Springs of Richmond: Family Not Told of Bruise - IN
By the time they found out, they were already standing in a hospital room. Their family member, a stroke survivor with enough cognitive clarity to make her own daily decisions, had been hospitalized on December 21, 2025. That's when they saw it: a large, darkening bruise spread across her back. She told them she had fallen during a transfer with staff about a week before she went to the hospital. Nobody at the facility had told them about the fall. Nobody had told them about the bruise.
Nobody had told them anything.
A complaint inspection conducted January 29, 2026, at The Springs of Richmond, a nursing facility at 400 Industries Road in Richmond, Indiana, found that the facility failed to notify the resident's family of a significant injury — a large bruised area on her back — in the case of one of three residents reviewed for injury notification.
The resident, identified in the inspection report as Resident B, had a diagnosis that included stroke. The inspection record noted she was cognitively intact for daily decision making and described as consistent and reasonable on her admission assessment from September 24, 2025. She was not someone whose account of events could be easily dismissed.
She told her family member that the fall happened during a transfer with staff. But when inspectors reviewed her clinical record on January 28, 2026, there was no documentation of a fall at all. No incident report. No fall notation. Nothing to suggest the facility had ever recorded that a resident fell in the care of one of its employees.
What the record did contain was a progress note dated December 21, 2025, at 2:23 in the afternoon. That note documented that the dark areas on Resident B's back had worsened and were getting darker. The area had increased in size. According to the note, an event was opened in the computer system to make sure the wound nurse was aware. The Nurse Practitioner was notified.
The family was not mentioned. The note contained no indication that anyone had called them, or tried to call them, or planned to call them.
The family member told inspectors during an interview on January 28, 2026, at 12:48 in the afternoon that they were not notified of the bruise on Resident B's back. They were not aware a fall had occurred. They were not aware of the bruising. They learned about both only when their family member was admitted to the hospital and the bruise was visible in front of them.
The Director of Nursing Services, interviewed that same afternoon at 2:06, offered an explanation for how the facility's documentation system works. When an event is created in the computer, she said, it becomes an incident report. Incident reports, she said, are internal documents.
She provided no further information. She provided no documentation showing the family had been contacted.
Thirty-nine minutes later, at 2:25 that afternoon, the Director of Nursing Services provided inspectors with the facility's own notification policy. The policy stated its purpose plainly: to ensure the resident's responsible party is notified of a change in condition in a timely manner. The responsible party, the policy said, would be notified immediately of a change in condition.
A large bruise, growing darker and larger over the days before a resident was hospitalized, is a change in condition. The facility's own written policy said the family should have been called immediately.
They were not called at all.
The distinction the Director of Nursing drew between an internal incident report and a notification to a resident's family reveals something about how the facility understood its own obligations. An incident report created inside a computer system serves the facility's administrative record. A phone call to a family member serves the resident. The two are not the same thing, and completing one does not accomplish the other. The facility appeared to treat them as equivalent.
The fall itself raises questions the inspection report cannot fully answer, because the clinical record did not document it. Resident B told her family it happened during a transfer with staff. Transfers, when performed incorrectly or by a staff member working alone in circumstances that require assistance, carry real injury risk, particularly for residents with neurological conditions like stroke that may affect muscle tone, balance, or the ability to brace against a fall. A fall during a transfer that goes undocumented is a fall that cannot be reviewed, analyzed for cause, or used to prevent the next one.
What the record shows is that a wound was observed. An event was opened. A Nurse Practitioner was notified. The clinical machinery of documentation turned over, and it produced no record of a fall and no contact with the family.
Inspectors classified the violation as causing minimal harm or potential for actual harm. The citation covers one of three residents reviewed for injury notification, meaning the deficiency was not facility-wide in its documented reach. But the resident at its center was cognitively intact. She knew what had happened to her. She told her family herself, from a hospital bed, that she had fallen a week before she got there.
She was the one who made the notification. She did it when she was admitted to the hospital.
The facility's response, as described by the Director of Nursing Services, was to point to an internal document that the family never saw, generated by a computer system that the family had no access to, treated as the functional equivalent of a phone call that was never made.
The Springs of Richmond's own policy required that call to happen immediately. By December 21, when the progress note recorded a bruise that had grown darker and larger, the family had still not been reached. By the time inspectors arrived five weeks later in January, there was still no documentation in the record showing they ever had been.
Resident B's family found out in a hospital room, looking at a bruise on their loved one's back, while she explained to them what had happened to her a week before.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 31, 2026 · Our methodology
SPRINGS OF RICHMOND, THE in RICHMOND, IN was cited for violations during a health inspection on January 29, 2026.
By the time they found out, they were already standing in a hospital room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.