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F0641
D

Inaccurate MDS Coding for Dental Status

Concord, North Carolina Survey Completed on 06-27-2025

Penalty

Fine: $123,76030 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of dental status. The resident, who was cognitively intact, had documented dental issues including malpositioned, decayed, and missing teeth as noted in a dental clinical note. However, the annual MDS assessment indicated that the resident had no obvious or likely cavities or broken teeth. Direct observation confirmed the presence of black/brown discolored and missing teeth. The MDS nurse responsible for the assessment was unaware of the resident's dental issues and did not code them on the MDS. The facility administrator acknowledged that the MDS should have accurately reflected the resident's dental condition.

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