Brookdale Medina South

Based on observation, staff interview, and the dryer vents system cleaning review the facility failed to ensure lint build up did not occur in and around the facility dryers. This deficient practice had the potential to affect all 74 residents residing in the facility. The facility census was 74.

Findings Include:

An observation on 10/08/25 at 1:05 P.M. during the laundry room tour revealed in the bottom section of the large commercial dryer the lint filter was noted to have a moderate amount of lint built up on the filter. The lint compartment was noted to have several piles of lint in the back two corners, and a white sock was lying on the bottom of the lint compartment approximately six inches from the door of the compartment with lint built up on the sock.

An observation on 10/08/25 at 1:30 P.M. revealed on the floor between two smaller residential dryers on the floor was a build up of lint. Upon moving of the one dryer it was observed the lint/vent tubing attached to the dryer was not attached to the vertical dryer vent tubing allowing for the lint to be blown out unto the floor instead of staying in the dryer vent tubing.

An interview on 10/08/25 at 1:15 P.M. with Licensed Practical Nurse (LPN) #125 confirmed the lint build up in the commercial dryer's lint compartment and the white sock lying on the bottom of the lint compartment.

An interview on 10/08/25 at 1:20 P.M. with the Maintenance Manager #266 confirmed the lint build up on the floor between the two residential dryers caused by the unattached lint/vent tubing.

An interview on 10/08/25 at 1:25 P.M. with Laundry Aid (LA) #165 revealed the commercial dryer lint filter had not been cleaned following the use of the dryer for several loads.

Review of the facility's In-house System Cleaning - Dryer Vents directions revealed the facility is to be weekly cleaning the exhaust piping leading to the outer wall and the lint catchers in the dryers are to be cleaned after each load.

Based on observation, staff interview, and facility policy review the facility failed to store food in a sanitary manner. This deficient practice had the potential to affect all 74 residents residing in the facility. The facility census was 74.

Findings Include:

An observation on 10/07/25 at 9:40 A.M. during the initial kitchen tour revealed an uncovered small bowl of ice cream sitting on a tray on a shelf in the walk-in freezer. On another shelf, in the walk-in freezer, were several covered tubs of ice cream sitting on the top of the covered tubs of ice cream was a tray with ten uncovered small bowls of sherbet.

An interview on 10/07/25 at 9:50 A.M. with Dietary Manager #145 confirmed the bowls of uncovered ice cream and sherbet observed on shelves in the walk-in freezer. Dietary Manager #145 stated those bowls of ice cream and sherbet were from dinner the previous night and should have been covered prior to being stored back in the walk-in freezer.

Review of the facility policy titled, Food Storage, date 06/2024 revealed All food must be stored in a manner that maximizes nutrient retention, quality, and food safety.

This deficiency is a recite to the surveys completed 10/30/19, 12/28/23 and 07/18/24.

Based on observation, staff interview and facility policy review, the facility failed to ensure a medication cart was securely locked when unattended. This had the potential to affect twelve (Residents #107, #109, #112, #113, #114, #116, #117, #118, #119, #120, #122, and #123) the facility identified as independently mobile and cognitively impaired in the memory care unit. The facility census was 74.

Findings include:

Observation on 07/21/25 at 1:45 P.M. of an unlocked and unattended medication cart in the dining room of the memory care unit.

Interview on 07/21/25 at 1:47 P.M. with Licensed Practical Nurse (LPN) #503 verified the medication cart was unlocked and unattended. LPN #503 revealed the nurse on the unit was currently on break.

Interview on 07/21/25 at 1:48 P.M. with Health and Wellness Director (HWD) #502, who had just arrived on unit, verified the medication cart was unlocked, and she locked the medication cart at that time.

The facility identified twelve (Residents #107, #109, #112, #113, #114, #116, #117, #118, #119, #120, #122, and #123) as independently mobile and cognitively impaired on the memory care unit.

Review of facilities Medication and Treatment-General Guidelines for Medication Administration/Assistance Policy

Based on observation, interview, and review of facility policy, the facility failed to ensure food items were properly stored and/or discarded once expired to prevent usage of outdated items. This had the potential to affect all 78 residents residing in the facility who received meals prepared from the facility kitchen.

