CMS-P-0015A Questionaire

2022 MCBS Facility Instrument

Variable Name

MR Screen Name

FQ-Facility Questionnaire

Question Type

Question Text/Description

Code List

Routing

FACILITY QUESTIONNAIRE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE=ALL
SEASON=ALL
PLACEMENT
Start of Facility Interview
BOX FQ1

routing

GO TO FQ1 - FNAMEOK.

(00) NO
(01) YES
(02) DISPLAYED GROUP HOME NAME IS CORRECT
(03) DISPLAYED GROUP HOME NAME IS NOT
CORRECT
(-8) Don't Know
(-9) Refused

(00) FQ1A - PLACNAME
(01) FQ2 - FADDROK
(02) FQ2 - FADDROK
(03) FQ1A - PLACNAME
(-8) FQCLOSE7 - NOTRESP
(-9) FQCLOSE7 - NOTRESP

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ2 - FADDROK
(-8) FQ2 - FADDROK
(-9) FQ2 - FADDROK

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FQ2A - ADDRESS
(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ2A - ADDRCITY
(-8) FQ2A - ADDRCITY
(-9) FQ2A - ADDRCITY

FNAMEOK

FQ1

code one

IF SP IS IN AN ADULT/GROUP HOME OR SIMILAR RESIDENCE AT ANOTHER LOCATION, CODE "2" OR "3"
WITHOUT ASKING.
Before we begin, I need to verify that our information is correct. Is (PRELOAD FACILITY) the exact name of the
place where (SP) (is/was) physically located [on or around (PREVIOUS INTERVIEW DATE)/on or around
(ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)?

PLACNAME

FQ1A

text

What is the exact name of the place where (SP) (is/was) physically located [on or around (PREVIOUS
INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)]?

FADDROK

FQ2

yes/no

Next, I would like to verify the address of the place where (SP) (is/was) physically located [on or around
(PREVIOUS INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)].
I have it listed as [READ ADDRESS BELOW]. Is this correct?

ADDRESS

FQ2A

address

What is the correct address of the place where (SP) (is/was) physically located [on or around (PREVIOUS
INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)]?
PRESS F1 FOR STATE ABBREVIATIONS.
ADDRESS

ADDRCITY

FQ2A

address

CITY

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ2A - ADDRSTAT
(-8) FQ2A - ADDRSTAT
(-9) FQ2A - ADDRSTAT

ADDRSTAT

FQ2A

address

STATE

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ2A - ADDRZIP
(-8) FQ2A - ADDRZIP
(-9) FQ2A - ADDRZIP

ADDRZIP

FQ2A

address

ZIP

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK
(00) FQ3A - FACRNAM1
(01) FQ4 - MADDROK
(02) FQ4 - MADDROK
(-8) FQ4 - MADDROK
(-9) FQ4 - MADDROK

FADMNOK

FQ3

code one

(CODE "2" WITHOUT ASKING.)
[Is (ADMINISTRATOR'S NAME)/Are you] (still) the current administrator of (FACILITY)?

(00) NO
(01) YES
(02) RESPONDENT CONSIDERED ADMINISTRATOR
(-8) Don't Know
(-9) Refused

FACRNAM1

FQ3A

roster

What is the current administrator's name?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

(01) [Continuous answer.]

(01) FQ4 - MADDROK

MADDROK

FQ4

yes/no

Next, I would like to verify your office address. I have it listed as [READ ADDRESS LISTED BELOW]. Is this
correct?

(00) NO
(01) YES
(-9) Refused

(00) FQ4A - MAILADD1
(01) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK

Page 1 of 13

2022 MCBS Facility Instrument

Variable Name

FQ4A

MR Screen Name

FQ4A

FQ-Facility Questionnaire

Question Type

text

Question Text/Description
What is the correct address for your office?
PRESS F1 FOR STATE ABBREVIATIONS.
ADDRESS

Code List

Routing

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ4A - MAILCIT1
(-8) FQ4A - MAILCIT1
(-9) FQ4A - MAILCIT1

MAILCIT1

MAILADD1

text

CITY

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ4A - MAILSTA1
(-8) FQ4A - MAILSTA1
(-9) FQ4A - MAILSTA1

MAILSTA1

FQ4A

text

STATE

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ4A - MAILZIP1
(-8) FQ4A - MAILZIP1
(-9) FQ4A - MAILZIP1

MAILZIP1

FQ4A

text

ZIP

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ5 - FPHONOK
(-8) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK

(VERIFY PHONE NUMBER IS FOR FQ RESPONDENT. DO NOT READ ALOUD.)
Is (FACILITY AREA CODE AND PHONE NUMBER) the correct phone number for (FACILITY)?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FQ5A - ADDRAREA
(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQ5A - ADDREXCH
(-8) FQ5A - ADDREXCH
(-9) FQ5A - ADDREXCH
(01) FQ5A - ADDRLOCL
(-8) FQ5A - ADDRLOCL
(-9) FQ5A - ADDRLOCL

FPHONOK

FQ5

yes/no

ADDRAREA

FQ5A

Numeric

What is the phone number?
AREACODE

ADDREXCH

FQ5A

Numeric

EXCHANGE

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

ADDRLOCL

FQ5A

Numeric

LOCAL

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7

BOX FQ7

routing

IF BASELINE FQ, GO TO FAINTRO1 - FAINT1TC.
IF FALL ROUND OR ANNUAL FQ, GO TO FB0PRE - ANSWERFB.
ELSE GO TO FC1PRE - FC1PRECT.

