The Laurels of Gahanna: Care Plan Failures - OH
The resident had developed an unstageable pressure ulcer on the right gluteus, measuring 2.6 centimeters by 2.0 centimeters. Unstageable wounds are among the most serious classifications: the wound bed is obscured by dead tissue, making it impossible to determine how deep the damage runs. This one was 70 percent slough, the yellow or white dead tissue that signals the wound is not healing cleanly, and only 30 percent granulation, the new tissue that indicates repair. It was producing a moderate amount of serosanguineous drainage, the pink-tinged fluid that leaks from damaged tissue.
A second unstageable wound had formed on the resident's right elbow, measuring 2.3 centimeters by 1.9 centimeters, with the same breakdown: 70 percent slough, 30 percent granulation, moderate drainage. The facility had already determined, in its own documentation, that the gluteal wound had deteriorated.
Both findings appeared in a progress note. Neither was correctly reflected in the care plan.
The care plan, the document that is supposed to drive every clinical decision about a resident's treatment, listed the gluteal wound as a Stage II pressure ulcer. Stage II wounds involve only the outermost layers of skin. Unstageable wounds, by definition, cannot be evaluated that way — the tissue covering the wound bed prevents any assessment of depth. The two classifications are not interchangeable, and the difference matters for how a wound is treated, how often it is reassessed, and what interventions staff are expected to follow.
The MDS Coordinator, identified in inspection records as Coordinator 215, confirmed the discrepancy during an interview on August 12. The care plan, she verified, reflected a Stage II designation rather than the unstageable classification the resident actually had.
The facility's own care planning policy, dated March 3, 2025, states that care plans must be specific, resident-centered, individualized, and unique to each resident. The plan in place for this resident was none of those things. It described a wound that did not exist in the form documented, for a resident whose actual condition was more serious and less understood.
Inspectors classified the deficiency under F0656, which covers the requirement that facilities develop and implement comprehensive, individualized care plans. The level of harm was cited as minimal harm or potential for actual harm, and the finding was noted to affect some residents. It surfaced as an incidental finding during a complaint investigation — meaning inspectors came to the facility for a different reason and found this along the way.
The inspection was completed August 20, 2025.
What the care plan said and what was actually happening to this resident's body were two different things. The wounds were open, draining, and classified as unstageable. The paperwork said Stage II. Anyone reading the care plan to guide treatment would have been working from the wrong picture.
Pressure ulcers classified as unstageable require a different level of clinical attention than Stage II wounds. Slough must be addressed before the wound can even be properly assessed. A care plan that understates the severity of a wound does not just reflect poor recordkeeping — it shapes what staff do, or don't do, when they walk into that resident's room.
The resident's name does not appear in the publicly available inspection record. What is documented is the condition of their skin, the composition of their wounds, and the gap between what the facility knew and what it wrote down.
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: 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.
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Last verified: November 3, 2026 · Our methodology
THE LAURELS OF GAHANNA in COLUMBUS, OH was cited for violations during a health inspection on August 20, 2025.
The resident had developed an unstageable pressure ulcer on the right gluteus, measuring 2.6 centimeters by 2.0 centimeters.
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.