The resident hit the side of her bed during the transfer with staff, she told inspectors. The resulting traumatic wound measured 22 centimeters by 9 centimeters and appeared purple and red with superficial reddening, according to hospital records from her January 21 admission.
But the facility's clinical records contained no bruising assessment for the resident's back. No other assessment of her back appeared anywhere in her file, inspectors found during their January 28 review.
The resident's family member learned about the bruise only when inspectors interviewed them. "The family member was not aware the resident had a fall or had the bruising," the inspection report stated.
Staff had documented the worsening condition in a December 21 progress note. The dark areas on the resident's back "worsened, was getting darker, and increasing in size," nurses wrote at 2:23 p.m. They opened an event notification to alert the wound nurse and notified the nurse practitioner.
Then nothing.
"The documentation had no further assessments of the area to the resident's back," inspectors found.
The resident's medical history included stroke, which the inspection report defined as lack of oxygen causing brain cells to die, potentially leading to lasting damage, paralysis, or speech impairment. Her clinical record showed no history of falls.
During the January 28 inspection, Director of Nursing Services explained that computer events automatically became incident reports classified as internal documents. She provided no additional documentation or assessments of the resident's back injury during the survey process.
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. The policy was provided to inspectors at 2:25 p.m. on January 28.
Federal inspectors classified the violation as providing minimal harm or potential for actual harm. The facility failed to complete a thorough and accurate assessment of the large bruised area for one of three residents reviewed for quality of care.
The wound measured nearly nine inches long and more than three inches wide. Hospital staff documented the traumatic nature of the injury upon the resident's admission, but the nursing home's wound management system showed no bruising assessment despite the facility's written procedures requiring such documentation.
The case illustrates a breakdown in basic wound assessment protocols. While staff recognized the severity of the injury enough to notify the wound nurse and nurse practitioner in December, they failed to follow through with required documentation and family notification.
The resident's family member discovered the extent of the injury and the circumstances surrounding it only when federal inspectors arrived to investigate a complaint about the facility. The family had no knowledge that their loved one had fallen during what should have been a routine transfer with staff assistance.
The Springs of Richmond's failure extended beyond documentation. The facility violated its own internal policies designed to ensure proper wound assessment and family communication. The bruising policy specifically outlined procedures that staff ignored in this resident's case.
Federal regulations require nursing homes to provide appropriate treatment and care according to physician orders and resident preferences. The Springs of Richmond's incomplete assessment of a traumatic 22-centimeter wound represents a fundamental failure to meet this standard.
The inspection occurred following a complaint and was completed on January 29. The violation affects few residents, according to the federal classification system, but highlights systemic problems in wound assessment and family communication at the facility.
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.