Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 61 residents residing in the facility. The facility did not cool pre-cooked leftover food with an approved cooling method. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at section 3-501.14 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour with Dietary Manager (DM)-C on 12/9/24 that began at 8:28 AM, Surveyor noted the freezer contained pre-cooked leftover food items labeled with use-by dates. DM-C verified the facility kept leftovers. Surveyor observed the following leftover foods in the freezer: ~Lasagna with a use-by date of 3/8/25 ~Meatloaf with a use-by date of 2/2/25 ~Veggie lasagna with a use-by date of 3/2/25 ~Hot dogs with a use-by date of 2/15/25 ~Pizza casserole with a use-by date of 1/18/25 ~Chopped fish with a use-by date of 2/19/25 ~Two containers of bacon with use-by dates of 2/16/25 ~Pureed ham with gravy with a use-by date of 2/13/25 ~Ground ham with a use-by date of 1/22/25 ~Ribs with a use-by date of 9/2025 ~Macaroni and cheese with a use-by date of 2/22/25 ~Pork ribs with a use-by date of 2/17/25 ~Minestrone soup with a use-by date of 1/8/25 ~Tuna noodle casserole with a use-by date of 2/5/25 ~Tuna noodle casserole with a use-by date of 3/8/24 ~Clam chowder with a use-by date of 2/17/25 ~Corn chowder with a use-by date of 2/26/25 ~Sausage gravy with a use-by date of 2/26/25 ~Pork ribs with a use-by date of 1/30/25 ~Taco meat with a use-by date of 3/9/25 ~Philly steak with a use-by date of 3/7/25 ~Lemon pepper chicken with a use-by date of 12/7/24 ~Cheeseburger casserole with a use-by date of 1/19/25 ~Loaded baked potato soup with a use-by date of 3/4/25 ~Roast chicken with a use-by date of 3/1/25 ~Two containers of loaded baked potato soup with use-by dates of 2/24/25 Surveyor reviewed the kitchen's food cooling logs. Surveyor noted there were no cooling log for October and November (2024) and noted the food observed in the freezer was not listed on the cooling logs provided. Surveyor interviewed DM-C who indicated DM-C would speak with [NAME] (CK)-D because DM-C was new and unsure of the process. Following the interview with DM-C, Surveyor interviewed CK-D who indicated the food in the freezer was leftovers and labeled with use-by dates which were three months after the cooked dates. When Surveyor asked about the expired items, CK-D indicated the dates were most likely mistakes, but because the items were not documented on the cooling log there was no way to ensure that. CK-D indicated the food in the freezer was not cooled using the facility's blast chiller and was not documented on the logs with an appropriate cooling method because that has never been the process. CK-D indicated the blast chiller was only used to cool roasts and pork loins. CK-D indicated food was left to cool and then labeled and stored in the freezer for future use.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R259) and their Guardian of 20 sampled residents were offered care conferences and involved in continued care planning. R259's last care conference was completed in March of 2023. Staff verified a care conference should be offered every 3 months or more frequently if needed. Findings include: The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements. In addition, a quarterly review assessment is completed. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently then once every 3 months .Quarterly care conferences will be held with invitations to resident and resident representative(s) .The resident and resident representative will be encouraged to review the care plan and provide input after each review and/or revision .The resident/resident representative has the right to participate in the development and implementation of his or her person-centered plan of care including, but not limited to: the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care .The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must: facilitate the inclusion of the resident/resident representative .the facility will assist residents/resident representatives with understanding the assessment and care planning process and will hold care plan review conferences at the time of day most advantageous for a resident/resident representative to be able to attend, if they so desire. Care review conferences will be held following admission, quarterly, with change of condition, prior to planned discharges and at other intervals as needed. On 8/29/23, Surveyor reviewed R259's medical record. R259 had diagnoses including schizophrenia, dementia, anxiety disorder, polydipsia (a disorder that causes extreme thirst), AEB (as evidenced by) hallucinations, excessive fluid seeking including drinking out of faucets and toilets, as well as delusional/paranoid statements. In addition, R259's MDS assessment, dated 2/10/23, indicated R259 required the assistance of one staff for ambulation and extensive assistance for all other activities of daily living, including toileting and catheter care. The MDS assessment contained a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R259 had moderately impaired cognition. R259 had a court-ordered Guardian and was