The Laurels Of Gahanna

Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit.

The assessment indicated the resident was dependent on staff for all activities of daily living (ADL).

Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was found to have an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right lateral elbow measuring 3.2 centimeters (cm) by 4.9 cm by less than 0.1 cm and described as 60% granulation tissue and 40% eschar (dead or devitalized tissue).

The wound had a moderate amount of serosanguineous exudate.

The facility continued the same treatment.

The facility determined the wound had deteriorated.

The note indicated the resident had a skin tear medial to the wound bed and it conjoined with the pressure ulcer which was the reasoning for the larger measurements in surface area.

Review of the medical record revealed no documentation on when the skin tear was found, how the skin tear occurred or documented evidence the resident's family or physician was notified of the skin tear. On 08/11/25 at 12:10 P.M., interview with Registered Nurse (RN) #147 verified the facility had no documentation of when, how the skin tear occurred or the physician and family were notified of the skin tear to her right elbow.

Review of the facility policy titled, Notification of Change, last revised 02/14/24 revealed the facility must inform the resident, consult with the resident's practitioner and notify consistent with his or her authority, the resident representative when there is a change in status. A change in status would include the following, a need to alter treatment significantly, that is need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner.

This affected four residents (#10, #11, #12, #67) of 107 residents.

The facility census was 107.Findings include:1.Review of Resident #10's medical record revealed an admission date of 12/14/23 with diagnoses including spinal stenosis, anxiety disorder, cognitive communication deficit, depression, and type two diabetes mellitus.Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Observation on 08/11/25 at 2:50 P.M. of Resident #10's room revealed a build up debris under her bed including bits of plastic. 2.Review of Resident #11's medical record revealed the resident admitted on [DATE] with diagnoses including unspecified mood disorder, type two diabetes mellitus, cerebral infarction, aphasia, and hemiplegia and hemiparesis affecting left non-dominant side.Review of Resident #11's five-day MDS 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Observation on 08/11/25 at 2:50 P.M. of Resident #11's room revealed brown splatters next to Resident #11's bed and her bedside table was covered in numerous white stains. 3.Review of Resident #12's medical record revealed an admission date of 06/04/22 with diagnoses including Alzheimer's disease, muscle weakness, dysphagia, legal blindness, and cerebrovascular disease.Review of Resident #12's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Observation on 08/11/25 beginning at 10:42 A.M., 2:50 P.M., and 4:20 P.M. of Resident #12's room revealed her comforter had multiple yellow stains and had food caked on it.

The wall next to her bed had unidentifiable black splatters covering it.4.Review of Resident #67's medical record revealed an admission date of 08/25/21 with diagnoses including dysphagia, cerebral infarction, unspecified dementia, major depressive disorder, and hemiplegia and hemiparesis affecting left non-dominant side.Review of Resident #67's five-day MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition.Observation on 08/11/25 at 4:20 P.M. of Resident #67's room revealed the wall next to her bed had brown splatters and under her bed had a buildup of dust and various items including straws and bits of plastic.

Additionally, her bedside table was covered in unidentifiable stains.

Interview on 08/11/25 at 4:20 P.M. with the Administrator verified the above observations in resident rooms.

Review of the policy ‘Housekeeping Services' dated 07/11/25 revealed thorough scrubbing was to be used for all environmental surfaces cleaned in resident areas.

Areas to be cleaned in resident rooms included all horizontal flat surfaces, over bed tables and walls should be spot cleaned if visibly soiled.

This deficiency represents noncompliance investigated under Complaint Number 1399441.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of the medical record for Resident #79 revealed an initial admission date of 12/17/20 with the diagnoses including but not limited to multiple sclerosis, diabetes mellitus, vitamin D deficiency, anxiety disorder, encounter for palliative care, opioid use, pain, cerebellar ataxia, history of falling, severe protein malnutrition, hypertension, chronic pain syndrome and adult failure to thrive.

Review of the resident’s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit.

