F0641

D

Inaccurate MDS Coding of Oral/Dental Status

Childress, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an accurate MDS assessment for a resident’s oral/dental status. A male resident with Guillain-Barre syndrome, lack of coordination, and need for assistance with personal care was admitted and later readmitted to the facility. His annual MDS assessment documented a BIMS score of 12, indicating he was cognitively intact, and Section L (Oral/Dental Status) was coded as "none of the above were present." The resident’s comprehensive care plan did not contain a focus area for dental care. During an observation and interview, the surveyor noted the resident had brown/discolored teeth, and the resident reported it had been a while since he had seen a dentist and that he likely needed to be placed back on a list to see a dentist due to some mouth pain.

In a phone interview, the MDS nurse stated she completed the annual MDS and that the resident told her he did not have any mouth pain and did not need anything, but he would not allow her to look in his mouth. The MDS nurse acknowledged she must have been in a hurry and should have coded Section L as "unable to examine," which, per her statement, would have triggered a care plan decision in Section V. Initially, the Interim Administrator stated he did not think the MDS nurse had marked the dental status incorrectly, explaining that he understood she did not see any issues and therefore marked no issues. After further discussion, the Interim Administrator stated he did think the MDS nurse had marked the dental status incorrectly and confirmed the facility did not have its own MDS policy and followed the CMS RAI guidelines. The RAI User’s Manual excerpt cited in the report specifies that "unable to examine" should be checked if the resident’s mouth cannot be examined.