to consolidate shared guidance from the respective GG0130 and GG0170 individual item subsections. Guidance that applies to both items has been merged and moved to this new subsection; moves are not annotated as a change. Only additions to the guidance are annotated as a change within subsection GG0130: Self-Care and GG0170: Mobility. GG0130 and GG0170

2. For the purposes of completing Section GGitems GG0130 and GG0170, a “helper” is defined as facility

staff who are direct employees and facility-contracted employees (e.g., rehabilitation staff, nursing agency staff). Thus, “helper” does not include individuals hired, compensated or not, by individuals outside of the facility’s management and administration such as hospice staff, nursing/certified nursing assistant students, etc. Therefore, when helper assistance is required because a resident’s performance is unsafe or of poor quality, consider only facility staff when scoring according to the amount of assistance provided. GG0130 and GG0170

Coding Tips

Assessment of the GG self-care and mobility items is based on the resident’s ability to complete the activity with or without assistance and/or a device. This is true regardless of whether or not the activity is being/will be routinely performed (e.g., walking might be assessed for a resident who did/does/will use a wheelchair as their primary mode of mobility, stair activities might be assessed for a resident not routinely accessing stairs).

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Performance Coding Tips General coding tips The assessment timeframe is up to 3 calendar days based on the target date. During the assessment timeframe, some activities may be performed by the resident multiple times, whereas other activities may only occur once. A dash (–) indicates “No information.” CMS expects dash use to be a rare occurrence. CMS does not provide an exhaustive list of assistive devices that may be used when coding self-care and mobility performance. Clinical assessments may include any device or equipment that the resident can use to allow them to safely complete the activity as independently as possible. o Do not code self-care and mobility activities with use of a device that is restricted to resident use during therapy sessions (e.g., parallel bars, exoskeleton, or overhead track and harness systems). GG0130 and GG0170

Coding tips for coding the resident’s usual performance If two or more helpers are required to assist the resident in completing the activity, code as 01, Dependent.

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Examples and Coding Tips

Note: The following are coding examples and coding tips for self-care items. Some examples describe a single observation of the resident completing the activity; other examples describe a summary of several observations of the resident completing an activity across different times of the day and different days.

Coding Tips for GG0130A, Eating

The intent of GG0130A, Eating is to assess the resident’s 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. The adequacy of the resident’s nutrition or hydration is not considered for GG0130A, Eating. GG0130

Examples for Coding Performance

Note: The following are coding examples for each Self-Care item. Some examples describe a single observation of the person completing the activity; other examples describe a summary of several observations of the resident completing an activity across different times of the day and different days.

Examples for GG0130A, Eating

1. Eating: Resident S has multiple sclerosis, affecting their

endurance and strength. Resident S prefers to feed themself as much as they are capable. During all meals, after eating three-fourths of the meal by themself, Resident S usually becomes extremely fatigued and requests assistance from the certified nursing assistant to feed them the remainder of the meal.

Coding: GG0130A would be coded 03,

Partial/moderate assistance.

Rationale: The certified nursing assistant provides

less than half the effort for the resident to complete the activity of eating for all meals.

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For residents with a single lower extremity amputation with or without use of a prosthesis, the activity of putting on/taking off footwear could apply to the intact limb or both the limb with the prosthesis and the intact limb. o If the resident performed the activity of putting on/taking off footwear for the intact limb only, then code based upon the amount of assistance needed to complete the activity. o If the resident performed the activity of putting on/taking off footwear for both the intact limb and the prosthetic limb, then code based upon the amount of assistance needed to complete the activity. Consider an item that covers all or part of the foot as footwear, even if it extends up the leg, and do not also consider it as a lower-body dressing item. If the resident wears just shoes or just socks (e.g., grip socks) that are safe for mobility, then GG0130H, Putting on/taking off footwear, may be coded. GG0170