The assessment indicated the resident was dependent on staff for all activities of daily living (ADL).

Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was found to have an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right lateral elbow measuring 3.2 centimeters (cm) by 4.9 cm by less than 0.1 cm and described as 60% granulation tissue and 40% eschar (dead or devitalized tissue).

The wound had a moderate amount of serosanguineous exudate.

The facility continued the same treatment.

The facility determined the wound had deteriorated.

The note indicated the resident had a skin tear medial to the wound bed and it conjoined with the pressure ulcer which was the reasoning for the larger measurements in surface area.

Review of the medical record revealed no documentation on when the skin tear was found or how the skin tear occurred.

On 08/11/25 at 12:10 P.M., interview with Registered Nurse (RN) #147 verified the facility had no documentation of when and how the skin tear occurred.

On 08/12/15 at 12:45 P.M., an interview with the Director of Nursing (DON) revealed she spoke with Registered Nurse (RN) #128 and the wound was from the resident’s Broda chair because her hospice company documented her up in the chair on 08/02/25 and she called the resident’s company and requested the resident hospice notes.

Review of the facility policy titled, “Abuse Prohibition Policy,” last revised 09/09/22 revealed each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property.

This deficiency represents noncompliance investigated under Complaint Number 1399441.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit.

The assessment indicated the resident was dependent on staff for all activities of daily living (ADL).

Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was found to have an unstageable(Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right lateral elbow measuring 3.2 centimeters (cm) by 4.9 cm by less than 0.1 cm and described as 60% granulation tissue and 40% eschar (dead or devitalized tissue).

The wound had a moderate amount of serosanguineous exudate.

The facility continued the same treatment.

The facility determined the wound had deteriorated.

The note indicated the resident had a skin tear medial to the wound bed and it conjoined with the pressure ulcer which was the reasoning for the larger measurements in surface area.

Review of the medical record revealed no documentation on when the skin tear was found or how the skin tear occurred. On 08/11/25 at 12:10 P.M., interview with Registered Nurse (RN) #147 verified the facility had no documentation of when and how the skin tear occurred. On 08/12/15 at 12:45 P.M., an interview with the Director of Nursing (DON) verified the medical record contained no documented evidence of how or when the skin tear occurred.

The DON verified the facility had not reported the injury of unknown origin to the state agency.

Review of the facility policy titled, Abuse Prohibition Policy, last revised 09/09/22 revealed each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property.

The staff will report an allegation or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property and injuries of unknown origin source to the Administrator and DON immediately.

The Administrator or designee will notify the resident's representative and also any state and federal agencies of allegation per state guidelines.This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit.

The assessment indicated the resident was dependent on staff for all activities of daily living (ADL).

Review of the weekly skin and wound evaluation dated 08/07/25 revealed the resident was found to have an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right lateral elbow measuring 3.2 centimeters (cm) by 4.9 cm by less than 0.1 cm and described as 60% granulation tissue and 40% eschar (dead or devitalized tissue).

The wound had a moderate amount of serosanguineous exudate.

The facility continued the same treatment.

The facility determined the wound had deteriorated.

The note indicated the resident had a skin tear medial to the wound bed and it conjoined with the pressure ulcer which was the reasoning for the larger measurements in surface area.

Review of the medical record revealed no documentation on when the skin tear was found or how the skin tear occurred. On 08/11/25 at 12:10 P.M., interview with Registered Nurse (RN) #147 verified the facility had no documentation of when and how the skin tear occurred. On 08/12/15 at 12:45 P.M., an interview with the Director of Nursing (DON) revealed she spoke with Registered Nurse (RN) #128 and the wound was from the resident's Broda chair because her hospice company documented her up in the chair on 08/02/25 and she called the resident's company and requested the resident hospice notes.

The DON verified the resident's medical record contained no documented evidence the resident had a skin tear to her right elbow, when the skin tear occurred or how the skin tear occurred.

Review of the facility policy titled, Abuse Prohibition Policy, last revised 09/09/22 revealed each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property.

