Based on observation, interview, and record review, the facility failed to ensure residents received dental services to meet their needs for one of forty sampled residents (Resident 84), when Resident 84 did not receive routine and urgent dental care services which contributed to Resident 84's unintended weight loss of 22.2 pounds over a six month time period (11/2023 - 5/2024). This failure had the potential for muscle loss, loss of resident independence, poor healing, and increased susceptibility to infections for Resident 84. …
F791 citations in California
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.
Against expectation — 2025
California cites F791 less often than its own record predicts
0.50 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F791.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F791 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 5) was provided with follow up dental care and treatment in a timely manner. This failure resulted in prolonged dental pain for Resident 5 and the potential for Resident 5 developing an infection. Findings:During a concurrent observation and interview on 6/16/26 at 8:40 a.m. with Resident 5, in Resident 5's room, Resident 5 had multiple bottom front teeth that were visible at the gumline. Resident 5 stated his teeth hurt. Resident 5 stated he had been seen by a dentist while at the facility and was supposed to have the teeth removed, but the dentist had not been back. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 0.39× |
| 2024 | 0.10% | 0.35× |
| 2025 | 0.14% | 0.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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