protectively placed in the facility. R259's medical record also indicated the following: ~An Annual MDS assessment was due on 6/10/23, but was not completed. A Quarterly MDS assessment was due on 8/10/23, but was not completed. A care conferences was also not completed between March and August of 2023. On 8/30/23 at 12:31 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated it is the facility's policy to complete all assessments and care conferences quarterly, annually, and as needed. NHA-A also indicated R259's last care conference was in March of 2023. NHA-A verified Social Services Director (SSD)-I is responsible for scheduling care conferences with residents and resident representatives. On 8/30/23 at 12:33 PM, Surveyor interviewed SSD-I who indicated the practice for completing and scheduling assessments and care conferences occurs when department staff are alerted that assessments are due through a monthly report provided by MDS Coordinator (MDSC)-E. SSD-I indicated after the report is received, SSD-completes sections of the assessments and schedules care conferences with residents and/or their representative(s). SSD-I confirmed R259's last care conference was in March of 2023. SSD-I could not provide an explanation why R259's most recent Quarterly and Annual MDS assessments were not completed, and why a care conference was not scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure the medical record of 2 Residents (R) (R54 and R42) of 7 residents reviewed for code status contained an advance directive/code status that was consistent with the residents' wishes. R54 had a code status of do not resuscitate (DNR). R54's care plan identified R54 as a full code. R42 had a code status of DNR. R42's care plan identified R42 as a full code. Findings include: The facility's Code ER, Medical Emergencies, Cardiopulmonary Resuscitation and Defibrillator Use Policy, revised 6/2022, contained the following information: Code Status is verified by observing the legal document in the client/resident chart or electronic medical record prior to performing CPR (cardiopulmonary resuscitation). The code status is reviewed upon admission, quarterly and with a significant change in condition. If the resident/resident representative indicates/signs No CPR in the advanced directives, as defined in Wisconsin State Statute 154.17 (2), a DNR order directs emergency medical technicians, first responders, and emergency health care facility's personnel, not to attempt CPR on the person for whom the order is issued if that person suffers cardiac or respiratory arrest. 1. On [DATE], Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance and adult failure to thrive. R54 was cognitively impaired and required assistance with activities of daily living (ADLs). R54 was under Guardianship. R54's medical record contained a document titled Emergency Care Do Not Resuscitate (DNR) signed by R54's physician on [DATE]. A progress note, dated [DATE] at 2:11 PM, stated, State advanced directive form sent to guardian. A progress note, dated [DATE] at 11:14 AM, stated, State DNR form received from representative. This was given to APNP (Advanced Practice Nurse Prescriber) and signed. Code status changed to DNR. R54's care plan, dated [DATE], indicated R54 was FULL CODE STATUS and contained the following interventions: - Resident/Resident Representative's request will be honored while in this facility. - Nursing staff will initiate CPR and transfer Resident to the hospital of choice. - Resident/Resident Representative will be notified with any change in condition. - Staff will review with Resident/Resident Representative any changes in code status at each care conference and PRN (as needed). 2. On [DATE], Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of bladder and adult failure to thrive. R42 was not cognitively impaired, but required set-up assistance with ADLs. R42's medical record contained a document titled Emergency Care Do Not Resuscitate (DNR) signed by R42 on [DATE] and by R42's physician on [DATE]. R42's care plan, dated [DATE], indicated R42 was FULL CODE STATUS and contained the following interventions: - Nursing staff will initiate CPR and transfer Resident to the hospital of choice. - Resident/Resident Representative will be notified with any change in condition. - Staff will review with Resident/Resident Representative any changes in code status at each care conference and PRN. On [DATE] at 9:56 AM, Surveyor interviewed Registered Nurse (RN)-C and Licensed Practical Nurse (LPN)-D who indicated if they came upon a pulseless and non-breathing resident, RN-C and LPN-D would confirm the resident's code status in the paper chart or would check the resident's code status on the face sheet in the electronic medical record. On [DATE] at 9:50 AM, Surveyor interviewed RN-C who indicated both R54 and R42 were DNR status. RN-C verified both R54 and R42's care plans indicated R54 and R42 were full code status, but should reflect DNR status. On [DATE] at 10:00 AM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-E who indicated MDSC-E should be notified of a change in code status by the staff member who receives the change.

