to stabilize with staff assistance 8.Activity did not occur ↓ Enter Codes in Boxes Enter code: 1 box A. Moving from seated to standing position Enter code: 1 box B. Walking (with assistive device if used) Enter code: 1 box C. Turning around and facing the opposite direction while walking Enter code: 1 box D. Moving on and off toilet Enter code: 1 box E. Surface-to-surface transfer (transfer between bed and chair or wheelchair)

G0400. Functional Limitation in Range of Motion

Code for limitation that interfered with daily functions or placed resident at risk of injury

Coding: 0.No impairment 1.Impairment on one side 2.Impairment on both sides ↓ Enter Codes in Boxes Enter code: 1 box A. Upper extremity (shoulder, elbow, wrist, hand) Enter code: 1 box B. Lower extremity (hip, knee, ankle, foot)

G0600. Mobility Devices

↓ Check all that were normally used

checkbox	A. Cane/crutch
checkbox	B. Walker
checkbox	C. Wheelchair (manual or electric)
checkbox	D. Limb prosthesis
checkbox	Z. None of the above were used

G0900. Functional Rehabilitation Potential

Complete only if A0310A = 01

Enter Code Enter Code: 1 box

A. Resident believes he or she is capable of increased independence in at least some ADLs B. Direct care staff believe resident is capable of increased independence in at least some ADLs MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 16 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Admission (Start of SNF PPS Stay)

GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current illness, exacerbation, or injury

Complete only if A0310B = 01

Coding: 3.Independent - Resident completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 2.Needed Some Help - Resident needed partial assistance from another person to complete activities. 1.Dependent - A helper completed the activities for the resident. 8.Unknown. 9.Not Applicable. ↓ Enter Codes in Boxes Enter code: 1 box A. Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury. Enter code: 1 box B. Indoor Mobility (Ambulation): Code the resident's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. Enter code: 1 box C. Stairs: Code the resident's need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. Enter code: 1 box D. Functional Cognition: Code the resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury

Complete only if A0310B = 01

↓ Check all that apply

checkbox	A. Manual wheelchair
checkbox	B. Motorized wheelchair and/or scooter
checkbox	C. Mechanical lift
checkbox	D. Walker
checkbox	E. Orthotics/Prosthetics
checkbox	Z. None of the above

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Admission (Start of SNF PPS Stay)

GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B)

Complete only if A0310B = 01

Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).

Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06.Independent - Resident completes the activity by him/herself with no assistance from a helper. 05.Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03.Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07.Resident refused 09.Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10.Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88.Not attempted due to medical condition or safety concerns

GG0130 Self-Care, admission: enter codes in boxes 1. Admission Performance 2. Discharge Goal Activity code entry: 2 boxes code entry: 2 boxes A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. code entry: 2 boxes code entry: 2 boxes B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. code entry: 2 boxes code entry: 2 boxes C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. code entry: 2 boxes code entry: 2 boxes E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. code entry: 2 boxes code entry: 2 boxes F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. code entry: 2 boxes code entry: 2 boxes G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. code entry: 2 boxes code entry: 2 boxes H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Admission (Start of SNF PPS Stay)

GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B)

Complete only if A0310B = 01

Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).

Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06.Independent - Resident completes the activity by him/herself with no assistance from a helper. 05.Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03.Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07.Resident refused 09.Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10.Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88.Not attempted due to medical condition or safety concerns

GG0170 Mobility, admission (A to K): enter codes in boxes 1. Admission Performance 2. Discharge Goal Activity code entry: 2 boxes code entry: 2 boxes A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. code entry: 2 boxes code entry: 2 boxes B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. code entry: 2 boxes code entry: 2 boxes C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. code entry: 2 boxes code entry: 2 boxes D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. code entry: 2 boxes code entry: 2 boxes E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). code entry: 2 boxes code entry: 2 boxes F. Toilet transfer: The ability to get on and off a toilet or commode. code entry: 2 boxes code entry: 2 boxes G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. code entry: 2 boxes code entry: 2 boxes I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If admission performance is coded 07, 09, 10, or 88 ➞then: Skip to GG0170M, 1 step (curb) code entry: 2 boxes code entry: 2 boxes J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. code entry: 2 boxes code entry: 2 boxes K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Admission (Start of SNF PPS Stay)

GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) - Continued

Complete only if A0310B = 01

Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).

Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06.Independent - Resident completes the activity by him/herself with no assistance from a helper. 05.Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03.Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07.Resident refused 09.Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10.Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88.Not attempted due to medical condition or safety concerns

GG0170 Mobility, admission (L to SS1): enter codes in boxes 1. Admission Performance 2. Discharge Goal Activity code entry: 2 boxes code entry: 2 boxes L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. code entry: 2 boxes code entry: 2 boxes M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. If admission performance is coded 07, 09, 10, or 88 ➞then: Skip to GG0170P, Picking up object code entry: 2 boxes code entry: 2 boxes N. 4 steps: The ability to go up and down four steps with or without a rail. If admission performance is coded 07, 09, 10, or 88 ➞then: Skip to GG0170P, Picking up object code entry: 2 boxes code entry: 2 boxes O. 12 steps: The ability to go up and down 12 steps with or without a rail. code entry: 2 boxes code entry: 2 boxes P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. code entry: 1 box Q1. Does the resident use a wheelchair and/or scooter? 0. No ➞then: Skip to GG0130, Self Care (Discharge) 1. Yes ➞then: Continue to GG0170R, Wheel 50 feet with two turns code entry: 2 boxes code entry: 2 boxes R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. code entry: 1 box RR1. Indicate the type of wheelchair or scooter used. 1. Manual 2. Motorized code entry: 2 boxes code entry: 2 boxes S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. code entry: 1 box SS1. Indicate the type of wheelchair or scooter used. 1. Manual 2. Motorized

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Discharge (End of SNF PPS Stay)

GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C)

Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03

Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason.

Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06.Independent - Resident completes the activity by him/herself with no assistance from a helper. 05.Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03.Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07.Resident refused 09.Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10.Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88.Not attempted due to medical condition or safety concerns

GG0130 Self-Care, discharge: enter codes in boxes 3. Discharge Performance Activity code entry: 2 boxes A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. code entry: 2 boxes B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. code entry: 2 boxes C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. code entry: 2 boxes E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. code entry: 2 boxes F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. code entry: 2 boxes G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. code entry: 2 boxes H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Discharge (End of SNF PPS Stay)

GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C)

Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03

Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason.

Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06.Independent - Resident completes the activity by him/herself with no assistance from a helper. 05.Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03.Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07.Resident refused 09.Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10.Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88.Not attempted due to medical condition or safety concerns

GG0170 Mobility, discharge (A to K): enter codes in boxes 3. Discharge Performance Activity code entry: 2 boxes A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. code entry: 2 boxes B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. code entry: 2 boxes C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. code entry: 2 boxes D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. code entry: 2 boxes E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). code entry: 2 boxes F. Toilet transfer: The ability to get on and off a toilet or commode. code entry: 2 boxes G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. code entry: 2 boxes I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If discharge performance is coded 07, 09, 10, or 88 ➞then: Skip to GG0170M, 1 step (curb) code entry: 2 boxes J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. code entry: 2 boxes K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section GGFunctional Abilities and Goals - Discharge (End of SNF PPS Stay)

GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued

Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03

Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason.

Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06.Independent - Resident completes the activity by him/herself with no assistance from a helper. 05.Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03.Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07.Resident refused 09.Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10.Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88.Not attempted due to medical condition or safety concerns

GG0170 Mobility, discharge (L to SS3): enter codes in boxes 3. Discharge Performance Activity code entry: 2 boxes L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. code entry: 2 boxes M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. If discharge performance is coded 07, 09, 10, or 88 ➞then: Skip to GG0170P, Picking up object code entry: 2 boxes N. 4 steps: The ability to go up and down four steps with or without a rail. If discharge performance is coded 07, 09, 10, or 88 ➞then: Skip to GG0170P, Picking up object code entry: 2 boxes O. 12 steps: The ability to go up and down 12 steps with or without a rail. code entry: 2 boxes P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. code entry: 1 box Q3. Does the resident use a wheelchair and/or scooter? 0. No ➞then: Skip to H0100, Appliances 1. Yes ➞then: Continue to GG0170R, Wheel 50 feet with two turns code entry: 2 boxes R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. code entry: 1 box RR3. Indicate the type of wheelchair or scooter used. 1. Manual 2. Motorized code entry: 2 boxes S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. code entry: 1 box SS3. Indicate the type of wheelchair or scooter used. 1. Manual 2. Motorized

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section HBladder and Bowel

H0100. Appliances

↓ Check all that apply

checkbox	A. Indwelling catheter (including suprapubic catheter and nephrostomy tube)
checkbox	B. External catheter
checkbox	C. Ostomy (including urostomy, ileostomy, and colostomy)
checkbox	D. Intermittent catheterization
checkbox	Z. None of the above

H0200. Urinary Toileting Program

Enter Code Enter Code: 1 box

A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? B. Response - What was the resident's response to the trial program? C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence? 0. No 1. Yes

H0300. Urinary Continence

Enter Code Enter Code: 1 box

Urinary continence - Select the one category that best describes the resident 0. Always continent 1. Occasionally incontinent (less than 7 episodes of incontinence) 2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) 3. Always incontinent (no episodes of continent voiding) 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days

H0400. Bowel Continence

Enter Code Enter Code: 1 box

Bowel continence - Select the one category that best describes the resident 0. Always continent 1. Occasionally incontinent (one episode of bowel incontinence) 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) 3. Always incontinent (no episodes of continent bowel movements) 9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days

H0500. Bowel Toileting Program

Enter Code Enter Code: 1 box

Is a toileting program currently being used to manage the resident's bowel continence? 0. No 1. Yes

H0600. Bowel Patterns

Enter Code Enter Code: 1 box

Constipation present? MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.1 Effective 10/01/2019Page 24 of 51

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section IActive Diagnoses

I0020. Indicate the resident’s primary medical condition category

Complete only if A0310B = 01 or 08

Enter Code Enter Code: 2 boxes

Indicate the resident's primary medical condition category that best describes the primary reason for admission I0020B. ICD Code8-character field

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section IActive Diagnoses

Active Diagnoses in the last 7 days - Check all that apply

Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists

	Cancer
checkbox	I0100. Cancer (with or without metastasis)
	Heart/Circulation
checkbox	I0200. Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell)
checkbox	I0300. Atrial Fibrillation or Other Dysrhythmias (e.g., bradycardias and tachycardias)
checkbox	I0400. Coronary Artery Disease (CAD) (e.g., angina, myocardial infarction, and atherosclerotic heart disease (ASHD))
checkbox	I0500. Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), or Pulmonary Thrombo-Embolism (PTE)
checkbox	I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema)
checkbox	I0700. Hypertension
checkbox	I0800. Orthostatic Hypotension
checkbox	I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
	Gastrointestinal
checkbox	I1100. Cirrhosis
checkbox	I1200. Gastroesophageal Reflux Disease (GERD) or Ulcer (e.g., esophageal, gastric, and peptic ulcers)
checkbox	I1300. Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease
	Genitourinary
checkbox	I1400. Benign Prostatic Hyperplasia (BPH)
checkbox	I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD)
checkbox	I1550. Neurogenic Bladder
checkbox	I1650. Obstructive Uropathy
	Infections
checkbox	I1700. Multidrug-Resistant Organism (MDRO)
checkbox	I2000. Pneumonia
checkbox	I2100. Septicemia
checkbox	I2200. Tuberculosis
checkbox	I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS)
checkbox	I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E)
checkbox	I2500. Wound Infection (other than foot)
	Metabolic
checkbox	I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
checkbox	I3100. Hyponatremia
checkbox	I3200. Hyperkalemia
checkbox	I3300. Hyperlipidemia (e.g., hypercholesterolemia)
checkbox	I3400. Thyroid Disorder (e.g., hypothyroidism, hyperthyroidism, and Hashimoto's thyroiditis)
	Musculoskeletal
checkbox	I3700. Arthritis (e.g., degenerative joint disease (DJD), osteoarthritis, and rheumatoid arthritis (RA))
checkbox	I3800. Osteoporosis
checkbox	I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and fractures of the trochanter and femoral neck)
checkbox	I4000. Other Fracture
	Neurological
checkbox	I4200. Alzheimer's Disease
checkbox	I4300. Aphasia
checkbox	I4400. Cerebral Palsy
checkbox	I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke
checkbox	I4800. Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases)