Coding Tips for GG0170A, Roll left and right; GG0170B Sit to lying; and GG0170C, Lying to sitting on side of bed For GG0170A, Roll left and right; GG0170B, Sit to lying; and GG0170C, Lying to sitting on side of bed, clinical judgment should be used to determine what is considered a “lying” position for the resident. For example, a clinician could determine that a resident’s preferred slightly elevated resting position is “lying” for a resident. If the resident does not sleep in a bed, clinicians should assess bed mobility activities using the alternative furniture on which the resident sleeps (for example, a recliner). GG0170

Coding Tip for GG0170A, Roll left and right

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Coding Tips for GG0170C, Lying to sitting on side of bed The activity includes resident transitions from lying on their back to sitting on the side of the bed without back support. The resident’s ability to perform each of the tasks within this activity and how much support the residents require to complete the tasks within this activity is assessed. For item GG0170C, Lying to sitting on side of bed, clinical judgment should be used to determine what is considered a “lying” position for a particular resident. Back support refers to an object or person providing support for the resident’s back. If the qualified clinician determines that bed mobility cannot be assessed because of the degree to which the head of the bed must be elevated because of a medical condition, then code the activities GG0170A, Roll left and right, GG0170B, Sit to lying, and GG0170C, Lying to sitting on side of bed, as 88, Not attempted due to medical condition or safety concern. GG0170

Coding Tips for GG0170E, Chair/bed-to-chair transfer Depending on the resident’s abilities, the transfer may be a stand-pivot, squat-pivot, or a slide board transfer. For item GG0170E, Chair/bed-to-chair transfer: o If the resident uses a recliner as their “bed” (preferred or necessary sleeping surface), assess the resident’s need for assistance using that sleeping surface when coding GG0170E, Chair/bed-to-chair transfer. GG0170

Coding Tips for GG0170G, Car transfer

Any vehicle model appropriate and available may be used for the assessment of GG0170G, Car transfer.

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In the event of inclement weather or if an indoor car simulator or outdoor car is not available during the entire assessment period, then use code 10, Not attempted due to environmental limitations. If at the time of the assessment the resident is unable to attempt car transfers, and could not perform the car transfers prior to the current illness, exacerbation or injury, code 09, Not applicable. Clinicians may use clinical judgment to determine if observing a resident performing a portion of the car transfer activity (e.g., getting into the car) allows the clinician to adequately assess the resident’s ability to complete the entire GG0170G, Car transfer, activity (transferring in and out of a car). If the clinician determines that this observation is adequate, code based on the type and amount of assistance required to complete the activity. GG0170

Walking activities do not need to occur during one session. Allowing a resident to rest between activities or completing activities at different times during the day or on different days may facilitate completion of the activities. When coding GG0170 walking items, do not consider the resident’s mobility performance when using parallel bars. Parallel bars are not a portable assistive device. If safe, assess and code walking using a portable walking device. Do not code walking activities with the use of a device that is restricted to resident use during therapy sessions (e.g., parallel bars, exoskeleton, or overhead track and harness systems). If the resident who participates in walking requires the assistance of two helpers to complete the activity, code 01, Dependent. If the only help a resident requires to complete the walking activity is for a helper to retrieve and place the walker and/or put it away after resident use, then enter code 05, Setup or clean-up assistance.

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While a resident may take a break between ascending or descending the 4 steps or 12 steps, once they start the activity, they must be able to ascend (or descend) all the steps, by any safe means, without taking more than a brief rest break to consider the stair activity completed. Getting to/from the stairs is not included when coding the curb/step activities. Do not consider the sit-to-stand or stand-to-sit transfer when coding any of the step activities.

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Examples for GG0170S, Wheel 150 feet and GG0170SS, Indicate the type of wheelchair/scooter used 1. Wheel 150 feet: Resident G always uses a motorized scooter to mobilize themself down the hallway and the certified nursing assistant provides cues due to safety issues (to avoid running into the walls).

Coding: GG0170S would be coded 04, Supervision

or touching assistance.

Rationale: The helper provides verbal cues to complete the activity.

2. Indicate the type of wheelchair/scooter used: In the

example above, Resident G uses a motorized scooter.

Coding: GG0170SS would be coded 2, Motorized.

Rationale: Resident G used a motorized scooter during the assessment period.