(01) Continue

(01) BOX FA1

(01) FREE STANDING NURSING HOME
(04) NURSING HOME UNIT WITHIN A CCRC OR
RETIREMENT CENTER
(06) HOSPITAL
(07) HOSPITAL-BASED SNF UNIT
(08) ASSISTED LIVING FACILITY
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(13) HOME OFFICE OR MANAGEMENT OFFICE FOR
A CHAIN OR GROUP OF OFF-SITE NURSING
FACILITIES
(15) MENTAL HEALTH CENTER/PSYCHIATRIC
SETTING
(16) INSTITUTION FOR THE INTELLECTUALLY
DISABLED/DEVELOPMENTALLY DISABLED
(17) REHABILITATION FACILITY
(91) OTHER
(-9) Refused

(01) FA1A - FACHOME
(04) FA1A - FACHOME
(06) FA2 - HOSPKIND
(07) FA1A - FACHOME
(08) FA1A - FACHOME
(09) FA1A - FACHOME
(10) FA1A - FACHOME
(11) FA1A - FACHOME
(12) FA1A - FACHOME
(13) FACLOSE5 - LVNORES
(15) FA1A - FACHOME
(16) FA1A - FACHOME
(17) FA1A - FACHOME
(91) FA1 - PLACTPO1
(-9) FA1A - FACHOME

FAINT1TC

FAINTRO1

code one

Now I have a few questions about the structure of (FACILITY) and its certification and licensing to confirm that it
is eligible for this study.
PRESS "1" TO CONTINUE.

BOX FA1

routing

IF ADULT/GROUP HOME, GO TO FA5A - EFOWNDES.
ELSE GO TO FA1 - PLACTYP1.

SHOW CARD FA2
What type of place is (FACILITY)?
PLACTYP1

FA1

code one

PRESS F1 FOR PLACE DEFINITIONS.
IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR
UNIT WHERE SP RESIDES. DO NOT ENTER "OTHER".

Page 2 of 13

2022 MCBS Facility Instrument

FQ-Facility Questionnaire

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

PLACTPO1

FA1

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) FA1A - FACHOME

FACHOME

FA1A

code one

IF ALREADY KNOWN, CODE WITHOUT ASKING:
Do you prefer that I call (FACILITY) a home or a facility?

(01) PREFERS HOME
(02) PREFERS FACILITY
(03) NO PREFERENECE

(01) BOX FA1A
(02) BOX FA1A
(03) BOX FA1A

BOX FA1A

routing

IF PLACTYP1 = 4/NursingHomeUnitCCRC or 7/HospitalBasedSNF, GO TO FA4 - PLACTYP2.
IF FA1-PLACTYP1 = 1/FreeStandingNursingHome, GO TO FA5A - EFOWNDES.
ELSE GO TO FA3 - FACLPART.
(01) ACUTE CARE HOSPITAL
(02) PRIVATE PYSCHIATRIC HOSPITAL
(03) STATE OR COUNTY HOSPITAL FOR THE
MENTALLY ILL
(04) VA HOSPITAL, VA MEDICAL CENTER
(05) STATE HOSPITAL FOR INDIVIDUALS WITH
INTELLECTUAL DISABILITIES
(06) CHRONIC DISEASE, REHABILITATION,
GERIATRIC, OR OTHER LONG-TERM CARE
HOSPITAL
(91) OTHER

(01) FA2A - LCNDBEDS
(02) FA2A - LCNDBEDS
(03) FA2A - LCNDBEDS
(04) FA2A - LCNDBEDS
(05) FA2A - LCNDBEDS
(06) FA2A - LCNDBEDS
(91) FA2 - HOSPKIOS

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) FA2A - LCNDBEDS

Does (FACILITY) have any beds that are either certified or licensed as a nursing facility or certified or licensed
as an ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities)?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FA2A
(01) FA3 - FACLPART
(-8) BOX FA2A
(-9) BOX FA2A

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA5A - EFOWNDES
(01) FA4 - PLACTYP2
(-8) BOX FA6
(-9) BOX FA6

(03) CONTINUING CARE RETIREMENT COMMUNITY
(CCRC)
(05) RETIREMENT COMMUNITY
(06) HOSPITAL
(08) ASSISTED LIVING FACILITY
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(91) OTHER
(-8) Don't Know
(-9) Refused

(03) FA5 - LGPLCNAM
(05) FA5 - LGPLCNAM
(06) FA5 - LGPLCNAM
(08) FA5 - LGPLCNAM
(09) FA5 - LGPLCNAM
(10) FA5 - LGPLCNAM
(11) FA5 - LGPLCNAM
(12) FA5 - LGPLCNAM
(91) FA4 - PLACTPO2
(-8) FA5 - LGPLCNAM
(-9) FA5 - LGPLCNAM

HOSPKIND

FA2

code one

HOSPKIOS

FA2

verbatim

LCNDBEDS

FA2A

yes/no

SHOW CARD FA3
You mentioned that (FACILITY) is a hospital. Please look at this card and tell me what kind of hospital it is.

PRESS F1 FOR SUGGESTED PROBES.
BOX FA2A

FACLPART

PLACTYP2

FA3

FA4

routing

Yes/No

code one

IF FA2 - HOSPKIND = 1/AcuteCareHospital, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA3 - FACLPART.

Is (FACILITY) part of a larger facility or campus?
PRESS F1 FOR DEFINITION, EXAMPLES OF "LARGER" PLACES.

SHOW CARD FA1
What type of place is (FACILITY) part of?
PRESS F1 FOR HOSPITAL DEFINITIONS.

PLACTPO2

FA4

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) FA5 - LGPLCNAM

LGPLCNAM

FA5

text

What is the name of the (CATEGORY SELECTED IN FA4 - PLACTYP2/place)?

(01) [Continuous answer.]

(01) FA5A - EFOWNDES

(01) FOR PROFIT (INDIVIDUAL, PARTNERSHIP, OR
CORPORATION)
(02) PRIVATE NONPROFIT (RELIGIOUS GROUP,
NONPROFIT CORPORATION, ETC)
(03) CITY/COUNTY GOVERNMENT
(04) STATE GOVERNMENT
(05) VETERAN'S ADMINISTRATION
(06) OTHER FEDERAL AGENCY
(91) OTHER

(01) BOX FA6
(02) BOX FA6
(03) BOX FA6
(04) BOX FA6
(05) BOX FA6
(06) BOX FA6
(91) FA5A - EFOWNDOS

(01) [Continuous answer.]

