Health inspection·March 6, 2024

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of personnel files, review of the Ohio Department of Health (ODH) Nurse Aide Registry, and staff interviews, the facility failed to ensure that three State Tested Nursing Aide's (STNA) registrations were not expired. This affected three (STNA #36, #123 and #131) out of three STNA's reviewed for active registrations and had the potential to affect all residents residing in the facility. The facility census was 97. Findings include: 1. Review of the personnel file for STNA #123 revealed a hire date of [DATE]. Review of the ODH Nurse Aide Registry revealed STNA #123's registration expired on [DATE] and had a registry status of expired. The registry stated expired: we have received no work verification in the past 24 months, therefore this individual is not eligible for employment in a long term care facility. Interview on [DATE] at 11:27 A.M. with STNA #123 revealed her STNA registration was expired. STNA #123 said she reported this to the Director of Nursing (DON) last month. STNA #123 said the facility had to send in paperwork. STNA #123 said human resources was supposed to renew her license. STNA #123 revealed she worked everywhere in the facility. 2. Review of the personnel file for STNA #36 revealed a hire date of [DATE]. Review of the ODH Nurse Aide Registry revealed STNA #36's registration expired on [DATE] and had a registry status of expired. The registry stated expired: we have received no work verification in the past 24 months, therefore this individual is not eligible for employment in a long term care facility. Interview on [DATE] at 11:36 A.M. with STNA #36 revealed her STNA registration was expired. STNA #36 said she was trained at the facility. STNA #36 stated after 24 years, she hadn't looked at it and indicated she talked to someone to update the registration for her but the person she talked to went to another building. 3. Review of the personnel file for STNA #131 revealed a hire date of [DATE]. Review of the ODH Nurse Aide Registry revealed STNA #131's registration expired on [DATE] and had a registry status of expired. The registry stated expired: we have received no work verification in the past 24 months, therefore this individual is not eligible for employment in a long term care facility. Interview on [DATE] at 12:37 P.M. with STNA #131 revealed he looked at the ODH Nurse Aide Registry Page 1 of 2 365839 365839 03/06/2024 Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and saw that his registration had expired. STNA #131 told the Director of Nursing (DON) that his registration had expired. STNA #131 also revealed that he had been working the whole time it was expired. Interview on [DATE] at 12:11 P.M. with the DON and Administrator revealed on [DATE], the DON was notified by an STNA that their STNA registration had expired. The DON stated she was not aware that the STNA registrations had lapsed. The interview revealed they sent The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE], the DON was made aware STNA registrations were expired. • On [DATE], a Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss STNA registrations. The attendees included the Administrator, [NAME] President of Clinical Operations, Regional Director of Operations, and Regional Nursing Director. • On [DATE], the DON completed an initial audit of all STNA's to ensure their STNA registration was valid and active. All STNA's, including STNA #36, STNA #123, and STNA #131, with an expired license had all necessary documentation sent to the Ohio Department of Health Nurse Aide Registry to ensure the STNA's had a valid and active registration. • The new Human Resource Representative began employment on [DATE] and was oriented to the process of verifying STNA registration status by [DATE]. • Ongoing audits of all STNA's will be conducted once per month by the Human Resource Representative to ensure STNA registrations remain current and valid. This deficiency represents non-compliance investigated under Complaint Number OH00151091. 365839 Page 2 of 2