The Springs of Richmond never notified the family about either the fall or the resulting injury, according to a federal inspection completed January 29. The traumatic wound measured 22 centimeters by 9 centimeters — roughly the size of a paperback book.
Hospital records from January 21 described the area as "purple and red with erythema," medical terminology for superficial reddening caused by injury. The resident had been admitted to the hospital with the wound already present.
Yet facility records show no bruising assessment was ever completed for the patient's back, despite the facility's own policy requiring incident reports and assessment progress notes for all bruising.
The resident suffers from stroke, a condition that can cause lasting brain damage, paralysis, and speech impairment. Her medical record contained no documentation of any fall.
Staff documented the injury's progression in a progress note dated December 21, more than a month before the hospital admission. The note stated the "dark areas to the resident's back worsened, was getting darker, and increasing in size."
An event was opened to notify the wound nurse. The nurse practitioner was also contacted.
Then nothing.
"The documentation had no further assessments of the area to the resident's back," inspectors found.
During the January 28 inspection, the Director of Nursing Services told investigators that computer events were converted into incident reports as internal documents. She provided no additional documentation or assessments of the resident's back injury.
The family member interviewed by inspectors said they had no knowledge of either the fall or the resulting bruise. The resident herself confirmed to inspectors that she had fallen during a staff-assisted transfer and struck the bed.
Federal inspectors reviewed the facility's bruising policy, provided by the nursing director during the survey. The written procedure explicitly required staff to complete a bruise incident report in the electronic health record along with an assessment progress note.
None of this happened for a wound the size of a small tablet.
The inspection found Springs of Richmond failed to provide appropriate treatment and care according to medical orders and resident preferences for quality of care. Inspectors classified the violation as causing minimal harm or potential for actual harm.
The case illustrates how documentation failures can leave vulnerable residents without proper medical attention. Stroke patients face particular risks from falls due to potential mobility limitations and medication effects that can increase bleeding or delay healing.
When facilities fail to follow their own assessment protocols, injuries can worsen without appropriate medical intervention. The December progress note showed staff recognized the bruising was deteriorating, yet no formal assessment process was initiated.
The family's lack of awareness meant they could not advocate for additional medical attention or monitor the injury's progression during visits. Federal regulations require facilities to notify families of significant changes in a resident's condition.
Springs of Richmond's violation occurred despite having written policies that should have triggered proper documentation and assessment. The gap between policy and practice left a stroke patient with an untreated traumatic wound that continued growing darker and larger.
The resident's account of hitting the bed during a transfer raises additional questions about staff training and fall prevention protocols, though inspectors did not cite violations in those areas.
Medical experts note that large bruises in elderly patients require careful monitoring for complications including infection, tissue death, or underlying fractures. Without proper assessment, such injuries can lead to serious medical consequences.
The inspection was conducted in response to a complaint. Federal regulators found the facility affected "few" residents with this particular violation, though the scope of assessment failures across the facility's resident population remains unclear.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Springs of Richmond, The from 2026-01-29 including all violations, facility responses, and corrective action plans.