(01) BOX FA6

SHOW CARD FA4

EFOWNDES

FA5A

code one

EFOWNDOS

FA5A

verbatim

OTHER (SPECIFY)

BOX FA6

routing

GO TO BOX FA6A.

Which one of the categories on this card best describes the ownership of (FACILITY)?

Page 3 of 13

2022 MCBS Facility Instrument

Variable Name

FQ-Facility Questionnaire

MR Screen Name

Question Type

Question Text/Description

BOX FA6A

routing

IF FACILTIY IS ELIGIBLE, GO TO FA10 - ANSRELIG.
ELSE GO TO FACLOSE2 - LEAVINEL.

Code List

Routing

(00) FA11 - FACRNAM2
(01) BOX FA7A
(-8) FA11 - FACRNAM2
(-9) FA11 - FACRNAM2
(01) CLOSING6 - FINOTRES

ANSRELIG

FA10

yes/no

Would you be able to answer some questions about the certification status and services offered at (FACILITY)?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

FACRNAM2

FA11

roster

What is the name of the most knowledgeable person to answer questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

(01) [Continuous answer.]

BOX FA7A

routing

IF PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF, or
17/Rehabilitation Facility, GO TO CCNINTRO.
ELSE GO TO FA12A - TOTLBEDA.

Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid Provider Number,
or Medicare Identification Number? The CMS Certification Number is a unique six-digit number assigned to any
facility certified to participate in Medicare and/or Medicaid.
CCNINTRO

FA11A

yes/no

(00) NO
(01) YES
[IF NEEDED: The CMS Certification Number is not the same as the National Provider Identifier (NPI), which is a (-8) Don't Know
unique 10-digit identification number issued to health care providers.]
(-9) Refused

(00)FA12A - TOTLBEDA
(01) CASPER_LU-CCN
(-8) FA12A - TOTLBEDA
(-9) FA12A - TOTLBEDA

[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]

Please tell me the CMS Certification Number. It would be helpful if I could look at a document with the CMS
Certification Number on it, such as an MDS form or other document. These materials will ensure that I record the
number accurately.
[IF NEEDED: If you don't know the CMS Certification Number I can look up the number using your Facility name
and address.]
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS
form.]
CCN

CASPER_LUA

lookup

START TYPING OR DOUBLE CLICK IN THE "CASPER_LU" BOX TO LAUNCH THE LOOKUP.
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, PROBE TO CONFIRM THAT THE FACILITY
IS CERTIFIED BY MEDICARE AND/OR MEDICAID. AFTER YOU HAVE CONFIRMED THIS, YOU CAN
SEARCH THE LOOKUP USING A DIFFERENT IDENTIFIER, SUCH AS THE FACILITY’S NAME AND/ OR
ADDRESS.

(01) (value selected from lookup)
(-8) DON'T KNOW
(-9) REFUSED
(NF) NOT FOUND

(01) BOX FA7C
(-8) BOX FA7C
(-9) BOX FA7C
(NF) BOX FA7C

ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS
CERTIFICATION NUMBER SHOULD BE [STATE PREFIX FILL].

SEARCH FOR THE FACILITY'S CCN BY TYPING THE CCN IN THE SEARCH BOX.WHEN YOU FIND THE
CORRECT CCN, HIGHLIGHT THE ROW AND PRESS THE SELECT BUTTON.
lookup

IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, SEARCHTHE LOOKUP USING A DIFFERENT
IDENTIFIER, SUCH AS THE FACILITY'S NAME OR ADDRESS.
IF YOU CANNOT FIND THE FACILITY'S CCN, PRESS THE "NOT FOUND" BUTTON.
IF YOU NEED TO EXIT THE LOOKUP, PRESS THE "CLOSE" BUTTON.

BOX FA7C

routing

IF CCN IN ('NF', MISSING, DK, RF), GO TO FA12A - TOTLBEDA.
ELSE GO TO BOX FA8.

Page 4 of 13

2022 MCBS Facility Instrument

Variable Name

MR Screen Name

FQ-Facility Questionnaire

Question Type

Question Text/Description

Code List

Routing

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FA8
(-8) BOX FA8
(-9) BOX FA8

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA14 - CARECRT1
(01) FA14 - CARECRT1
(-8) FA14 - CARECRT1
(-9) FA14 - CARECRT1

(00) FA15 - CAIDICF
(01) FA15 - CAIDICF
(-8) FA15 - CAIDICF
(-9) FA15 - CAIDICF

How many beds does (FACILITY) have that provide long-term care?

TOTLBEDA

FA12A

Numeric

[PROBE: Do not count "independent living" beds or those that don't provide 24-hour a day assistance or
supervision with daily living activities.]
IF THIS FACILITY CONTAINS BEDS THAT ARE CERTIFIED AS ICF/IID (INTERMEDIATE CARE FACILITIES
FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), THEN COUNT ICF/IID BEDS IN THE TOTAL.
PRESS F1 FOR LONG-TERM CARE DEFINITION..

BOX FA8

routing

IF FA12A - TOTLBEDA < 3 AND FA12A - TOTLBEDA <> DK,RF, GO TO FACLOSE2 - LEAVINEL.
ELSE IF PLAC.PLACTYPE = 1/Free Standing Nursing Home, 4/NursingHomeorNHUnit, 7/HospitalBasedSNF,
OR 17/RehabilitationFacility, GO TO FA13 - CAIDCRT1.
ELSE IF PLAC.PLACTYPE = 16/InstitutionForMentallyRetarded OR FA2 - HOSPKIND =
3/StateCountyHospitalForMentallyIll OR 5/StateHospitalForIndividualsWithIntellectualDisabilities OR
6/ChronicDiseaseLongTermHospital, GO TO FA15 - CAIDICF.
ELSE GO TO FA18 - HDEPTPCH.

Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as Nursing
Facility (NF) beds?
CAIDCRT1

FA13

yes/no

[READ IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
IF R MENTIONS:
ICF/IID (INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), SAY
THAT YOU WILL ASK ABOUT THOSE IN A MOMENT.

CARECRT1

CAIDICF

FA14

FA15

yes/no

Does (FACILITY) have any beds certified by Medicare as SNF beds?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

yes/no

Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as ICF/IID
(Intermediate Facilities For Individuals With Intellectual Disabilities) beds?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA16 - HDEPTLIC
(01) FA16 - HDEPTLIC
(-8) FA16 - HDEPTLIC
(-9) FA16 - HDEPTLIC

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused

(00) FA18 - HDEPTPCH
(01) FA18 - HDEPTPCH
(02) FA16 - HDEPTLOS
(-8) FA18 - HDEPTPCH
(-9) FA18 - HDEPTPCH

HDEPTLIC

FA16

code one

Does (FACILITY) have any beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid) but are]
licensed as nursing home beds by the (STATE) State Health Department or by some other State or Federal
Agency?

HDEPTLOS

FA16

verbatim

OTHER AGENCY (SPECIFY)

(01) [Continuous answer.]

(01) FA18 - HDEPTPCH
(00) BOX FA9
(01) BOX FA9
(02) FA18 - HDEPTPOS
(-8) BOX FA9
(-9) BOX FA9

HDEPTPCH

FA18

code one

Does (FACILITY) have any beds licensed as personal care, board and care, assisted living, or domiciliary care
beds by the (STATE) State Health Department or by some other state or local government agency?

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused

HDEPTPOS

FA18

verbatim

OTHER AGENCY (SPECIFY)

(01) [Continuous answer.]

(01) BOX FA9

BOX FA9

routing

IF CCN IN ('NF', MISSING, DK, RF), GO TO FA19 - NORMCARE.
ELSE GO TO BOX FA13.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA19 - SUPRMEDI
(01) FA19 - SUPRMEDI
(-8) FA19 - SUPRMEDI
(-9) FA19 - SUPRMEDI

NORMCARE

FA19

list

In addition to room and board, does (FACILITY) routinely provide…
a. nursing or medical care?

Page 5 of 13

2022 MCBS Facility Instrument

Variable Name

SUPRMEDI

HELPBATH

HELPDRES

HELPEAT

RNLPNSUP

CARESUP

MR Screen Name

FA19

FA19

FA19

FQ-Facility Questionnaire

Question Type

list

list

list

Question Text/Description

Code List

Routing

b. supervision over medications?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA19 - HELPBATH
(01) FA19 - HELPBATH
(-8) FA19 - HELPBATH
(-9) FA19 - HELPBATH

c. help with bathing?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA19 - HELPDRES
(01) FA19 - HELPDRES
(-8) FA19 - HELPDRES
(-9) FA19 - HELPDRES

d. help with dressing?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA19 - HELPEAT
(01) FA19 - HELPEAT
(-8) FA19 - HELPEAT
(-9) FA19 - HELPEAT

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FA13
(01) BOX FA13
(-8) BOX FA13
(-9) BOX FA13

Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FA23 - FACRNAM3
(01) BOX FA17
(-8) BOX FA17
(-9) FA23 - FACRNAM3

(01) [Continuous answer.]

(01) CLOSING6 - FINOTRES

(01) Continue

(01) BOX FA18

FA19

list

e. help with eating?

BOX FA13

routing

IF FA13 - CAIDCRT1, FA14 - CARECRT1, OR FA15 - CAIDICF = 1/Yes, GO TO FA20 - CARESUP.
ELSE GO TO FA19A - RNLPNSUP.

FA19A

yes/no

FA20

yes/no

Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week

BOX FA16A

routing

GO TO BOX FA16.

routing

IF FQ.ELIGSTAT = 1/FacilityEligible and CCN IN ('NF', MISSING, DK, OR RF), GO TO FA22 - ANSRFACQ.
IF FQ.ELIGSTAT = 1/FacilityEligible and (CCN=NON-MISSING AND CCN NOT EQUAL TO 'NF'), GO TO FA35 MIDNTRES.
ELSE IF FQ.ELIGSTAT = 2/FacilityIneligible, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA11 - FACRNAM2.

The next questions are about the number of nursing beds and residents by payer type and staffing. Can you
answer these questions about (FACILITY)?

BOX FA16

ANSRFACQ

FA22

yes/no

FACRNAM3

FA23

roster

BOX FA17

routing

Who would be the best person to answer questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
IF FA12A - TOTLBEDA <> DK OR RF, GO TO FA24PRE - FA24PRCT.
ELSE GO TO BOX FA18.
From information I collected earlier, I understand that (FACILITY) has a total of (NUMBER OF BEDS IN
FACILITY) beds.

FA24PRCT

FA24PRE

code one

[IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
PRESS "1" TO CONTINUE.

BOX FA18

routing

IF FACILITY CERTIFIED BY BOTH MEDICAID AND MEDICARE, GO TO FA26 - MANDMBED.
ELSE IF FACILITY IS CERTIFIED BY MEDICAID, GO TO FA27 - MCAIDBED.
ELSE GO TO BOX FA20.

Page 6 of 13

2022 MCBS Facility Instrument

FQ-Facility Questionnaire

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

MANDMBED

FA26

Numeric

I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] as Nursing Facility beds and by Medicare as Skilled Nursing Facility beds. How many
beds are dually certified (that is, certified by both)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FA27 - MCAIDBED
(-8) FA27 - MCAIDBED
(-9) FA27 - MCAIDBED

MCAIDBED

FA27

Numeric

I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] as Nursing Facility beds. How many beds are certified under [(PREFERRED NAME(S)
FOR MEDICAID)/MEDICAID] (only)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FA20
(-8) BOX FA20
(-9) BOX FA20

BOX FA20

routing

IF FA14 - CARECRT1 = 1/Yes, GO TO FA28 - MCAREBED.
ELSE GO TO BOX FA21.