Findings include:

On 07/17/24 at 3:25 P.M. an observation with Cook #222 of the facility pantry revealed food items were expired:

Eight boxes of Pearled Barley were expired 05/10/24

A gallon of light corn syrup approximately ¾ used expired 09/22/17

Two-gallon jugs of white distilled vinegar expired 05/20/24

One gallon of rice vinegar partially used expired 10/13/14. The gallon of rice vinegar had a thick film of dust.

Additionally, on the spice shelf with multiple spices was a bottle of lemon extract that was approximately ¾ used. The bottle had a thick coating of oily dust and was dated 09/05/13. The lettering on the bottle in several areas were faded and no expiration date could be found.

Interview with Cook #222 at the time of the observation revealed she never looked at the dates. Cook #222 revealed she would not use the expired items in her home. The Administrator and Cook #222 confirmed the expired items.

Interview on 07/18/24 between 2:36 P.M. and 2:43 P.M. with Resident #77, #47, and #70 revealed they would not use expired food items at home.

Review of the facility policy titled, Food Storage revised 06/2024 revealed all foods must be stored in a manner that maximizes nutrient retention, quality and food safety. The store rooms should be maintained free from dirt and dust.

This violation is an incidental finding to Complaint Number OH00155105. This violation is also an example of continued non-compliance from the survey dated 12/28/23 and 10/30/19.

Based on observation and interview the facility failed to remove food from the facility panty that was past the best if used by date to prevent possible contamination and/or food borne illness. This had the potential to affect 67 residents residing in the facility who received meals prepared from the facility kitchen. The facility census was 67.

Findings include:

On 12/28/23 at 10:20 A.M. an observation of the facility pantry revealed some food items were past the best if used by date. A can of pastry filling had a best if used by date of 05/31/23, and the fine red vinegar had a best if used by date of 09/12/16.

On 12/28/23 at 10:35 A.M. an observation of food items on the top shelf of the pantry storage revealed two cans of water chestnuts that had a best if used by date of 04/01/18.

On 12/28/23 at 10:24 A.M. an interview with the Dietary Manager confirmed the food items found in the pantry were past their respective best if used by dates, and it is the Dietary Manager's responsibility to remove food that is past the best if used by date.

Based on observations, record review and interviews the facility failed to maintain clean kitchen equipment. This had the potential to affect all 67 residents residing in the facility.

Findings include:

On 12/28/23 at 10:42 A.M. an observation of the kitchen revealed the facility's only deep fryer had a yellowish / tan build up adhered to the sides and front of the deep fryer. Also, there was a buildup of old food batter noted inside the frypot (the area where the oil in the fryer is held and where the food is cooked) of the deep fryer.

On 12/28/23 at 10:45 A.M. an interview with the Dietary Manager confirmed there was a yellowish, tan build up stuck to the sides and front of the deep fryer and had a buildup of old food batter inside the frypot. The dietary manager confirmed the deep fryer was to be cleaned weekly.

Review of an undated and untitled document which lists refill and clean deep fryer (Sat or Sun) as a task was not signed or initialed as completed for the Sunday cleaning slot on the form.

On 12/28/23 at 11:10 A.M. an interview with the Executive Director (E.D.) confirmed the deep fryer is to be cleaned weekly and then documented on a cleaning schedule in the kitchen. The ED confirmed an untitled and undated document which listed the Refill and Clean deep fryer as a task was not signed off for the current week beginning 12/24/23.

Review of the facility policy Cleaning Schedule - DS-04.020 last revised 05/10, revealed a cleaning schedule must be posted and initiated to ensure cleaning tasks are completed. The policy states the Dining Services Management is responsible for reviewing the cleaning schedule to confirm the cleaning is thoroughly completed.

Based on review of facility fire drill documentation and staff interview, the facility failed to conduct at least one fire drill every three months on the second shift. This had the potential to affect all 67 residents residing in the facility.

Findings include:

Review of the facility fire drills for the last 12 months revealed the facility did not complete a fire drill at least every three months on the second shift. The facility completed fire drills on the second shift on the following dates 01/30/23, 05/01/23, 07/28/23, and 10/30/23.

On 12/28/23 at 12:34 P.M. an interview with the Maintenance Director confirmed no fire drill was completed in the month of April 2023.

On 12/28/23 at 12:41 P.M. an interview with the Executive Director confirmed that a fire drill was not completed in the month of April 2023.