1. Wheel 150 feet: Resident N uses a below-the-knee

prosthetic limb. Resident N has peripheral neuropathy and limited vision due to complications of diabetes. Resident N’s prior preference was to ambulate within the home and use a manual wheelchair when mobilizing themself within the community. Resident N is assessed for the activity of 150 feet wheelchair mobility. Resident N’s usual performance indicates a helper is needed to provide verbal cues for safety due to vision deficits.

Coding: GG0170S would be coded 04, Supervision

or touching assistance.

Rationale: Resident N requires the helper to provide

verbal cues for their safety when using a wheelchair for 150 feet.

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Include the primary medical condition coded in this item I0020B in Sectionitems I0100–I8000: Active Diagnoses in the lLast 7 dDays. — Code 01, Stroke, if the resident’s primary medical condition category is due to stroke. Examples include ischemic stroke, subarachnoid hemorrhage, cerebral vascular accident (CVA), and other cerebrovascular disease. — Code 02, Non-Traumatic Brain Dysfunction, if the resident’s primary medical condition category is non-traumatic brain dysfunction. Examples include Alzheimer’s disease, dementia with or without behavioral disturbance, malignant neoplasm of brain, and anoxic brain damage. I0100– I8000: Active Diagnoses in the Last 7 Days I-5–I-18 I0100–I8000: Active Diagnoses in the Last 7 Days I-7–I-18 Page length changed due to revised content. I0100– I8000: Active Diagnoses in the Last 7 Days

Coding Instructions

Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period (except Item I2300 UTI, which does not use the active diagnosis 7-day look-back. Please refer to Item I2300 UTI, Page I-134 for specific coding instructions).

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Page length changed due to revised content. J1700

Content included in the definition below has been reorganized and removals may instead be moved. Please refer to the Coding Tips section for item J1700: Fall History on Admission/Entry or Reentry for the guidance that was moved to that section.

DEFINITION

FALL Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if they had not caught themself or had not been intercepted by another person – this is still considered a fall.

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Section below is new for item J1700: Fall History on Admission/Entry or Reentry. Some guidance previously contained in the definition for the term “Falls” has been moved to this section; moves are not annotated as new guidance.

Coding Tips

The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. CMS understands that challenging a resident’s balance and training them to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls. However, if there is a loss of balance during supervised therapeutic interventions and the resident comes to rest on the ground, floor or next lower surface despite the clinician’s effort to intercept the loss of balance, it is considered a fall. CMS understands that challenging a resident’s balance and training them to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls. However, if there is a loss of balance during supervised therapeutic interventions and the resident comes to rest on the ground, floor or next lower surface despite the clinician’s effort to intercept the loss of balance, it is considered a fall.

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Replaced screenshot.

OLD NEW J1900

DEFINITIONS

INJURY RELATED TO A FALL Any documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall.

DEFINITIONS

INJURY (EXCEPT MAJOR) Includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. MAJOR INJURY Includes,but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries. Includes,but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries. closed Includes,but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries. with Includes,but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries. , Includes,but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries. and crush Includes,but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries.

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Coding Tips

If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to the Internet Quality Improvement and Evaluation System (iQIES), the assessment must be modified to update the level of injury that occurred with that fall. Fractures confirmed to be pathologic (vs. traumatic) are not considered a major injury resulting from a fall. J1900

6. The therapist had Resident S, who has Parkinson’s disease, stand on one foot during their therapy session to intentionally challenge the resident’s balance. Despite providing contact guard assistance and use of safety mats, Resident S fell and landed on their left side. An X-ray was ordered due to pain and swelling of the left wrist which confirmed a distal radius fracture of the left wrist. Coding: J1800 would be coded 1, yes and J1900C would be coded 1, one. Rationale: Despite safety precautions in place, Resident S sustained a radius fracture as a result of a fall during a therapeutic intervention with physical therapy. This is a fall, as the clinician’s interventions did not intercept the loss of balance, and the resident landed on the floor and sustained a fracture, which is a major injury.

