Lakeview Post Acute

Review of the resident's Braden Scale Observation/Assessment, dated 3/10/26, showed a

medical record, showed no skin assessments documented as completed from 3/9/26 through

the hospital for respiratory distress. No skin evaluation/assessment noted.

During an interview on 3/15/26 at 8:45 A.M., Hospital Nurse G said the resident returned to the same hospital from where he/she had been discharged to the facility 3/9/26. He/She returned to the hospital from the facility with a deep tissue injury (a serious form of pressure injury where intense, prolonged pressure damages soft tissue under the skin) to his/her coccyx.

Upon admission to the hospital on 3/14/26, the resident was noted to still be wearing the same protective skin dressing the hospital staff had applied prior to the resident's discharge to the facility on 3/9/26. 3.

During an interview on 3/26/26 at 3:33 P.M., the Director of Nursing (DON) and Administrator-in-Training said, both Wound Nurse C and ADON B were terminated effective 3/25/26 for poor work performance related to wound care and wound care management. 4.

During an interview on 3/26/26 at 2:28 P.M., the facility's Medical Director and primary care physician for both residents said he was not informed of Resident #1's wounds when they were first identified by nursing staff. He was not informed Resident #2 had a dressing on his/her coccyx when he/she was re-admitted to the facility on [DATE].

Nursing staff should absolutely assess every resident from head to toe on admission and/or re-admission.

Skin assessments should be completed on a weekly basis, at minimum.

The facility has had problems with communication regarding pressure ulcers and wound care. 27912022804303