The DON or designee will complete and assessment of the resident and document the findings. An incident report will be completed.

The licensed nurse will notify the physician if required and notify the family member/responsible party/emergency contact/legal guardian. A preliminary, no-site investigation will be initiated with 24 hours of any report.This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility policy titled, Transfer and Discharge, last revised 04/22/25 revealed the transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility.

When a resident is transferred on an emergency basis to an acute care facility a transfer from is completed, a list of medications and a copy of the care plan goals is sent to the receiving hospital.

Nursing documents the hospital transfer in the medical record.

Further review revealed a notice of transfer or discharge must be made by the facility in writing 30 days before the resident was transferred or discharged .

The exception to this was when the resident’s welfare was at risk such as an emergency transfer, however, the notice must be made as soon as practicable.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

The assessment indicated the resident was at risk for skin breakdown and had two unstageable pressure ulcers on admission and one deep tissue injury present on admission.

The MDS did not address the vascular wounds to the resident’s right first and second toes.

On 08/12/25 at 11:13 A.M., an interview with Minimum Data Set (MDS) Coordinator #215 verified the resident's MDS assessments did not reflect the vascular wound on his left and right feet.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of policy ‘Care planning’ dated 03/03/25 revealed the care plan must be specific, resident centered, individualized and unique to each resident.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #109's physician order dated 03/21/25 to 04/14/25 revealed an order for Apixban (an anticoagulant) 2.5 milligrams (mg) one tablet by mouth twice a day for atrial fibrillation.

Review of Resident #109's progress note dated 04/10/25 revealed the resident had bruises on the left side of her upper body from using a gait belt during transfer by staff.

The resident denied any pain from the bruises. An X-ray was ordered by the Certified Nurse Practitioner (CNP) to rule out any fracture.

Review of Resident #109's progress note dated 04/11/25 revealed an order to discontinue the order for an X-ray to the arm.

The resident did not have any falls or incidents that could cause injuries.

Review of Resident #109's interdisciplinary team note dated 04/11/25 revealed the team met to review a bruise noted to the residents left upper body. It was noted that there was a bruise to her left underarm that extended under her left breast.

After speaking with the resident and Certified Nursing Assistant (CNA) it was revealed that during a transfer from the bed to the wheelchair the resident's knees gave out.

The CNA tightened the gait belt and guided the resident to the wheelchair to prevent a fall.

Intervention was to offer and encourage two person assistance with all transfers.

Review of Resident #109's medical record revealed no measurement of the bruise or further monitoring.

Review of Resident #109's hospital notes dated 04/13/25 revealed a CT scan was done.

The resident was found to have a chest wall hematoma that was being monitored to ensure it was not spreading.

Interview on 08/07/25 at 10:28 A.M. with Assistant Director of Nursing (ADON) #128 revealed initially they thought the resident had an unwitnessed fall, so an X-ray was ordered.

When they figured out what happened the nurse practitioner cancelled the X-ray because the resident had not fallen.

They were notified of the bruising by therapy and the actual incident occurred on 04/09/25. ADON #128 stated she brought the CNA to the residents room and had her explain what happened.

She had the resident had started to fall and the gait belt started to slide up and it tightened around her breast area.

They educated the CNA that she should have let the nurse know of the incident.

She verified there was no monitoring of the bruise, but stated it was a big bruise and they would have noticed if it had gotten bigger.

She indicated it was from the waist up to the shoulder.

She reported the incident happened quickly and she would not have wanted the resident to fall.

Review of the facility policy titled, Skin Management, last revised 08/14/24 revealed a skin tear is an opening or break in the skin due to friction, shear or trauma and is technically a separation of the epidermis and dermis.

All skin tears will be evaluated, documented and treated based on physician orders. On occurrence all skin tears will be reported to the licensed nurse, an incident and accident report is to be completed, the licensed nurse is responsible for documenting skin tears upon occurrence and monitoring on a weekly basis until healed.