The therapist had Resident S, who has Parkinson’s disease, stand on one foot during their therapy session to intentionally challenge the resident’s balance. Despite providing contact guard assistance and use of safety mats, Resident S fell and landed on their left side. An X-ray was ordered due to pain and swelling of the left wrist which confirmed a distal radius fracture of the left wrist. Coding: J1800 would be coded 1, yes and J1900C would be coded 1, one. Rationale: Despite safety precautions in place, Resident S sustained a radius fracture as a result of a fall during a therapeutic intervention with physical therapy. This is a fall, as the clinician’s interventions did not intercept the loss of balance, and the resident landed on the floor and sustained a fracture, which is a major injury.

Coding: J1800 would be coded 1, yes and J1900C

would be coded 1, one.

Rationale: Despite safety precautions in place, Resident S sustained a radius fracture as a result of a

fall during a therapeutic intervention with physical therapy. This is a fall, as the clinician’s interventions did not intercept the loss of balance, and the resident landed on the floor and sustained a fracture, which is a major injury.

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Differentiating from Traumatic vs. Pathological Fractures

7. Resident A, who has osteoporosis, falls, resulting in a right hip fracture. The Emergency Department physician confirms that the fracture is a result of the resident’s bone disease and not a result of the fall. Coding: J1800 would be coded 1, yes and J1900C would be coded 0, none. Rationale: The physician determined that the fracture was a pathological fracture due to osteoporosis. Because the fracture was determined to be pathological, it is not coded as a fall with major injury.

Resident A, who has osteoporosis, falls, resulting in a right hip fracture. The Emergency Department physician confirms that the fracture is a result of the resident’s bone disease and not a result of the fall. Coding: J1800 would be coded 1, yes and J1900C would be coded 0, none. Rationale: The physician determined that the fracture was a pathological fracture due to osteoporosis. Because the fracture was determined to be pathological, it is not coded as a fall with major injury.

Coding: J1800 would be coded 1, yes and J1900C

would be coded 0, none.

Rationale: The physician determined that the fracture was a pathological fracture due to osteoporosis. Because the fracture was determined to

be pathological, it is not coded as a fall with major injury.

8. Resident L, who has osteoporosis, falls, resulting in a right

hip fracture. The physician in the acute care hospital confirms that the fracture is a result of the resident’s fall and not the resident’s history of osteoporosis.

Coding: J1800 would be coded 1, yes and J1900C

would be coded 1, one.

Rationale: Because the physician determined that the fracture was a result of the fall, it is a traumatic

fracture and, therefore, is a fall with major injury.

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Intent: The items in this section are intended to assess the many conditions that could affect the resident’s ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. K0100

3. Review the medical record, including nursing, physician,

dieticiandietary, and speech language pathologist notes, and any available information on dental history or problems. Dental problems may include poor fitting dentures, dental caries, edentulous, mouth sores, tumors and/or pain with food consumption. K-4−

Page length changed due to revised content. K0300

Steps for Assessment

This item compares the resident’s weight in the current observation period with their weight at two snapshots in time: At a point closest to 30 days preceding the current weight. At a point closest to 180 days preceding the current weight. This item does not consider weight fluctuation outside of these two time points, althoughThe resident’s weight captured closest to these two time points are the only two weights considered for this item, but the resident’s weight should be monitored on a continual basis and weight loss assessed and addressed on the care plan as necessary. K0300

Weight Comparison Examples *Weight as determined in item K0200B. Based on an ARD of 10/15/25.

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Coding Tips

A resident may experience weight variances in between the snapshot time periods. Although these require follow up at the time, they are not captured on the MDS. In cases in which multiple weights for the resident may exist during the time period being evaluated, select the weight on the date closest to the appropriate time point. K0310

Steps for Assessment

This item compares the resident’s weight in the current observation period with their weight at two snapshots in time: At a point closest to 30 days preceding the current weight. At a point closest to 180 days preceding the current weight. This item does not consider weight fluctuation outside of these two time points, althoughThe resident’s weight captured closest to these two time points are the only two weights considered for this item, but the resident’s weight should be monitored on a continual basis and weight gain assessed and addressed on the care plan as necessary. K0310

Weight Comparison Examples *Weight as determined in item K0200B. Based on an ARD of 10/15/25.