Based on staff interview and record review, the facility did not complete a comprehensive Annual Minimum Data Set (MDS) assessment within the required timeframe for 1 Resident (R) (R259) of 20 sampled residents. R259's Annual MDS assessment, due on 8/11/23, was marked in process. The Annual assessment was not completed and was 17 days overdue. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2019, indicates: The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements . On 8/28/23, Surveyor reviewed R259's medical record. R259 had diagnoses including schizophrenia, dementia, anxiety disorder, polydipsia (a disorder that causes extreme thirst), AEB (as evidenced by) hallucinations, excessive fluid seeking including drinking out of faucets and toilets, as well as delusional/paranoid statements. In addition, R259 had a court-ordered Guardian and was protectively placed in the facility. R259's medical record indicated R259's last Quarterly MDS assessment was completed on 2/10/23. An Annual MDS assessment was due on 8/11/23. Surveyor noted an Annual MDS assessment, dated 8/28/23, was in progress, but was not completed. On 8/30/23 at 11:57 AM, Surveyor interviewed MDS Coordinator (MDSC)-E regarding R259's last MDS assessment (dated 2/10/23) and indicated an Annual MDS assessment was due on 8/11/23, but not yet completed. MDSC-E confirmed R259's Annual MDS assessment was overdue and stated, We missed (R259). MDSC-E did not provide an explanation why the Annual assessment was not completed. On 8/30/23 at 12:31 PM, Surveyor interviewed Nursing Home Administrator(NHA)-A who indicated it is the facility's policy to complete all MDS assessments quarterly, annually, and as needed. NHA-A was not aware R259's last MDS assessment was completed in February of 2023 and that R259's Annual MDS assessment was not completed and was overdue. On 8/30/23 at 12:33 PM, Surveyor interviewed Social Services Director (SSD)-I who indicated the practice for completing and scheduling MDS assessments occurs when department staff are alerted through a monthly report provided by MDSC-E that assessments are due. SSD-I confirmed an Annual MDS assessment for R259 was not completed by 8/11/23 as required.

Based on staff interview and record review, the facility did not complete a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for 1 Resident (R) (R259) of 20 sampled residents. R259's last Quarterly MDS assessment was completed on 2/10/23. R259's next Quarterly MDS assessment (due in May of 2023) was not completed. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2019, indicates: .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements. In addition, a quarterly review assessment is completed. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently then once every 3 months . On 8/28/23, Surveyor reviewed R259's medical record. R259 had diagnoses including schizophrenia, dementia, anxiety disorder, polydipsia (a disorder that causes extreme thirst), AEB (as evidenced by) hallucinations, excessive fluid seeking including drinking out of faucets and toilets, as well as delusional/paranoid statements. In addition, R259 had a court-ordered Guardian and was protectively placed in the facility. R259's medical record indicated R259's last Quarterly MDS assessment was completed on 2/10/23. Surveyor noted a Quarterly MDS assessment (due 5/10/23) was not completed within three months and was overdue. On 8/30/23 at 11:57 AM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-E regarding R259's MDS assessment (dated 2/10/23) and indicated a Quarterly assessment was not completed since that date. MDSC-E confirmed R259's Quarterly MDS assessment was overdue and stated, We missed (R259). MDSC-E did not provide an explanation why the assessment was not completed. On 8/30/23 at 12:31 PM, Surveyor interviewed Nursing Home Administrator(NHA)-A who indicated it is the facility's policy to complete all quarterly assessments as needed. NHA-A was not aware R259's last Quarterly MDS assessment was completed in February of 2023 and that R259's next Quarterly MDS assessment was not completed and was overdue. On 8/30/23 at 12:33 PM, Surveyor interviewed Social Services