FA28

Numeric

I have recorded that (FACILITY) contains beds that are certified by Medicare as Skilled Nursing Facility beds.
How many beds are certified under Medicare (only)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FA21
(-8) BOX FA21
(-9) BOX FA21

BOX FA21

routing

IF FA16 - HDEPTLIC = 1/YesStateHealthDept OR 2/YesOtherAgency, GO TO FA29 - MNORMBED.
ELSE GO TO BOX FA22.

FA29

Numeric

I have recorded that (FACILITY) contains beds that are licensed as nursing facility beds but not certified by
[(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] or Medicare. How many beds are licensed but not
certified as nursing home beds (only)?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FA22
(-8) BOX FA22
(-9) BOX FA22

BOX FA22

routing

IF FA15 - CAIDICF = 1/Yes, GO TO FA30 - ICFMRBED.
ELSE GO TO BOX FA23.

FA30

Numeric

I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
(01) [Continuous answer.]
MEDICAID)/MEDICAID] as ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities) beds. (-8) Don't Know
How many beds are certified as ICF/IID beds (only)?
(-9) Refused

(01) BOX FA23
(-8) BOX FA23
(-9) BOX FA23

BOX FA23

routing

IF FA18 - HDEPTPCH = 1/YesStateHealthDept OR 2/YesOtherAgency, GO TO FA31 - OTLTCBED.
ELSE GO TO BOX FA24.

FA31

Numeric

I recorded earlier that (FACILITY) contains beds that are licensed as personal care, board and care, assisted
(01) [Continuous answer.]
living, domiciliary care, or other type of long-term care beds. How many beds are licensed as one of these types (-8) Don't Know
of long-term care (only)?
(-9) Refused

BOX FA24

routing

IF CANNOT CALCULATE NUMBER OF REMAINING BEDS, GO TO FA35 - MIDNTRES.
ELSE, GO TO FA32 - NHBEDCOR.

MCAREBED

MNORMBED

ICFMRBED

OTLTCBED

(01) BOX FA24
(-8) BOX FA24
(-9) BOX FA24

So, there are a total of (TOTAL # LTC BEDS) LTC beds in the (facility/home).
[REVIEW NUMBER OF BEDS BY TYPE.]
NHBEDCOR

FA32

yes/no

That leaves (NUMBER OF BEDS LEFT) long-term care beds that are neither certified or licensed as nursing
home or other long-term care beds.

(00) No
(01) Yes

(00) FA32VB - NHBEDEX
(01) FA35 - MIDNTRES

Is that correct?

NHBEDEX

FA32VB

verbatim

PLEASE ENTER A BRIEF EXPLANATION:

(01) [Continuous answer.]

(01) FA35 - MIDNTRES

MIDNTRES

FA35

Numeric

How many residents were in (FACILITY) altogether at midnight last night?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FR1PRE - FR1PRECT
(-8) FR1PRE - FR1PRECT
(-9) FR1PRE - FR1PRECT

Would you be able to answer some questions about the certification status and services offered at (FACILITY)?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FB19 - FACRNAM4
(01) FB1PRE - FB1PRECT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

(01) Continue

(01) BOX FA36

ANSWERFB

FB0PRE

yes/no

FB1PRECT

FB1PRE

code one

I would like to review with you some information that I collected about (FACILITY) the last time I was here.
PRESS "1" TO CONTINUE.

Page 7 of 13

2022 MCBS Facility Instrument

Variable Name

MR Screen Name

FQ-Facility Questionnaire

Question Type

Question Text/Description

Code List

Routing

IF BPRELOADPLAC.PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC,
7/HospitalBasedSNF, or 17/Rehabilitation Facility AND PRELOADED CMS CERTIFICATION NUMBER
(BPRELOADFQ.CCN) IS NON-MISSING AND NOT IN ( DK, RF, "NF") GO TO FB11A - CCNCNFRM.
BOX FA36

routing

IF BPRELOADPLAC.PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC,
7/HospitalBasedSNF, or 17/Rehabilitation Facility AND PRELOADED CMS CERTIFICATION NUMBER
(BPRELOADFQ.CCN) IN ("NF", MISSING, DK, RF), GO TO FB11B - CCNINTRO.
ELSE GO TO BOX FB1.

You previously told me that (FACILITY)'s CMS Certification Number is [(BPRELOADFQ.CCN]. Is that still your
CMS Certification Number?
CCNCNFRM

FB11A

yes/no

(00) NO
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number,
(01) YES
Medicare Identification Number, or Provider Number. The CMS Certification Number is a unique six-digit number (-8) Don't Know
assigned to any facility certified to participate in Medicaire and/or Medicaid.The CMS Certification Number is not (-9) Refused
the same as the National Provider Identifier (NPI), which is a unique 10-digit identification number issued to
health care providers.]

Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid Provider Number,
or Medicare Identification Number? The CMS Certification Number is a unique six-digit number assigned to any
facility certified to participate in Medicare and/or Medicaid.
CCNINTRO

FB11B

yes/no

(00) NO
(01) YES
[IF NEEDED: The CMS Certification Number is not the same as the National Provider Identifier (NPI), which is a (-8) Don't Know
unique 10-digit identification number issued to health care providers.]
(-9) Refused

(00) FB11B - CCNINTRO
(01) BOX FB1
(-8) FB11B - CCNINTRO
(-9) FB11B - CCNINTRO

(00) BOX FB1
(01) CASPER_LU-CCN
(-8) BOX FB1
(-9) BOX FB1

[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]

Please tell me the CMS Certification Number. It would be helpful if I could look at a document with the CMS
Certification Number on it, such as an MDS form or other document. These materials will ensure that I record the
number accurately.
[IF NEEDED: If you don't know the CMS Certification Number I can look up the number using your Facility name
and address.]
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS
form.]
CCN

CASPER_LUB

lookup

START TYPING OR DOUBLE CLICK IN THE "CASPER_LU" BOX TO LAUNCH THE LOOKUP.
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, PROBE TO CONFIRM THAT THE FACILITY
IS CERTIFIED BY MEDICARE AND/OR MEDICAID. AFTER YOU HAVE CONFIRMED THIS, YOU CAN
SEARCH THE LOOKUP USING A DIFFERENT IDENTIFIER, SUCH AS THE FACILITY’S NAME AND/ OR
ADDRESS.

(01) (value selected from lookup)
(-8) DON'T KNOW
(-9) REFUSED
(NF) NOT FOUND

(01) BOX FB1
(-8) BOX FB1
(-9) BOX FB1
(NF) BOX FB1

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FB5 - CARECERT
(01) FB5 - CARECERT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS
CERTIFICATION NUMBER SHOULD BE [STATE PREFIX FILL].

SEARCH FOR THE FACILITY'S CCN BY TYPING THE CCN IN THE SEARCH BOX.WHEN YOU FIND THE
CORRECT CCN, HIGHLIGHT THE ROW AND PRESS THE SELECT BUTTON.
lookup

IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, SEARCH THE LOOKUP USING A
DIFFERENT IDENTIFIER, SUCH AS THE FACILITY'S NAME OR ADDRESS.
IF YOU CANNOT FIND THE FACILITY'S CCN, PRESS THE "NOT FOUND" BUTTON.
IF YOU NEED TO EXIT THE LOOKUP, PRESS THE "CLOSE" BUTTON.

BOX FB1

CAIDCERT

FB2

routing

yes/no

IF PreloadFQ.CAIDCERT = EMTPY, GO TO BOX FB3.
ELSE GO TO FB2 - CAIDCERT.

Is (FACILITY) (still) certified by Medicaid as a Nursing Facility (NF)?

Page 8 of 13

2022 MCBS Facility Instrument

Variable Name

CARECERT

FMRCERT

MR Screen Name

FQ-Facility Questionnaire

Question Type

Question Text/Description

Code List

Routing

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FB3
(01) BOX FB3
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FB4
(01) BOX FB4
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

FB5

yes/no

Is (FACILITY) (still) certified by Medicare as a Skilled Nursing Facility (SNF)?

BOX FB3

routing

IF PreloadFQ.FMRCERT <> EMPTY, GO TO FB9 - FMRCERT.
ELSE GO TO BOX FB4.

FB9

yes/no

Is (FACILITY) (still) certified by Medicaid as an Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF/IID)?

BOX FB4

routing

IF PreloadFQ.HDLICEN <> EMPTY, GO TO FB11 - HDLICEN.
ELSE GO TO FB14 - PCHLICEN.

(00) FB14 - PCHLICEN
(01) FB14 - PCHLICEN
(02) FB11 - HDLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

HDLICEN

FB11

code one

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Does (FACILITY) (still have/have any) beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid)
DEPARTMENT
but are] licensed as nursing (facility/home) beds by the (STATE) State Health Department or by some other
(02) YES, LICENSED BY SOME OTHER AGENCY
State or Federal agency?
(-8) Don't Know
(-9) Refused

HDLICOS

FB11

verbatim

OTHER AGENCY (SPECIFY)

(01) [Continuous answer.]

(01) FB14 - PCHLICEN

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused

(00) BOX FB4A
(01) BOX FB4A
(02) FB14 - PCHLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

(01) [Continuous answer.]

(01) BOX FB4A

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FB15 - MEDISUPR
(01) FB15 - MEDISUPR
(-8) FB15 - MEDISUPR
(-9) FB15 - MEDISUPR

b. supervision over medications?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FB15 - BATHHELP
(01) FB15 - BATHHELP
(-8) FB15 - BATHHELP
(-9) FB15 - BATHHELP

c. help with bathing?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FB15 - DRESHELP
(01) FB15 - DRESHELP
(-8) FB15 - DRESHELP
(-9) FB15 - DRESHELP

d. help with dressing?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FB15 - EATHELP
(01) FB15 - EATHELP
(-8) FB15 - EATHELP
(-9) FB15 - EATHELP

PCHLICEN

FB14

code one

Is (FACILITY) (still) licensed as a personal care home, board and care home, assisted living facility, domiciliary
care home or rest home by the (STATE) State Health Department or by some other state or local government
agency?

PCHLICOS

FB14

verbatim

OTHER AGENCY (SPECIFY)

BOX FB4A

routing

IF CCN= MISSING, DK, RF, NF GO TO FB15 - NURSCARE
ELSE GO TO BOX FB5.

NURSCARE

MEDISUPR

BATHHELP

DRESHELP

FB15

FB15

FB15

FB15

List

List

List

List

In addition to room and board, does (FACILITY) routinely provide…
a. nursing or medical care?

Page 9 of 13

2022 MCBS Facility Instrument

Variable Name

EATHELP

NURSSUP

CGIVSUP

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FB5AA
(01) BOX FB5AA
(-8) BOX FB5AA
(-9) BOX FB5AA

Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

yes/no

Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

routing

IF FB2-CAIDCERT = 1/Yes OR FB5-CARECERT = 1/Yes OR FB9-FMRCERT = 1/Yes OR FB11-HDLICEN =
1/YesStateHealthAgency OR 2/YesOtherAgency OR FB14-PCHLICEN = 1/YesStateHealthAgency OR
2/YesOtherAgency OR FQ.PROVHELP = 1/Indicated OR FB15A-NURSSUP = 1/Yes OR FB16-CGIVSUP =
1/Yes OR CCN= NON-MISSING, GO TO BOX FB9.
ELSE GO TO FBCLOSE2 - LEVINEL2.

routing

IF PreloadFQ.TOTELBED = DK, RF AND CCN in ('NF', MISSING, DK, RF), GO TO FB18 - TOTELBED.
ELSE IF CCN IN ('NF', MISSING, DK, RF) AND PreloadFQ.TOTELBED<>DK and
PreloadFQ.TOTELBED<>REF, GO TO FB17 - SAMEBEDS.
ELSE GO TO FB27-MIDNTCNT.