This deficiency represents noncompliance related to complaint 2580593, 2574352, and 1399347.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Registered Nurse (RN) #172 verified the mattress was not on the physician ordered setting of five.

Review of the facility policy titled, Skin Management, last revised on 08/14/24 revealed upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record.

Residents admitted with any skin impairment will have appropriate interventions implemented to promote healing, a physician's order for treatment and skim impairment location, measurements and characteristics documented.

The licensed nurse will initiate documentation in the electronic health record which includes a description of the skin impairment.

This deficiency represents non-compliance investigated under Complaint Number 2580593 and Complaint Number 2574352.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #38’s KUB results dated 07/23/25 revealed the resident had a nonobstructive bowel gas pattern.

Review of Resident #38’s medical record from 07/24/25 to 07/27/25 revealed no further mention of the resident’s left sided pain.

Review of Resident #38’s physician order dated 07/28/25 revealed an order for a urinary analysis with culture and sensitivity for urinary tract infection (UTI).

Review of Resident #38’s progress notes from 07/28/25 to 08/09/25 revealed no further mention of a UTI.

Review of Resident #38’s urine culture collected 07/29/25 and reported 08/01/25 revealed it did not indicate any bacteria present in the urine but, it indicated what the bacteria was sensitive to.

Review of Resident #38’s urine screen and culture collected 08/05/25 and reported 08/07/25 revealed her results were abnormal, and she had bacteria present that was sensitive to specific bacteria, however, no bacteria was listed.

Review of Resident #38’s lab result reported 08/06/25 revealed the resident had Escherichia coli in her urine.

Review of Resident #38’s nurse practitioner note dated 08/08/25 revealed the resident was on ciprofloxacin for a urinary tract infection.

The nurse practitioner suspected the flank pain was more musculoskeletal in nature.

Interview on 08/11/25 at 12:00 P.M. with the Director of Nursing (DON) revealed on 07/22/25 or 07/23/25 the resident reported flank plan.

This was thought to be constipation, so when it came back negative they reassessed her and decided to check for a UTI. It came back negative so she was checked for a urinary tract infection.

The first results on 08/01/25 came back without the organism, so they sent it back.

She was unsure of what happened with the lab and verified there was no documentation of the nurse practitioner or physician being notified of any results.

Additionally, there was no documentation of the physician or nurse practitioner’s plans after the negative KUB results.

From the negative KUB to an order for a urinary analysis there was five days.

This deficiency represents noncompliance investigated under complaint 2580593 and 2574352.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #26's minimum data set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition.

Review of Resident #26's plan of care revealed it did not address his oxygen usage.

Review of Resident #26's physician orders from 06/18/25 to 08/06/25 revealed no orders for oxygen.Review of Resident #26's progress note dated 06/18/25 revealed the resident arrived to the facility with oxygen on at two liters.

Review of the skilled nursing notes dated 6/20/25, 07/04/25, 07/06/25, 07/07/25, 07/08/25, 07/09/25, 07/11/25, 07/12/25, 07/13/25, 07/15/25, 07/16/25, 07/18/25, 07/19/25, 07/22/25, 07/23/25, 07/24/25, 07/26/25, 07/29/25, 07/31/25, 08/01/25, 08/04/25, 08/05/25, 08/06/25, revealed the resident received oxygen.

Review of Resident #26's physician order dated 08/07/25 revealed an order for oxygen at two liters via continuous oxygen.Interview on 08/11/25 at 11:34 A.M. with the Director of Nursing (DON) verified Resident #26 had been receiving oxygen his entire stay and an order and care plan had not been in place.This deficiency represents noncompliance investigated under Complaint Number 2574352.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #26's minimum data set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition.

Review of Resident #26's progress note dated 07/20/25 revealed the resident called emergency medical services for pain in his legs.Review of Resident #26's progress note dated 07/20/25 revealed the resident returned from the hospital with a new order for pain medication.

