The resident hit the side of her bed during the fall with staff, she told inspectors. Hospital records from her January 21 admission show the traumatic wound measured 22 centimeters by 9 centimeters on the right side of her back. The area was purple and red with superficial reddening from injury.
But nursing home records contained no bruising assessment for the resident's back. No assessment of any kind.
The facility's own progress notes from December 21 documented that the dark areas on the resident's back had worsened, were getting darker, and were increasing in size. Staff opened an internal event report and notified the nurse practitioner.
Then nothing.
Federal inspectors found no further assessments of the area on the resident's back in the clinical record. The Director of Nursing Services confirmed during interviews that when staff created events in the computer system, they became internal incident reports. She provided no additional documentation or assessments during the survey process.
The resident's family member learned about the injury only when inspectors interviewed them on January 28. They had never been notified of the large bruise on their loved one's back. They were unaware the resident had fallen or sustained the bruising.
The resident suffers from stroke, a condition that occurs when lack of oxygen causes brain cells to die and can lead to lasting damage, paralysis, or speech impairment. Stroke is a leading cause of long-term disability. Her medical record showed no history of falls.
The facility's own bruising policy required staff to complete a bruise incident report in the electronic health record along with a template assessment progress note. Neither happened.
The traumatic wound was discovered during a complaint investigation at the nursing home. Inspectors reviewed three residents for quality of care and found the facility failed to complete thorough and accurate assessments for one of them.
Hospital documentation shows the wound existed when the resident was admitted to The Springs of Richmond. But the December progress note indicates the injury worsened significantly under the facility's care, growing darker and larger over time.
The gap between the facility's written policies and actual practice created a dangerous situation. Staff identified a worsening wound, opened an internal event, and notified medical providers. But they failed to follow their own procedures for documenting bruise incidents or conducting proper assessments.
More troubling, the family remained completely unaware of their loved one's condition. The resident herself had to tell inspectors about the fall during transfer that caused her injury. Her family learned about the traumatic wound only through the federal investigation.
The facility's wound management system contained no record of the bruising assessment that should have been completed. The Director of Nursing Services could not produce documentation showing proper evaluation of the 22-centimeter traumatic area.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. But for the stroke patient and her family, the consequences were immediate and personal. A traumatic wound went unassessed for weeks while growing darker and larger, and family members who should have been informed about their loved one's fall and injury were kept in the dark.
The resident's account of hitting the bed during a staff-assisted transfer raises questions about how the fall occurred and whether proper transfer techniques were followed. But without adequate documentation and assessment, those questions may never be answered.
The Springs of Richmond's failure to follow its own bruising policy left a vulnerable stroke patient without proper wound evaluation and her family without critical information about her care and condition.
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.