Based on medical record review, review of hospital records, review of dental records, staff interview, and facility policy review, the facility failed to ensure one resident (Resident #72) was provided dental care in a timely manner. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or medical emergency on 03/30/23 when Resident #72 was readmitted to the facility from the hospital where Resident #72 had been treated with three antibiotics for sepsis (the body's extreme response to an infection) caused by several abscessed teeth. Resident #72 was discharged from the hospital with an order to follow-up with a dentist as soon as possible (ASAP) for tooth extractions. …
F791 · Dental services
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F791 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F791 finding.
The harm level
How severely F791 is cited
2.1% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J20.2% | K— | L— |
| Actual harm | G251.9% | H— | I— |
| No harm, potential for more than minimal | D1,15687.9% | E13210.0% | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F791 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
This citation pertains to intake 3069088. Based on interview and record review, the facility failed to ensure a dental evaluation was completed in a timely manner for one resident (R901) of two residents reviewed for Nutrition, resulting in continued oral pain, facial swelling, delay in starting speech/language pathology therapy (SLP) and subsequently being kept on a pureed diet. Findings include:On 7/22/26 a concern submitted to the State Agency was reviewed which alleged R901 was unable to eat properly and did not receive the appropriate treatment for mouth pain. On 7/22/26 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and was discharged to the hospital on 6/27/26 and did not return. …
Based on observation, interview and record review it was determined the facility failed to ensure routine dental services were provided for 1 of 2 sampled residents (#13) reviewed for dental care needs. This placed residents at risk for delays in receiving necessary dental care. Findings include:The facility's Dental Services policy, dated 2001, indicated routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Resident 13 was admitted to the facility in 9/2025 with diagnoses including diabetes, end-stage renal disease, major depressive disorder and dysphagia (difficulty swallowing). …
Based on observation and interview, it was determined that the facility failed to provide emergency dental services for 1 resident in a final survey sample of 22 residents. (Resident identifier is #26.) Findings include: Resident #26 Interview on 7/17/19 at approximately 9:15 a.m. with Resident #26 revealed that on or around (MONTH) 9, 2019 the resident's right tooth, adjacent to the front tooth, had broken down the middle from the gum line. Resident #26 was concerned, stating that he/she didn't know if his/her insurance would pay for it or if he/she would have to pay for it himself/herself. Resident #26 stated that he/she did not have an appointment yet for the consultation or repair. …
Saint Vincent Rehabilitation & Nursing Center · New Hampshire
By state — 2025
Where F791 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Pennsylvania1.97× · 36 citations
- Ohio1.63× · 29 citations
Co-occurrence
Cited alongside F791
Of the 2025 surveys that cited F791, these tags appeared in the same inspection more often than chance would predict.
- F68515.7% of F791 surveys · 15.6× chance
Assist a resident in gaining access to vision and hearing services.
- F73011.3% of F791 surveys · 7.9× chance
Observe each nurse aide's job performance and give regular training.
- F69910.3% of F791 surveys · 7.6× chance
Provide care or services that was trauma informed and/or culturally competent.
- F67914.0% of F791 surveys · 6.7× chance
Provide activities to meet all resident's needs.
- F68821.7% of F791 surveys · 6.6× chance
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Cited in the same inspection, not caused by one another.
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