Review of Resident #26's physician order dated 07/21/25 revealed an order for one tablet every eight hours as needed for severe pain for three days.Review of Resident #26's physician order dated 07/21/25 to 07/23/25 revealed an order for hydrocodone-acetaminophen 325 mg one tablet by mouth every eight hours as needed for severe pain for three days.

Nonpharmacological interventions were to be attempted.Review of resident #26's physician order beginning 07/23/25 revealed an order for hydrocodone-acetaminophen 325 mg one tablet by mouth every eight hours as needed for severe pain.

Nonpharmacological interventions were to be attempted.Review of Resident #26's Medication Administration Record for July 2025 and 08/01/25 to 08/09/25 revealed hydrocodone-acetaminophen was administered on 07/21/25 for an unknown pain and a pain of seven, on 07/22/25 for a pain of six and eight, on 07/25/25 for a pain of eight, on 07/26/25 for a pain of seven, on 07/29/25 for a pain of four, on 07/31/25 for a pain of three, on 08/02/25 for a pain of three, on 08/05/25 for a pain of seven and four, on 08/06/25 for a pain of four, on 08/08/25 for a pain of eight and six, and on 08/09/25 for a pain of eight.Review of Resident #26's progress notes revealed there was no description of the pain for medication administration on 07/21/25, 07/22/25, 07/25/25, 07/26/25, 07/29/25, 07/31/25, 08/02/25, 08/05/25, 08/06/25, 08/08/25, and 08/09/25.Review of Resident #26's plan of care revealed it did not address his pain.Interview on 08/11/25 at 2:24 P.M. with the Director of Nursing (DON) revealed a severe pain would be a pain of seven or above.

She verified pains of three and four were not considered severe.

The DON verified there was no description of pain or assessment of Resident #26's change in pain.Interview on 08/11/25 at 2:47 P.M. with Resident #26 revealed his pain was continuous and it was in his feet, he believed it was up to diabetic neuropathy.

Review of the policy ‘pain management' dated 04/28/25 revealed residents were to be monitored for the presence of pain and evaluated when there was a change in condition and whenever new pain was suspected.

Staff was asked to determine the location of pain.

Each resident identified with pain was to have a pain management care plan.This deficiency represents noncompliance investigated under Complaint Number 2574352 and 2580593.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #108's plan of care dated 04/26/25 revealed resident was at risk for complications related to dialysis.

Interventions included encouraging him to go for the scheduled appointments, observing for signs of fluid retention, observing for signs of infection to access site, observing for bruising or bleeding, and palpitating for the presence of thrill and listen for bruit as needed.

The plan of care was not specific to the resident, did not include where he went to dialysis, how to contact them, or when he was to go to dialysis.

Review of Resident #108's physician order dated 04/29/25 to 05/14/25 revealed he was to attend hemodialysis every Tuesday, Thursday, and Saturday.

Review of Resident #108's progress note dated 05/10/25 revealed the resident refused dialysis due to agitation and discomfort.

There was no indication the resident was educated on the risks and benefits of refusals.Interview on 08/07/25 at 1:13 P.M. with the Director of Nursing (DON) revealed if a resident refuses dialysis nursing should educate them on the risks and benefits of refusal.

Interview on 08/11/25 at 1:07 P.M. with MDS Nurse #215 verified Resident #108's care plan was not specific to the resident. 2.

Review of Resident #102's medical record revealed an admission date of 06/05/25 with diagnoses including end stage renal disease (ESRD) with dependence on renal dialysis, cognitive communication deficit, moderate protein-calorie malnutrition, and type two diabetes mellitus.

Review of Resident #102's comprehensive Minimum Data Set (MDS) dated [DATE] revealed he had impaired cognition.Review of Resident #102's plan of care dated 06/05/25 revealed the resident was at risk for complications related to dialysis due to ESRD and history of noncompliance with hemodialysis.

