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 Page 1 of 2 365988 365988 05/26/2023 Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235

F 0839 without a valid nursing license. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142799. Residents Affected - Few 365988 Page 2 of 2