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Coding Tips

A resident may experience weight variances in between the snapshot time periods. Although these require follow up at the time, they are not captured on the MDS. In cases in which multiple weights for the resident may exist during the time period being evaluated, select the weight on the date closest to the appropriate time point. K0710

Steps for Assessment

1. Review intake records within the last 7 days to determine

actual intake through parenteral or tube feeding routes.

2. Calculate proportion of total calories received through

these routes. If the resident took no food or fluids by mouth or took just sips of fluid, stop here and code 3, 51% or more. If the resident had more substantial oral intake than sips of fluid, consult with the dieticianqualified dietitian or other clinically qualified nutrition professional.

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Step 3: Determine “Present on Admission” For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement.

1. Review the medical record for the history of the

ulcer/injury.

2. Review for location and stage at the time of admission/entry or reentry.

3. If the pressure ulcer/injury was present on admission/entry

or reentry and subsequently increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as “present on admission.” 4. If a numerically stageable pressure ulcer/injury was present on admission/entry or reentry and becomes unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is coded at M0300F and should not be coded as “present on admission.” If (b egin inserted text) a numerically stageable (end inserted t ext) pressure ulcer/injury was present on admission/entry or reentry and becomes unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is coded at M0300F and should not be coded as “present on admission.”

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9. If a pressure ulcer was numerically staged, then became

unstageable, and is subsequently debrided sufficiently to be numerically staged, compare its numerical stage before and after it was unstageable. If the numerical stage has increased, code this pressure ulcer as not “ present on admission.”(end inserted text. If a pressure ulcer was numerically staged, then became unstageable, and is subsequently debrided sufficiently to be numerically staged, compare its numerical stage before and after it was unstageable. If the numerical stage has increased, code this pressure ulcer as not “ present on admission.”(end inserted text.

10. If a resident has a pressure ulcer/injury that was

documented on admission then closed that reopens at the same stage (i.e., not a higher stage), the ulcer/injury is coded as “present on admission.” 11. If two pressure ulcers merge, that were both “present on admission,” continue to code the merged pressure ulcer as “present on admission.” Although two merged pressure ulcers might increase the overall surface area of the ulcer, there needs to be an increase in numerical stage or a change to unstageable due to slough or eschar in order for it to be considered not “present on admission.”

12. If a pressure ulcer/injury was unstageable on admission/entry or reentry and then becomes unstageable

for another reason, it should be considered “present on admission” at the new unstageable status. For example, if a resident is admitted with a deep tissue injury, but later the injury opens, the wound bed is covered with slough, and the wound is still unstageable, this wound would still be considered “present on admission.” M0300C

DEFINITION

STAGE 3 PRESSURE ULCER Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M- 20 ). Full thickness tissue loss. Subcutaneous f at may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M- 20 ). Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M- 20 ). Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M- 20 ). 19 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M- 20 ).

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Steps for Assessment

1. Review the medical record for documentation of a

pressure ulcer/injury covered by a non- removable dressing/device.

2. Determine the number of documented pressure ulcers/injuries covered by a non-removable dressing/device. Examples of non-removable dressings/devices include a dressing or an orthopedic

device that is not to be removed per physician’s order, or a cast.

3. Identify the number of these pressure ulcers/injuries that

were present on admission/entry or reentry (see page M- 7 for assessment process). Identify the number of these pressure ulcers/injuries that were present on admission/entry or reentry (see page M- 7 for assessment process). M0300F

Steps for Assessment

1. Determine the number of pressure ulcers that are

unstageable due to slough and/or eschar.

2. Identify the number of these pressure ulcers that were present on admission/entry or reentry (see page M- 7 for assessment process).

Identify the number of these pressure ulcers that were present on admission/entry or reentry (see page M- 7 for assessment process). M0300G

5. Determine the number of pressure injuries that are

unstageable related to deep tissue injury.

6. Identify the number of these pressure injuries that were present on admission/entry or reentry (see page M- 7 for instructions).

Identify the number of these pressure injuries that were present on admission/entry or reentry (see page M- 7 for instructions).

