Health inspection·May 26, 2023

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on personnel record review and staff interview, the facility failed to ensure a nurse had a valid license. This affected one (Former Staff #59) of 23 nurses who work in the long term care section of the facility. Residents Affected - Few Findings include: Review of Former Licensed Practical Nurse (LPN) #59 by the Board of Nursing on an unrelated matter revealed LPN #59 was employed by the facility without a valid state license. It was determined by the Board of Nursing through the e-license system that LPN #59 was issued a temporary LPN license under Ohio Governors Covid 19 Omnibus Amendment. LPN #59 failed to complete the NCLEX exam within the 90 day period and his license was closed and abandoned as of 03/01/21. LPN #59 continued to work as a nurse at the facility until 05/07/23 without a valid state license. Review of LPN #59's personnel file revealed a hire date of January 2021. The facility verified LPN #59's license on on 01/07/21 which documented LPN #59's license was current through 10/31/22. There was no indication LPN #59 had a temporary license due to COVID 19 and still needed to take his NCLEX exam. Review of license checks revealed the facility checked for current licenses on 08/24/22. In February they identified they missed checking LPN #59's license. On 02/28/23 at 2:26 P.M., LPN #59's license check was done and the license was listed as closed, sub status abandoned. The license issue date was 12/24/20 and expiration date 03/01/21. Review of the payroll records revealed LPN #59's last day of work was 05/07/23. Review of the termination notice revealed LPN #59 was terminated 05/10/23 for not having a current license. During an interview 05/26/23 at 2:18 P.M., Human Resource Staff #60 stated when LPN #59 was hired, the facility did not know he had a temporary license. She does not check the licenses every two years to see if they are current. The facility discovered there was an issue with LPN#59's license when an employee called in a complaint to the board for an unrelated matter. During interview 05/26/23 at 5:22 P.M., the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) did a license check on LPN #59 in February, but neither she or the ADON read the report. They verified licenses in August 2022 and should have checked in October, because they expire the end of October. During an interview 05/26/23 at 5:30 P.M., the Administrator stated LPN #59 had been employed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365988 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365988 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)