Interventions included administering medications as ordered, checking and reinforcing dressing to access cite as needed, encourage to avoid contact with individuals with infection, hemodialysis three times a week as ordered, if the resident chose not follow the recommended treatment they were to remind him of the consequences and document on it.

Review of Resident #102's progress note dated 06/27/25 revealed the resident refused dialysis.

There was no indication his family was notified.

Interview on 08/07/25 at 1:13 P.M. with the Director of Nursing (DON) revealed if a resident refuses dialysis nursing should educate the resident and notify the family.This deficiency represents non compliance investigated under Complaint Number 2574352 and 2580593.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit.

Review of the May 2025 Medication Administration Record (MAR) revealed the resident had not received the medication Calcitriol 0.25 micrograms (mcg) by mouth daily for hypocalcemia on 04/27/25, 04/28/25 and 04/29/25.

Further review of the MAR revealed the resident had not received the medication Sevelamer 800 milligrams (mg) with the special instructions to administer three tablets by mouth three times a day, the resident also was not provided with Diphenhydramine-Zinc Acetate 2-0.1% cream with the special instructions to apply to skin topically twice daily for skin itching/irritation on 04/26/25, 04/27/25, 04/28/25 and 04/29/25 when the medication was discontinued.

The resident was also not provided with Brimonidine Tartrate Ophthalmic solution 0/2% with the special instruction to instill one drop in right eye three times daily on 04/26/25.

Review of the June 2025 MAR revealed the resident had not been administered the medications Sevelamer 800 mg with the special instructions to administer three tablets by mouth three times a day on 06/14/25, 06/16/25 and 06/17/25. On 08/11/25 at 12:10 P.M., an interview with the Director of Nursing (DON) verified the medication was not available for administration as physician ordered.

Review of the facility policy titled, Medication Administration, last revised 10/17/23 revealed resident medications are administered in an accurate, safe, timely and sanitary manner.

This deficiency represents non-compliance investigated under Complaint Number 1399441.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

08/06/25 from 1:07 P.M. to 1:50 P.M. revealed Dietary Manager #130 did not think the sanitation strips were working right, she reported they did not change color when she dipped it directly into the sanitizer.

The dietary aides were observed putting dishes through the dishwasher, the three-compartment sink was empty.

Dietary Manager #130 verified she was still unable to verify the dishwasher was running appropriately and the aides were using it anyways.

The dietary manager reported she expected the dietary aides to check the sanitation level and temperature of the dishwasher with the first rack of dishes in the morning, she verified this had not been done.

Dietary Manager #130 reported the sanitizer had been delivered yesterday and the staff connected it.

She reported the machine determined the mount of chemicals and other than connecting the sanitizer nobody in the facility had to do anything.Interview on 08/06/25 at 2:23 P.M., 2:47 P.M., and 3:27 P.M. with Plant and Maintenance Director #129 revealed he was unaware of any concerns with the dishwasher. He reported when a new chemical was connected to the dishwasher kitchen staff should be checking that its pumping and press the button above the pump to get it moving if it is not.

Review of the dishwasher sanitation log provided on 08/06/25 at 2:50 P.M. revealed for 08/06/25 it was indicated that the dishwasher was at the appropriate temperature and sanitation level for breakfast and lunch.

Interview with Dietary manager #130 at that time verified this was incorrect and she was unsure how she knew if the forms were ever being completed accurately if the aides were documenting it was working when it was not.Observation and interview on 08/06/25 at 3:35 P.M. with Plant and Maintenance Director #129 and [NAME] Serviceman #232 revealed the [NAME] serviceman brought his own test strips and the dishwasher was running appropriately. [NAME] Serviceman #232 stated if the previous sanitizer was run to empty then there may have been air in the tube preventing sanitizer from coming out.

This would require using the button above the pump to get things moving.

When it is working right, sanitizer comes out immediately when the button is pressed. He reported dipping the test strips directly into the sanitizer would be ineffective because the test strip requires water.

Additionally, he reported soap coming out the front of the dishwasher could have been related to a clog that fixed itself, as this was no longer occurring.