Director (SSD)-I who indicated the practice for completing and scheduling assessments occurs when department staff are alerted that assessments are due through a monthly report provided by MDSC-E. SSD-I confirmed a Quarterly MDS assessment for R259 was not completed in May of 2023 as required. SSD-D was unsure why the Quarterly assessment was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, and administered for 3 Residents (R) (R18, R8, and R26) of 5 residents reviewed for vaccines. The facility did not review R18's vaccination history or offer R18 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20®) vaccine. The facility did not review R8's vaccination history or offer R8 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20®) vaccine. The facility did not review R26's vaccination history or offer R26 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20®) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent CDC (Centers for Disease Control and Prevention) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. The facility's Resident Immunizations Policy, last revised 8/2019, included the following: .2. Pneumonia Vaccine a. Upon admission .residents 65 years and older and residents designated as high risk for pneumonia who have not received the pneumonia vaccine will be offered the vaccination. b. Pneumococcal vaccination will be offered and administered per the Prevnar 13/pneumococcal vaccine policy following the CDC guidelines . 1. R18 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease. R18 received the PPSV23 vaccine on 12/19/03 and the PCV13 vaccine on 5/18/15. R18's medical record did not indicate R18 was offered or administered the PVC20 vaccine. 2. R8 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, and dementia. R8 received the PPSV23 vaccine on 10/26/15 and the PCV13 vaccine on 3/4/17. R8's medical record did not indicated R8 was offered or administered the PCV20 vaccine. 3. R26 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, and peripheral vascular disease. R26 received the PPSV23 vaccine on 1/31/14 and the PCV13 vaccine on 6/23/15. R26's medical did not indicate R26 was offered or administered the PCV20 vaccine. On 8/29/23 at 11:16 AM, Surveyor interviewed Infection Preventionist (IP)-K who indicated IP-K completed an audit on residents for the PCV20 vaccine, but was also focused on Respiratory Syncytial Virus (RSV) vaccination. IP-K stated IP-K would review the audit tool to see if anything was completed for R18, R8, and R26. On 8/30/23, Surveyor confirmed with IP-K and Director of Health Services (DHS)-F that there was no documented information regarding the PCV20 vaccine for R18, R8, and R26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 8/30/23, Surveyor reviewed R1's medical record. R1 had to diagnoses including dementia, seizure disorder, anxiety, depression, and schizophrenia. R1's Quarterly MDS assessment, 6/13/23, contained a BIMS score of 4 out of 15 which indicated R1 was severely cognitively impaired. R1's medical record contained the following MDS assessments: ~Quarterly MDS assessments, dated 9/12/22 and 12/12/22, and an Annual MDS assessment, dated 3/13/23, indicated R1 was rarely/never understood. Staff assessment indicated R1 had moderately impaired cognition. The MDS' also indicated there was not an acute change in R1's baseline mental status. A progress note, dated 6/20/23, indicated the following: BIMS score of 4 out of 15. (R1) repeated all three words and recalled none. (R1) stated the correct day of the week, however, was incorrect on the month and year. PHQ-9 (Patient Health Questionnaire) (used to diagnose and monitor the severity of depression) score of 5 (which indicates either no or subthreshold depression). (R1) stated (R1) sometimes feels down/depressed, has trouble sleeping, feels tired, feels bad about (R1's) self, and has trouble concentrating. The MDS indicated R1 had verbal aggression, delusions, hallucinations and insomnia, refused care, screamed (not at others), and was agitated, and anxious R1's medical record did not contain a Significant Change assessment that indicated a change in cognition or ability to communicate. 