Based on observation, record review, staff, Dentist and Medical Director interviews, the facility failed to schedule a dental cleaning and examination for Resident #51 after he had a recommendation from Dentist #1 on 10/28/2021 for a routine follow up in 2-6 months. Ten months after the recommendation, an 8/17/22 dental assessment identified two gingival abscesses, infection, and pain. A week later, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy began on 8/15/22 when dental pain and swollen areas were noted in Resident #51's mouth and it was discovered the follow-up dental appointment had not been schedule in the timeframe recommended. Immediate Jeopardy was removed on 8/28/22 when the facility implemented a credible allegation of immediate jeopardy removal. …
F791 citations in North Carolina
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
North Carolina cites F791 more often than its own record predicts
1.04 times the share F791 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F791 findings written in North Carolina, 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 record review, resident and staff interviews the facility failed to obtain dental services when ordered by the medical provider for 1 of 1 resident reviewed for dental services (Resident #52). The findings included: Resident #52 was admitted on [DATE]. with diagnosis that included quadriplegia. Resident #52's quarterly Minimal Data Set (MDS) dated [DATE] coded Resident #52 as cognitively intact and with no dental concerns. A review of a Nurse Practitioner (NP) progress note dated 7/14/23 read in part Resident #52 was seen for reports of dental pain and possible infected gum. The NP additionally wrote the resident had a cavity in the left lower molar and a referral to the inhouse dentist was made. …
Based on observations, record review and Medical Director, Nurse Practitioner, staff and resident interviews the facility failed to provide the necessary assistance to obtain dental services for 1 of 2 residents reviewed for dental services (Resident #57).The findings included:Resident #57 was admitted to the facility on [DATE] with diagnoses that included dysphagia oral phase (difficulty chewing or moving food from the mouth to the throat) and protein calorie malnutrition.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was cognitively intact and received a mechanically altered diet. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.43% | 1.48× |
| 2024 | 0.20% | 0.71× |
| 2025 | 0.29% | 1.04× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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