7. Clearly document assessment findings in the resident’s

medical record, and track and document appropriate wound care planning and management. M1030

Coding Instructions

Pressure ulcers/injuries coded in M0210 through M0300 should not be coded here.

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Coding Instructions

Check all that apply in the last 7 days. If there is no evidence of such problems in the last 7 days, check none of the above. Pressure ulcers/injuries coded in items M02 1 0 through M0300 should not be coded here. Pressure ulcers/injuries coded in items M02 1 0 through M0300 should not be coded here. Pressure ulcers/injuries coded in items M02 1 0 through M0300 should not be coded here. M1200

Examples

1. A resident is admitted with a Stage 3 pressure ulcer on the

sacrum. Care during the last 7 days has included one debridement by the wound care consultant, application of daily dressings with enzymatic ointment for continued debridement, nutritional supplementation, and use of a pressure reducing pad on the resident’s wheelchair. The medical record documents delivery of care and notes that the resident is on a two-hour turning/repositioning program that is organized, planned, documented, monitored, and evaluated based on an individualized assessment of their needs. The physician documents, after reviewing the resident’s nutritional intake, healing progress of the resident’s pressure ulcer, dietitian ’s nutritional assessment, and laboratory results, that the resident has protein-calorie malnutrition. In order to support proper wound healing, the physician orders an oral supplement that provides all recommended daily allowances for protein, calories, nutrients, and micronutrients. All mattresses in the nursing home are pressure reducing mattresses. A resident is admitted with a Stage 3 pressure ulcer on the sacrum. Care during the last 7 days has included one debridement by the wound care consultant, application of daily dressings with enzymatic ointment for continued debridement, nutritional supplementation, and use of a pressure reducing pad on the resident’s wheelchair. The medical record documents delivery of care and notes that the resident is on a two-hour turning/repositioning program that is organized, planned, documented, monitored, and evaluated based on an individualized assessment of their needs. The physician documents, after reviewing the resident’s nutritional intake, healing progress of the resident’s pressure ulcer, dietitian ’s nutritional assessment, and laboratory results, that the resident has protein-calorie malnutrition. In order to support proper wound healing, the physician orders an oral supplement that provides all recommended daily allowances for protein, calories, nutrients, and micronutrients. All mattresses in the nursing home are pressure reducing mattresses. A resident is admitted with a Stage 3 pressure ulcer on the sacrum. Care during the last 7 days has included one deb ridement by the wound care consultant, application of da ily dressings with enzymatic ointment for continued deb ridement, nutritional supplementation, and use of a pre ssure reducing pad on the resident’s wheelchair. The medical record documents delivery of care and notes that the resident is on a two-hour turning/repositioning program that is organized, planned, documented, monitored, and evaluated based on an individualized assessment of their needs. The physician documents, after reviewing the resident’s nutritional intake, healing progress of the resident’s pressure ulcer, dietitian ’s nutritional assessment, and laboratory results, that the resident has protein-calorie malnutrition. In order to support proper wound healing, the physician orders an oral supplement that provides all recommended daily allowances for protein, calories, nutrients, and micronutrients. All mattresses in the nursing home are pressure reducing mattresses.

Coding: Check items M1200A, M1200B,

M1200C, M1200D, and M1200E.

Rationale: Interventions include pressure reducing

pad on the wheelchair (M1200A) and pressure reducing mattress on the bed (M1200B), turning and repositioning program (M1200C), nutritional supplementation (M1200D), enzymatic debridement and application of dressings (M1200E).

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Facilities may wish to identify a resource that their staff consistently use to identify pharmacological classification as assessors should be able to identify the source(s) used to support coding the MDS 3.0. Assessors should consult the manufacturer’s package insert, which may contain the medication’s pharmacological classification. They can also work with the resident’s pharmacist to confirm the medication classification(s) for a resident’s medication(s). N0415

Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require laboratory monitoring, should be coded in N0415E, Anticoagulant. Do not code flushes to keep an IV access patent in N0415E, Anticoagulant. Code a medication even if it was given only once during the look-back period. N0415

Over-the-counter sleeping medications are not coded as hypnotics, as they are not categorized as hypnotic medications. In circumstances where reference materials vary in identifying a medication’s therapeutic category and/or pharmacological classification, consult the resources/links cited in this section or consult the medication package insert, which is available through the facility’s pharmacy or the manufacturer’s website. If necessary, request input from the consulting pharmacist.

