The peeling extended about an inch up from the floor surface.
Nursing Home News — Page 432
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Resident #1 should have received 12 mg of warfarin on November 11, 12, and 13, according to Unit Manager #1's explanation to federal inspectors.
The longest delay occurred November 12, when one resident pressed the call button at 5:15 p.m.
The incident occurred at Memorial Manor on September 14th, when Staff B discovered the alarming vital signs but chose not to contact the resident's doctor.
Resident 103 attended dialysis three times weekly through a central line surgically placed in her right chest.
The resident also carried a diagnosis of chronic pain syndrome.
Resident 1 required specialized urinals due to their medical condition, but the facility's infection preventionist had no idea the equipment existed.
The incident occurred July 13, 2025, when Resident 5 made the statement to Licensed Practical Nurse D during an evening shift.
The facility's communication failures ran deep.
Resident #1 was transferred to the hospital emergency department on September 21.
The September incident involved a patient who takes Percocet four times daily for pain management through a specialized clinic.
The oversight meant staff had no written guidance about monitoring for life-threatening complications like blood clots, infections, or catheter displacement.