This deficiency represents noncompliance with Complaint Number 1399439.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Observation 0n 08/06/25 from 9:40 A.M. to 10:08 A.M. of the kitchen revealed Dietary Aide #226 putting away trays that had been removed from the dishwasher.

There was one rack of trays remaining on the clean side of the dishwasher and next to it were piles of soiled cups.

Upon four attempts at running the dishwasher Dietary Manager #130 was unable to confirm the sanitizer was running at an appropriate level.

Interview with Dietary Aide #226 verified she had washed dishes in the dishwasher but had not checked the sanitation level or temperature that morning.Interview on 08/06/25 from 1:07 P.M. to 1:50 P.M. revealed Dietary Manager #130 revealed she expected the dietary aides to check the sanitation level and temperature of the dishwasher with the first rack of dishes in the morning.

Review of the dishwasher sanitation log provided on 08/06/25 at 2:50 P.M. revealed for 08/06/25 it was indicated that the dishwasher was at the appropriate temperature and sanitation level for breakfast and lunch.

Interview with Dietary manager #130 at that time verified this was incorrect and she was unsure how she knew if the forms were ever being completed accurately if the aides were documenting it was working when it was not.3.

Interview on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed they were short staffed and were particularly short on cooks.

She reported Dietary [NAME] #123 was actually a dietary aide, however, they had been sharing the roll of cook.

Dietary [NAME] #123 worked as the sole cook on the weekends.Interview on 08/06/25 from 12:25 P.M. to 12:55 P.M. with Resident #96 revealed the food was not great.

Interview with Resident #97 revealed the food was awful.

Interview with Resident #102 revealed the food was not good.Review of Dietary [NAME] #123's personnel file revealed she was hired on 04/27/22 as a dietary aide.

The only job description in her personnel file was dietary aide, there was no evidence she had received training as a cook.Interview on 08/06/25 at 3:50 P.M. with the Administrator verified Dietary [NAME] #123 was not trained as a cook. He reported he was unaware of this and she had been in the position when he started.This deficiency represents noncompliance investigated under Complaint Number 1399439.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation and interview the facility failed to ensure food was served at a palatable temperature.

This had the potential to affect 104 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth.Findings include: Interview on 08/06/25 from 12:25 P.M. to 12:55 P.M. with Resident #96 and #97 revealed the food was not always hot when it got to them.

Interview with Resident #102 revealed the food was often cold and lunch on that day had been cold as well.Observation on 08/06/25 at 12:30 P.M. revealed the last trays being passed on the E Hall, the cart was open and remained open as Certified Nursing Assistant (CNA) #106 passed the trays.

She finished the trays at 12:39 P.M.Observation on 08/06/25 at 12:41 P.M. of a test tray with Dietary Manager #130 revealed the stuffed pepper was 119 degrees Fahrenheit (F), the peas were 102 degrees F, and the [NAME] was 103 degrees F.

All foods were cold when sampled.Interview on 08/06/25 at 12:41 P.M. with Dietary Manager #130 verified the foods were not at an appropriate temperature.

She reported in the kitchen the foods were at least 175 degrees F and should be 140 degrees F when it got to the residents.

She reported all carts had left the kitchen by 12:00 P.M.Interview on 08/07/25 at 1:01 P.M. with Resident #48 revealed the food was not always hot when it got to her.

Review of the menu for 08/06/25 revealed it included one stuffed pepper, four ounces of rice, four ounces of diced vegetables, and four ounces of bread pudding.This deficiency represents noncompliance investigated under Complaint Number 1399441.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Review of the chemical instructions for SparClean Sanitizer revealed the dishwasher's chemical dispensing device could be adjusted to ensure to meter the proper amount of product into the machine.

Review of the owner's manual for the dishwasher revealed the minimum wash temperature was 120 degrees F and chemical sanitizer concentration should be 50 parts per million (ppm) to 100 ppm.This violation represents noncompliance investigated under Complaint Number 1399439.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Gahanna

5151 North Hamilton Road Columbus, OH 43230

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure kitchen equipment was in working order and a system was in place to track maintenance requests.