Yes/No

(00) NO
I have recorded that (FACILITY) has [PREVIOUS TOTAL # LTC BEDS] beds that provide long-term care. Is this (01) YES
still the number of beds providing long-term care in (FACILITY)?
(-8) Don't Know
(-9) Refused

(00) FB18 - TOTELBED
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

FB15

List

e. help with eating?

BOX FB5AA

routing

IF ANY ITEM IN FB15 = DK OR RF, GO TO FB19 - FACRNAM4.
ELSE GO TO BOX FB5.

BOX FB5

routing

IF FB2-CAIDCERT = 1/Yes OR FB5-CARECERT = 1/Yes OR FB9-FMRCERT = 1/Yes, GO TO FB16 CGIVSUP.
ELSE GO TO FB15A - NURSSUP.

FB15A

FB16

BOX FB8

BOX FB9

SAMEBEDS

FQ-Facility Questionnaire

FB17

yes/no

How many beds does (FACILITY) have that provide long-term care?

TOTELBED

FB18

Numeric

[PROBE: Do not count "independent living" beds or those that don't provide 24-hour a day assistance or
supervision with daily living activities.]
IF THIS FACILITY CONTAINS BEDS THAT ARE CERTIFIED AS ICF/IID (INTERMEDIATE CARE FACILITIES
FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), THEN COUNT ICF/IID BEDS IN THE TOTAL.

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4

(01) [Continuous answer.]

(01) CLOSING6B - FINOTRSB

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FB12
(-8) BOX FB12
(-9) BOX FB12

PRESS F1 FOR LONG-TERM CARE DEFINITION.

FACRNAM4

CANDCBED

FB19

Roster

Who would be the best person to answer these questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

BOX FB11

routing

IF FQ.ELIGSTAT = 2/FacilityIneligible, GO TO FBCLOSE2 - LEVINEL2.
ELSE IF FB2-CAIDCERT = 1/Yes AND FB5-CARECERT = 1/Yes, GO TO FB20 - CANDCBED.
ELSE GO TO BOX FB12.

Numeric

I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] as Nursing Facility beds and by Medicare as Skilled Nursing Facility beds. How many
beds are dually certified (that is, certified by both)?

FB20

Page 10 of 13

2022 MCBS Facility Instrument

Variable Name

CAIDBEDS

CAREBEDS

HDLICBED

FMRBEDS

PCHBED

FQ-Facility Questionnaire

MR Screen Name

Question Type

Question Text/Description

Code List

BOX FB12

routing

IF FB2-CAIDCERT = 1/Yes, GO TO FB21 - CAIDBEDS.
ELSE GO TO BOX FB13.

FB21

Numeric

[I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
(01) [Continuous answer.]
MEDICAID)/MEDICAID] as Nursing Facility beds.] How many beds are certified under [(PREFERRED NAME(S) (-8) Don't Know
FOR MEDICAID)/MEDICAID] (only)?
(-9) Refused

BOX FB13

routing

IF FB5-CARECERT = 1/Yes, GO TO FB22 - CAREBEDS.
ELSE, GO TO BOX FB14.

FB22

Numeric

[I have recorded that (FACILITY) contains beds that are certified by Medicare as Skilled Nursing Facility beds.]
How many beds are certified under Medicare (only)?

BOX FB14

routing

IF FB11-HDLICEN = 1/YesStateHealthAgency or 2/YesOtherAgency, GO TO FB23 - HDLICBED.
ELSE GO TO BOX FB15.

FB23

Numeric

I have recorded that (FACILITY) contains beds that are licensed as nursing facility beds but not certified by
[(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] or Medicare. How many beds are licensed but not
certified as nursing home beds (only)?

BOX FB15

Routing

(01) BOX FB13
(-8) BOX FB13
(-9) BOX FB13

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FB14
(-8) BOX FB14
(-9) BOX FB14

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) BOX FB15
(-8) BOX FB15
(-9) BOX FB15

routing

IF FB9-FMRCERT = 1/Yes, GO TO FB24 - FMRBEDS.
ELSE GO TO BOX FB16.

FB24

Numeric

I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
(01) [Continuous answer.]
MEDICAID)/MEDICAID] as ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities) beds. (-8) Don't Know
How many beds are certified as ICF/IID beds (only)?
(-9) Refused

(01) BOX FB16
(-8) BOX FB16
(-9) BOX FB16

BOX FB16

routing

IF FB14-PCLICEN = 1/YesStatHealthDept OR 2/YesOtherAgency, GO TO FB25 - PCHBED.
ELSE GO TO BOX FB17.

FB25

Numeric

I recorded earlier that (FACILITY) contains beds that are licensed as personal care, board and care, assisted
(01) [Continuous answer.]
living, domiciliary care, or other type of long-term care beds. How many beds are licensed as one of these types (-8) Don't Know
of long-term care (only)?
(-9) Refused

BOX FB17

routing

IF CANNOT CALCULATE NUMBER OF REMAINING BEDS, GO TO FB27 - MIDNTCNT.
ELSE GO TO FB26 - FBBEDCOR.

(01) BOX FB17
(-8) BOX FB17
(-9) BOX FB17

So, there are a total of (TOTAL # LTC BEDS) LTC beds in the (facility/home).
FBBEDCOR

FB26

yes/no

[REVIEW NUMBER OF BEDS BY TYPE.]

