Laurels of Gahanna: Failed to Report Skin Injury - OH
The Laurels of Gahanna failed to document when the skin tear occurred, how it happened, or whether anyone was notified about the worsening injury to Resident 79's right elbow, federal inspectors found during an August complaint investigation.
The resident had lived at the facility since December 2020 with multiple sclerosis, diabetes, severe cognitive deficits and complete dependence on staff for daily care. A comprehensive assessment showed the resident also suffered from malnutrition, chronic pain, anxiety and a history of falling.
By August 7, nursing staff had documented an unstageable pressure ulcer on the resident's right lateral elbow measuring 3.2 centimeters by 4.9 centimeters. The wound contained 60 percent healing tissue and 40 percent dead tissue, with moderate drainage.
But the weekly evaluation revealed something had changed. The facility noted the wound had "deteriorated" and grown larger because "the resident had a skin tear medial to the wound bed and it conjoined with the pressure ulcer."
No record existed of when staff discovered the skin tear.
No documentation showed how the injury occurred.
Nobody had notified the resident's physician or family about the additional wound.
Registered Nurse 147 confirmed during an August 11 interview that the facility had no documentation about when or how the skin tear happened, and verified that neither the physician nor family had been told about the injury.
The facility's own policy, last revised in February, required staff to inform residents, consult with physicians and notify family representatives when there was a change in status requiring altered treatment. The policy specifically included situations requiring new forms of treatment or discontinuation of existing treatment due to adverse consequences.
An unstageable pressure ulcer represents full-thickness skin and tissue loss where inspectors cannot determine the extent of damage because the wound bed is obscured by dead tissue or other material. These wounds typically require specialized treatment and close monitoring to prevent infection and further deterioration.
The resident's complex medical conditions made proper wound care critical. Multiple sclerosis affects the nervous system and can impair sensation, while diabetes slows healing and increases infection risk. The resident's severe malnutrition further compromised the body's ability to repair tissue damage.
Federal regulations require nursing homes to immediately notify residents, their doctors and family members of situations that affect the resident, including injuries and changes in condition. The requirement exists to ensure families can make informed decisions about care and physicians can adjust treatment plans when medical conditions change.
The inspection occurred as part of a complaint investigation at the 107-bed facility. Inspectors reviewed three residents' records for pressure ulcer care and found the notification failure affected one resident.
Facility staff continued the same wound treatment despite documenting that the condition had deteriorated. The larger wound surface area resulted from the skin tear connecting with the existing pressure ulcer, creating a more complex injury requiring potentially different care approaches.
The resident's medical record contained no explanation for how a skin tear severe enough to join with an adjacent pressure ulcer could occur without staff knowledge or documentation. Skin tears in elderly residents often result from friction during transfers, repositioning or daily care activities.
The facility's failure to document the incident left the resident's family unaware their loved one had sustained an additional injury. The physician treating the resident also remained uninformed about the change in wound status that facility staff had determined represented deterioration.
Resident 79 remained at the facility with the enlarged wound, dependent on staff who had failed to follow their own policies for reporting significant changes in medical condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Laurels of Gahanna from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE LAURELS OF GAHANNA in COLUMBUS, OH was cited for violations during a health inspection on August 20, 2025.
A comprehensive assessment showed the resident also suffered from malnutrition, chronic pain, anxiety and a history of falling.
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.