This had the potential to affect 104 residents who consumed food from the kitchen the facility identified three residents (#2, #84, and #92) who ate nothing by mouth.

The facility also failed to ensure a safe and clean environment when 35 resident rooms had missing transition strips from residents to hallways.

This affected 48 residents (#1, #3, #4, #6, #7, #10, #11, #12, #13, #19, #20, #26, #27, #31, #33, #36, #39, #42, #43, #44, #45, #46, #47, #53, #54, #55, #56, #57, #58, #77, #78, #85, #88, #89, #90, #91, #93, #95, #96, #97, #98, #99, #100, #103, #104, #105, #106, and #107) of 107 residents residing in the facility.Findings include: 1.Observation on 08/06/25 from 9:40 A.M. to 10:08 A.M. with Dietary Manager #130 revealed the disposal connected to the dishwasher was being replaced.

Dietary Manager #130 reported the disposal had been down for over a month.

The three-compartment sink was leaking from the bottom into a bucket on the floor.

Additionally, the food prep sink was leaking into the sink.

Dietary Manager #130 reported the sinks had been leaking for over a month and she had told maintenance.Interview on 08/06/25 at 2:23 P.M., 2:47 P.M., and 3:56 P.M. with Plant and Maintenance Director #129 revealed he was unaware of leaks in the kitchen.

He reported they fixed a leak in the three compartment sink the previous week and was unaware it was leaking again. He reported for the disposal he called the company when he was aware it was down, which was on 07/07/25.

The company came out that day and sent a quote on 07/09/25. He reported the quote was approved on 07/24/25. He was unsure why there was a delay in approving it.Interview on 08/07/25 at 10:00 A.M. with the Administrator revealed there were no maintenance work orders to track when requests were submitted and completed. He reported staff called, texted, or found maintenance to notify him of any concerns.

Review of the service order for Advanced Mechanical Plus dated 07/07/25, revealed they arrived to work on the garbage disposal and found the unit down.

The unit motor was locked and leaking water. An order for a new disposal was to be submitted.

Review of the quote from Advanced Mechanical Plus dated 07/09/25 revealed replacement of and maintenance to the disposal would cost $4,468.66.Review of an email to Plant and Maintenance Director #129 on 08/06/25 revealed a timeline for the disposal. On 07/07/25 it was reported that there was a problem with the garbage disposal. On 07/08/25 there was a request for a quote. On 07/09/25 the quote was finished and emailed to a corporate staff member. On 07/23/25 the corporate staff member was emailed to follow up on the quote. On 07/24/25 the corporate staff member approved the quote.

Review of the policy ‘Maintenance and Repairs of Equipment in Nutritional Services Department' dated 12/19/24 revealed the nutritional professional will notify the maintenance department in writing of any equipment issues. 2.

Observation on 08/11/25 at 8:51 A.M., 9:59 A.M., 10:42 A.M., 2:50 P.M., and 4:20 P.M. revealed 35 resident rooms containing residents #1, #3, #4, #6, #7, #10, #11, #12, #13, #19, #20, #26, #27, #31, #33, #36, #39, #42, #43, #44, #45, #46, #47, #53, #54, #55, #56, #57, #58, #77, #78, #85, #88, #89, #90, #91, #93, #95, #96, #97, #98, #99, #100, #103, #104, #105, #106, and #107 were missing the transition strips from the room to the hallway.

Some of these rooms had a wide gap between the flooring of the hallway and the flooring of the bedroom and some of them had a build-up of a black sticky residue.

Interview on 08/11/25 at 4:20 P.M. with the Administrator verified the missing transition strips. He reported some of the flooring had been replaced up to a year and a half ago and they had been working on ordering new strips.This deficiency represents noncompliance investigated under Complaint Number 1399439.

Facility ID: