Health inspection·December 23, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40. Findings include Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40. Findings Include:Review of the medical record for Resident #44 revealed an admission date of 02/01/22 and death/discharge date of 09/11/25. Diagnoses included vitamin D and B12 deficiencies, dementia with behavioral disturbance, malnutrition and Alzheimer's disease late onset.Review of the care plan dated 02/01/22 revealed Resident #44 had the potential for skin impairment related to fragile skin and decreased mobility with interventions to wear geri-sleeves for bilateral arms. Review of the physician orders dated 10/17/23 revealed Resident #44 should be transferred using the Hoyer lift (mechanical lift). On 11/20/24 revealed an order for geri-sleeves or long sleeves for bilateral hands every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) assessment was not completed as resident was rarely/never understood indicating impaired cognition and Resident #44 was dependent for all activities of daily living and mobility. Review of the progress note dated 09/03/25 revealed a skin tear was noted on Resident #44 in the morning measuring five and a half centimeters by one centimeter (cm). The skin tear was cleansed with normal saline and a foam dressing was applied. Hospice was notified and would be in the facility on 09/04/25 to assess. Review of the incident report dated 09/03/25 revealed a Registered Nurse (RN) #200 was alerted of a skin tear (5.5 cm by 1.0 cm). Preview of the progress note dated 09/04/25 revealed staff spoke with Resident #44's daughter about the skin tear found on 09/03/25. The note stated their was an ongoing investigation to ascertain the cause of it. Review of the skin assessment dated [DATE] revealed a laceration to the right upper extremity measuring 5.5 cm by 0.6 cm by 0.1 cm. Review of the self reported incident dated 09/11/25 revealed Residents daughter alleged Resident #44 received a skin tear due to mistreatment. The investigation summary reported the skin tear was identified on 09/03/25 by the aide during the morning shift and the nurse obtained treatment orders. According to the investigation, the resident had a history of striking out at others during care and had an order for geri-sleeves. Resident #44 also used a Broda chair and the investigation found no evidence of abuse or mistreatment. Interview on 12/23/25 at 8:42 A.M. with RN #200 revealed she was informed of Resident #44 having a skin tear. She revealed at the time of the aide report, she was not aware how it occurred and had not asked the staff present if they knew how she obtained the injury. RN #200 stated she assumed it occurred during the Hoyer transfer but acknowledged she had not asked staff. Interview on 12/23/25 at 9:42 A.M. with Certified Nursing Aide (CNA) #99 Page 1 of 4 365988 365988 12/23/2025 Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed she observed some blood on Resident #44's arm after a Hoyer transfer and revealed she informed the other CNA also participating in the Hoyer transfer. They lifted the resident's sleeve and found a large skin tear and they informed the nurse. CNA #99 reported no issues during the transfer and no reason to believe it occurred during the Hoyer transfer. She reported she was unsure how the skin tear occurred. Interview on 12/23/25 at 10:34 A.M. with the Director of Nursing (DON) verified RN #200 was given a written disciplinary action due to a delay in reporting an injury of unknown origin. The DON first revealed she was informed of the injury of unknown origin the next day at the care conference with Residents daughter (09/04/25). The DON verified after review of the self reported incident documentation and staff statements Resident #44's family reported concerns to facility during the care conference on 09/11/25. The DON stated it was believed the resident was cut by a buckle on the Broda chair and after doing the investigation that was the cause determined by the facility. The DON also acknowledged if the injury was not known and observed to occur it should be reported timely and then the investigation would be initiated. A follow-up interview on 12/23/25 at 10:56 A.M. with RN #200 verified she filled out the incident report related to the Resident #44's skin tear but reported she had not completed the section asking what happened. She reported that was filled out by another staff after the investigation was completed. Interview on 12/23/25 at 10:56 A.M. with the Assistance Director of Nursing (ADON) #315 verified she updated the incident report reasoning after facility completed the investigation as they did not know how the injury occurred. Interview on 12/23/25 at 11:20 A.M. with the Regional Administrator #250 and the DON revealed the facility felt they could determine the cause of the injury based on the information obtained in the investigation and that Resident #44 had just been transferred by using the Hoyer. She stated it most likely occurred from a buckle from the Broda chair. They acknowledged it was not reported to the state agency until 09/11/25 after family had reported concerns. Interview on 12/23/25 at 1:10 P.M. with CNA #210 reported Resident #44's injury was found after a Hoyer transfer, but reported their was no incident that occurred that would have caused the large skin tear injury during that transfer. CNA #210 reported she was unsure what would have caused the injury. Interviews on 12/23/25 with Hospice staff #360 and #370 reported Resident #44 did not have a skin tear, it was a deep laceration through the subcutaneous tissue. They reported they were not witnessed to care the morning of the transfer prior to the injury being found by staff. They stated Hospice spoke with Resident #44's family as well as the DON and the ADON #315 on 09/04/25 and at that time a cause of the injury was under investigation and had not been determined. Review of the facility policy titled Abuse, Neglect and Exploitation dated 07/2025, revealed facility shall report allegation to the administrator and the state agency within required timeframes. The Administrator shall follow up with state agencies with updates and to report final findings within five days. This deficiency represents non-compliance investigated under Complaint Number 2627023. 365988 Page 2 of 4 365988 12/23/2025 Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40. Findings include Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40. Findings include:Review of the medical record for Resident #44 revealed an admission date of 02/01/22 and death/discharge date of 09/11/25. Diagnoses included vitamin D and B12 deficiencies, dementia with behavioral disturbance, malnutrition and Alzheimer's disease late onset.Review of the care plan dated 02/01/22 revealed Resident #44 had the potential for skin impairment related to fragile skin and decreased mobility with interventions to wear geri-sleeves for bilateral arms. Review of the physician orders dated 10/17/23 revealed Resident #44 should be transferred using the Hoyer lift (mechanical lift). On 11/20/24 revealed an order for geri-sleeves or long sleeves for bilateral hands every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) assessment was not completed as resident was rarely/never understood indicating impaired cognition and Resident #44 was dependent for all activities of daily living and mobility. Review of the progress note dated 09/03/25 revealed a skin tear was noted on Resident #44 in the morning measuring five and a half centimeters by one centimeter (cm). The skin tear was cleansed with normal saline and a foam dressing was applied. Hospice was notified and would be in the facility on 09/04/25 to assess. Review of the incident report dated 09/03/25 revealed a Registered Nurse (RN) #200 was alerted of a skin tear (5.5 cm by 1.0 cm). Preview of the progress note dated 09/04/25 revealed staff spoke with Resident #44's daughter about the skin tear found on 09/03/25. The note stated their was an ongoing investigation to ascertain the cause of it. Review of the skin assessment dated [DATE] revealed a laceration to the right upper extremity measuring 5.5 cm by 0.6 cm by 0.1 cm. Review of the self reported incident dated 09/11/25 revealed Residents daughter alleged Resident #44 received a skin tear due to mistreatment. The investigation summary reported the skin tear was identified on 09/03/25 by the aide during the morning shift and the nurse obtained treatment orders. According to the investigation, the resident had a history of striking out at others during care and had an order for geri-sleeves. Resident #44 also used a Broda chair and the investigation found no evidence of abuse or mistreatment. Interview on 12/23/25 at 8:42 A.M. with Registered Nurse (RN) #200 revealed she was informed of Resident #44 having a skin tear. She revealed at the time of the aide report, she was not aware how it occurred and did not ask staff present if they knew how she obtained the injury. RN stated she assumed it occurred during the Hoyer transfer but acknowledged she did not ask staff. Interview on 12/23/25 at 9:42 A.M. with Certified Nursing Aide (CNA) #99 revealed she observed some blood on residents arm after a Hoyer transfer and revealed she informed the other CNA also participating in the Hoyer transfer. They lifted the resident's sleeve and found a large skin tear and they informed the nurse. CNA #99 reported no issues during the transfer and no reason to believe it occurred during the Hoyer transfer. She reported she was unsure how the skin tear occurred. Interview on 12/23/25 at 10:34 A.M. with the Director of Nursing (DON) revealed she was informed of the injury of unknown origin the next day (09/04/25). The DON verified the facility investigation was started on 09/11/25 after the family reported Resident #44 was mistreated. Interview on 12/23/25 at 10:56 A.M. RN #200 verified she filled out the incident report related to the Resident #44's skin tear but had not completed the section asking what happened. She reported that was filled out by another staff after Residents Affected - Few 365988 Page 3 of 4 365988 12/23/2025 Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the investigation was completed. Interview on 12/23/25 at 10:56 A.M. the Assistance Director of Nursing (ADON) #315 verified she updated the incident report reasoning after the facility completed the investigation as they did not know how the injury occurred. Interview on 12/23/25 at 11:20 A.M. the Regional Administrator #250 and the DON revealed the facility felt they could determine the cause of the injury based on the information obtained in the investigation and Resident #44 had just been transferred by using the Hoyer. She stated it most likely occurred from a buckle from the Broda chair. They acknowledged the Self reported incident (SRI) investigation was not started until after 09/11/25 and verified staff and resident interviews were done after 09/11/25. Interview on 12/23/25 at 1:10 P.M. the CNA #210 reported Resident #44's injury was found after a Hoyer transfer, but reported their was no incident that occurred that would have caused the large skin tear injury during that transfer. CNA #210 reported she was unsure what would have caused the injury. Interviews on 12/23/25 with the Hospice staff #360 and #370 reported Resident #44 did not have a skin tear it was a deep laceration through the subcutaneous tissue. They reported they were not witness to care the morning of the transfer prior to the injury being found by staff. They stated Hospice spoke with Resident #44's family as well as the DON and the ADON #315 on 09/04/25 and at that time a cause of the injury was under investigation and had not been determined. Review of the Self Reported incident investigation revealed staff statements were obtained after 09/11/25 with a final summary report dated 09/17/25. The incident had not defined a cause of the injury, but determined the evidence supported abuse and neglect did not occur. Review of the facility policy titled Abuse, Neglect and Exploitation dated 07/2025, revealed the facility shall begin an immediate investigation after a suspicion of abuse and neglect. This should include identifying staff responsible for the investigation, interviews with any witnesses or anyone with knowledge of the allegations and provide documented evidence of a thorough investigation. The Administrator shall follow up with state agencies with updates and to report final findings within five days. This deficiency represents non-compliance investigated under Complaint Number 2627023. 365988 Page 4 of 4