Neurological Diagnoses continued on next page

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section IActive Diagnoses

Active Diagnoses in the last 7 days - Check all that apply

Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists

	Neurological - Continued
checkbox	I4900. Hemiplegia or Hemiparesis
checkbox	I5000. Paraplegia
checkbox	I5100. Quadriplegia
checkbox	I5200. Multiple Sclerosis (MS)
checkbox	I5250. Huntington's Disease
checkbox	I5300. Parkinson's Disease
checkbox	I5350. Tourette's Syndrome
checkbox	I5400. Seizure Disorder or Epilepsy
checkbox	I5500. Traumatic Brain Injury (TBI)
	Nutritional
checkbox	I5600. Malnutrition (protein or calorie) or at risk for malnutrition
	Psychiatric/Mood Disorder
checkbox	I5700. Anxiety Disorder
checkbox	I5800. Depression (other than bipolar)
checkbox	I5900. Bipolar Disorder
checkbox	I5950. Psychotic Disorder (other than schizophrenia)
checkbox	I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders)
checkbox	I6100. Post Traumatic Stress Disorder (PTSD)
	Pulmonary
checkbox	I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis)
checkbox	I6300. Respiratory Failure
	Vision
checkbox	I6500. Cataracts, Glaucoma, or Macular Degeneration
	None of Above
checkbox	I7900. None of the above active diagnoses within the last 7 days
	Other
	I8000. Additional active diagnoses Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box. A.diagnosis A: write-in line,ICD code: 8-character field B.diagnosis B: write-in line,ICD code: 8-character field C.diagnosis C: write-in line,ICD code: 8-character field D.diagnosis D: write-in line,ICD code: 8-character field E.diagnosis E: write-in line,ICD code: 8-character field F.diagnosis F: write-in line,ICD code: 8-character field G.diagnosis G: write-in line,ICD code: 8-character field H.diagnosis H: write-in line,ICD code: 8-character field I.diagnosis I: write-in line,ICD code: 8-character field J.diagnosis J: write-in line,ICD code: 8-character field

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Resident (blank for resident)Identifier (blank for identifier)Date (blank for date)

Section JHealth Conditions

J0100. Pain Management - Complete for all residents, regardless of current pain level

At any time in the last 5 days, has the resident:

Enter Code Enter Code: 1 box

A. Received scheduled pain medication regimen? B. Received PRN pain medications OR was offered and declined? C. Received non-medication intervention for pain? 0. No 1. Yes

J0200. Should Pain Assessment Interview be Conducted?

Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea)

Enter Code Enter Code: 1 box

0.No (resident is rarely/never understood) ➞then: Skip to and complete J0800, Indicators of Pain or Possible Pain 1. Yes ➞then: Continue to J0300, Pain Presence

Pain Assessment Interview

J0300. Pain Presence

Enter Code Enter Code: 1 box

Ask resident: "Have you had pain or hurting at any time in the last 5 days?" 0.No ➞then: Skip to J1100, Shortness of Breath 1. Yes ➞then: Continue to J0400, Pain Frequency 9. Unable to answer ➞then: Skip to J0800, Indicators of Pain or Possible Pain

J0400. Pain Frequency

Enter Code Enter Code: 1 box

Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?" 1.Almost constantly 2. Frequently 3. Occasionally 4. Rarely 9. Unable to answer

J0500. Pain Effect on Function

Enter Code Enter Code: 1 box

A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?" B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?" 0. No 1. Yes 9. Unable to answer

J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B)

Enter Rating Enter Rating: 2 boxes	A. Numeric Rating Scale (00-10) Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00 -10 pain scale) Enter two-digit response. Enter 99 if unable to answer.
Enter Code Enter Code: 1 box	B. Verbal Descriptor Scale Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale) 1. Mild 2. Moderate 3. Severe 4. Very severe, horrible 9. Unable to answer

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