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Coding Tips and Special Populations

(N0450B and N0450C) Compliance with the requirement to perform a GDR may be met if, for example, Wwithin the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempts a GDR in two separate quarters (with at least one month between the attempts), unless physician documentation is present in the medical record indicating that a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated. Information on GDR and tapering of medications can be found in the State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (see F758)in accordance with 42 CFR 483.45. The State Operations Manual can be found at guidance/guidance/manuals/internet-only-manuals- ioms-items/cms1201984.

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Planning for Care

Early detection of outbreaks is essential to control outbreaks of pneumococcal disease in long-term care facilities. Individuals living in nursing homes and other long-term care facilities with an identified increased risk of invasive pneumococcal disease or its complications, i.e., those 65 years of age and older with certain medical conditions, should receive pneumococcal vaccination. Conditions that increase the risk of invasive pneumococcal disease include decreased immune function; damaged or no spleen; sickle cell and other hemoglobinopathies; cerebrospinal fluid (CSF) leak; cochlear implants; and chronic diseases of the heart, lungs, liver, and kidneys, including dialysis, diabetes, alcoholism, and smoking. CDC guidance about risk conditions can be found at https://www.cdc.gov/pneumococcal/hcp/vaccine- recommendations/risk-indications.html. O0300

Examples

1. Resident L, who is 72 years old, received the PCV13

pneumococcal vaccine at their physician’s office last year. They had previously been vaccinated with PPSV23 at age 66.

Coding: O0300A would be coded 1, yes; skip to

O0350, Resident’s COVID-19 vaccination is up to date.

Rationale: Resident L, who is over 65 years old, has

received the recommended PCV13 and PPSV23 vaccines. Because it is not at least 5 years after the last pneumococcal vaccine, PCV20 isor PCV21 are not considered by the physician at this time.

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3. Resident A, who has congestive heart failure, received

PPSV23 vaccine at age 62 when they were hospitalized for a broken hip. They are now 78 years old and were admitted to the nursing home one week ago for rehabilitation. They were offered and given PCV1320 on admission.

Coding: O0300A would be coded 1, yes; skip to

O0350, Resident’s COVID-19 vaccination is up to date.

Rationale: Resident A received PPSV23 before age 65 years because they have a chronic heart disease and

received PCV13 at the facility because they are age 65 years or older. They should receive another dose of PPSV23 at least 1 year after PCV13 and 5 years after the last PPSV23 dose (i.e., Resident A should receive 1 dose of PPSV23 at age 79 years, but is currently up to date because they must wait at least 1 year since they received PCV13). The resident is not eligible to receive a PCV20 dose until at least 5 years after the last pneumococcal vaccine; therefore, the physician advises the resident to receive the PPSV23 when eligible instead of waiting to receive the PCV20. Because it was at least one year since Resident A received the PPSV23, the facility offered and administered PCV20.

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4. Resident T, who has a long history of smoking cigarettes,

received the PPSV23 pneumococcal vaccine at age 62 when they were living in a congregate care community. They are now 64 years old and are being admitted to the nursing home for chemotherapy and respite care. They have not been offered any additional pneumococcal vaccines.

Coding: O0300A would be coded 0, no; and

O0300B would be coded 3, Not offered.

Rationale: Resident T is not up to date with their

pneumococcal vaccination and has not been offered another vaccination to bring them up to date per current vaccination recommendations. Resident T received 1 dose of PPSV23 vaccine prior to 65 years of age because they are a smoker. Because Resident T is now immunocompromised, they should receive 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination regardless of risk conditionage 50 years or older and it is at least one year since they received the PPSV23 vaccine, they should receive one dose of PCV20 or PCV21 or one dose of PCV15. Their vaccines would then be complete. O0390