Federal inspectors arrived on January 2, 2026, and found the doors that way.
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That resident, identified in inspection records only as R1, told inspectors the hot water had been out on his hall for a couple of months.
On December 10, the medication administration record showed Midodrine given at 2:00 p.m.
The Director of Nursing told state inspectors on December 30 that she contacted the pharmacy to determine why the medication never arrived.
The facility failed to ensure residents received accurate assessments, a fundamental requirement for proper care delivery.
The May 17 incident triggered an immediate facility-wide search and prompted administrators to completely overhaul their security procedures within 48 hours.
The October incident at Dow Rummel Village involved a resident who required assistance with transfers.
Federal inspectors responding to a complaint found the facility violated meal service timing requirements on December 29, 2025.
Resident #2 was admitted with paraplegia, vertebra fractures, pneumothorax, and traumatic wounds to the neck and chest.
When this committee fails to operate as mandated, facilities lose their most important internal safeguard against declining care standards.
Federal regulations require nursing homes to prominently display current staffing levels where residents and visitors can easily access this information.
Resident #1, who has chronic pain syndrome, morbid obesity, lymphedema and osteoarthritis, was brought to their room after bingo and asked to go to bed.