The bruise appeared on September 2nd, measuring more than four inches long and nearly three inches wide.
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The administrator at NHC Healthcare Springfield later decided the incident didn't need to be reported to state authorities.
The physician ordered blood work on August 13 to be completed two days later.
Two to three minutes later, LVN 1 entered Room A to find Resident 1 on the floor near the foot of his bed.
The family member, identified as Person #1 in inspection records, immediately reported the allegation to the Assistant Director of Nursing.
Federal inspectors found Torrance Care Center West created generic, unmeasurable care plans that ignored what residents actually needed.
The failure left unanswered questions about whether the incident was related to neglect and put other residents at risk for repeated errors.
Despite physician orders for daily wound care beginning June 21, staff skipped treatments on 12 separate days through August 11.
was supposed to weigh Resident #29 every week starting June 11.
State regulations require nursing homes to report suspected abuse within two hours of notification.
The resident, identified in inspection records as R3, scored 4 out of 15 on a cognitive screening test, indicating severe mental impairment.
The resident entered the facility in January with lumbar spinal stenosis and high blood pressure.