The resident at Prairie Estates told federal inspectors in September that her dentures "didn't look like real teeth and they felt like plastic." She said they fell out of her mouth and made eating and talking difficult.
"I have not worn them since I got them," she told inspectors during a September 23 interview.
The woman had complained to the facility's social worker about the denture problems and even sent an email about a month before the inspection. The social worker never responded to her email, she said.
A couple of weeks before the inspection, the resident broke a tooth while eating. She reported the broken tooth to her nurse, who promised to relay the information to the social worker.
Nothing happened.
"She told her nurse about the broken tooth and was told by the nurse she would relay that information to the Social Worker," according to the inspection report. The tooth initially hurt but the pain subsided.
The broken tooth made the resident self-conscious because it affected how she talked and chewed. When eating, "she had to mostly use her gums and what few teeth she did have," inspectors found.
The facility had scheduled a dental appointment for another resident in April, but that patient wasn't seen by the dentist either. The dentist's records showed the reason as "Patient was Unavailable: hygiene."
LVN A told inspectors she didn't recall any issues with the first resident's dentures or broken tooth. She said her standard practice was to notify the social worker when residents reported dental problems, and the social worker would schedule care either within the facility or with an outside dentist.
The nurse said she was "unsure why Resident #1 did not wear her dentures and stated that the resident refused to wear them."
CNA B said she wasn't aware the resident even had dentures. "She reported she had never seen her wearing her dentures," the inspection found.
Inspectors discovered the resident's comprehensive care plan from July contained no goals or interventions related to dental or oral health care needs. The Regional Director of Clinical Services admitted during a September 23 interview that he was unaware the resident's care plan failed to address dental needs.
"He stated it was something that would need to be in her care plan," inspectors wrote. "He stated the risk to the resident was not receiving appropriate interventions."
The facility's own policy requires comprehensive care plans to include measurable objectives and time frames, along with residents' stated goals and desired outcomes. The interdisciplinary team is supposed to review and update care plans when there's been a significant change in a resident's condition, when desired outcomes aren't met, after hospital readmissions, and at least quarterly.
The dental care failures affected multiple residents. Beyond the woman with broken teeth and unusable dentures, at least one other resident missed a scheduled dental appointment with no follow-up care arranged.
The inspection found the facility failed to ensure residents received necessary dental services to maintain oral health. Federal inspectors cited Prairie Estates for not providing appropriate treatment and services for dental care needs.
The resident with the broken tooth continues to eat primarily with her gums, unable to wear dentures that never fit properly and with no dental intervention despite months of complaints to staff and management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prairie Estates from 2025-11-24 including all violations, facility responses, and corrective action plans.