(00) NO
(01) YES

(00) FB26VB - FBBEDEX
(01) FB27 - MIDNTCNT

Is that correct?
FBBEDEX

FB26VB

verbatim

PLEASE ENTER A BRIEF EXPLANATION:

(01) [Continuous answer.]

(01) FB27 - MIDNTCNT

MIDNTCNT

FB27

Numeric

How many residents were in (FACILITY) altogether at midnight last
night?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FR1PRE - FR1PRECT
(-8) FR1PRE - FR1PRECT
(-9) FR1PRE - FR1PRECT

(01) Continue

(01) FR2 - RATEPRB

FR1PRECT

FR1PRE

No Entry

Next, I'd like to get some information on the basic rates residents in (FACILITY) are charged. Most facilities
have one or more set rates they charge their residents for room and board and basic services. Usually this rate
includes basic nursing services and sometimes it includes medical services as well. I'm interested in the basic
rates charged by (FACILITY) for [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID], Medicare, and private
pay/[(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] and private pay/Medicare and private pay/private
pay) residents.
[IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
PRESS "1" TO CONTINUE.

Page 11 of 13

2022 MCBS Facility Instrument

FQ-Facility Questionnaire

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

RATEPRB

FR2

yes/no

Do you have more than one basic rate?

(00) NO
(01) YES
(-8) Don't Know

(00) FR5 - SINGRATE
(01) FR3-HIGHRATE
(-8) FR5 - SINGRATE

HIGHRATE

FR3

Quantity Unit

What is the highest rate you bill for residents' basic care?
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY A DECIMAL AND CENTS ".00" TO ".99".

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FR3 - HIGHPER
(-8) FR4-LOWRATE
(-9) BOX FR2
(01) FR4 - LOWRATE
(02) FR4 - LOWRATE
(03) FR4 - LOWRATE
(91) FR3 - HIGHPROS

HIGHPER

FR3

code one

HIGH RATE UNIT

(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER

HIGHPROS

FR3

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) FR4 - LOWRATE

Quantity Unit

HIGHEST RATE: [INPUT AT FR3-HIGHRATE]
HIGHEST RATE UNIT: [INPUT AT FR3-HIGHPER]
What is the lowest rate you bill for residents' basic care?
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY A DECIMAL AND CENTS ".00" TO ".99".

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FR4 - LOWPER
(-8) BOX FR2
(-9) BOX FR2

(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER

(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR4 - LOWPEROS

LOWRATE

FR4

LOWPER

FR4

code one

HIGHEST RATE: [INPUT AT FR3-HIGHRATE]
HIGHEST RATE UNIT: [INPUT AT FR3-HIGHPER]
LOW RATE UNIT

LOPEROS

FR4

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) BOX FR2

SINGRATE

FR5

Quantity Unit

What is the rate you bill for residents' basic care?
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY A DECIMAL AND CENTS ".00" TO ".99".

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FR5 - SINGPER
(-8) BOX FR2
(-9) BOX FR2

(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR5 - SINGPEROS

(01) BOX FR2

SINGPER

FR5

code one

SINGLE RATE UNIT

(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER

SINGPEROS

FR5

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

BOX FR2

routing

GO TO CLOSING1 - RETURNAV.

Thank you. Those are all the facility-level questions I have for you at the moment. Next we will move on to
questions about (SP). Someone from my office may call you to verify some of the data I have collected. We
appreciate your help on this important study.
RETURNAV

CLOSING1

code one

THE FACILITY-LEVEL VERIFICATION AND/OR CERTIFICATION STATUS QUESTIONS FOR THIS CASE ARE (01) Continue
COMPLETE FOR THIS ROUND. FACILITY-LEVEL QUESTIONS ABOUT THE FACILITY’S COVID-19
PANDEMIC EXPERIENCES MAY BE ASKED IN A LATER SECTION.

(01) BOX FACEND

PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.

LEAVINEL

FACLOSE2

code one

LEVINEL2

FBCLOSE2

code one

YOU ARE ABOUT TO LEAVE FQ BECAUSE THE FACILITY IS INELIGIBLE.
IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, ENTER 1.

YOU ARE ABOUT TO LEAVE FQ BECAUSE THE FACILITY IS INELIGIBLE.

(01) Continue

(01) BOX FACEND

(01) Continue

(01) BOX FACEND

Page 12 of 13

2022 MCBS Facility Instrument

Variable Name

MR Screen Name

FQ-Facility Questionnaire

Question Type

Question Text/Description

Code List

Routing

(01) Continue

(01) BOX FACEND

(01) Continue

(01) BOX FACEND

(01) Continue

(01) BOX FACEND

(01) Continue

(01) BOX FACEND

YOU ARE ABOUT TO LEAVE FQ BECAUSE THIS IS A "HOME OFFICE" WITH NO RESIDENTS.
LVNORES

FINOTRES

FACLOSE5

CLOSING6

code one

code one

IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, COLLECT
FACILITY CONTACT INFORMATION FOR FACILITY WHERE SP IS LOCATED.

Thank you. Those are all the questions I have for you at the moment. Right now, I need to make arrangements
to speak to (NAMED RESPONDENT).
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.

FINOTRSB

CLOSING6B

code one

Thank you. Those are all the questions I have for you at the moment. Right now, I need to make arrangements
to speak to (NAMED RESPONDENT).
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.

NOTRESP

FQCLOSE7

code one

BOX FACEND

routing

YOU ARE ABOUT TO LEAVE FQ BECAUSE THE RESPONDENT IS NOT ABLE TO VERIFY INFORMATION
ABOUT THE FACILITY.
IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, PRESS "1" TO
RETURN TO FACILITY NAVIGATION SCREEN.
GO TO NAVIGATOR

Page 13 of 13