4. On 8/30/23, Surveyor reviewed R2's medical record. R2 had diagnoses including anxiety, depression, schizophrenia, and renal insufficiency. R2's Annual MDS assessment, dated 5/25/23, indicated R2 was rarely/never understood. A staff assessment indicated R2 had moderately impaired cognition. The MDS did not indicate there was an acute change in R2's baseline mental status and R2 is able to communicate. R2's medical record contained the following MDS assessments: ~Quarterly MDS assessments, dated 2/22/23, and 11/23/22, contained BIMS scores of 12 out of 15 which indicated R2 had moderately impaired cognition. 5. On 8/28/23 at 10:13 AM, Surveyor interviewed R14 who indicated R14 used a side rail on R14's bed to assist with sitting up, rolling, and for stability during cares and transfers. R14 stated R14 used the bed rail daily and required the bed rail to remain independent. On 8/28/23, Surveyor reviewed R14's medical record. R14 had diagnoses including diabetes type 2 with diabetic neuropathy, contracture of muscle, right hand and left hands, difficulty in walking, and non-pressure ulcer of left heel and midfoot limited to breakdown of skin. R14's Quarterly MDS assessment, dated 6/16/23, contained a BIMS score of 15 out of 15 which indicated R14 had intact cognition. The MDS also indicated R14 had a bed rail that was used daily and considered a physical restraint. R14's medical record contained the following information: ~An occupational therapy Enabler Bar Assessment, dated 7/25/23, indicated R14 utilized the left U bar bed rail independently, and refused other options such as raising the head of the bed, and a lipped mattress or trapeze. Education was provided to R14 on the risks of the enabler bar, including the risk of entrapment. R14 declined to have the enabler bar removed. ~A Side Rail Informed Consent indicated an assessment was completed to determine the appropriateness of the grab bar/side rail, and the risks and benefits of use. The document was signed by R14 on 8/22/23. R14's medical record did not contain a Physical Restraint Assessment. 6. On 8/29/23, Surveyor reviewed R20's medical record. R20 had diagnoses including Huntington's disease. R20's Quarterly MDS assessment, dated 6/14/23, indicated R20 was rarely/never understood. A staff assessment indicated R20 had severely impaired cognition. R20 was admitted to Hospice services on 1/6/20. R20's medical also included the following: ~Quarterly MDS assessments, dated 3/16/23 and 6/14/23, indicated R20 was not enrolled in Hospice services. ~A skilled nursing compliance physician note, dated 3/28/23, indicated R20 was enrolled in Hospice services. ~An Annual MDS assessment, dated 12/14/22, indicated R20 was enrolled in Hospice services. Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 7 Residents (R) (R16, R8, R1, R2, R14, R20 and R53) of 20 sampled residents. R16's Quarterly MDS assessment, dated 8/1/23, did not contain a Brief Interview for Mental Status (BIMS) assessment (used to determine level of cognition). A progress note, dated 8/8/23, indicated R16 had mild cognitive impairment. In addition, the MDS inaccurately indicated R16 had a physical restraint. R8's Quarterly MDS assessment, dated 7/7/23, did not contain a BIMS assessment. R1's Quarterly MDS assessment, dated 6/13/23, contained a BIMS score of 4 out of 15 which indicated R1 had severely impaired cognition; however, R1 is able to communicate. R2's Annual MDS assessment dated [DATE], contained a BIMS assessment that indicated R2 is rarely/never understood; however, R2 is able to communicate. R14's Quarterly MDS assessment, dated 6/16/23, indicated R14's side rail was a physical restraint. R14's medical record indicated the side rail was for therapeutic use and contained an assessment for independent use, and consent. R20 was enrolled in Hospice services. R20's Quarterly MDS assessments, dated 6/14/23 and 3/16/23, indicated R20 was not enrolled in Hospice services. R53's Quarterly MDS assessment, dated 7/26/23, did not contain a BIMS assessment to determine R53's level of cognition. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual (a guide for completing MDS assessments (a screening and assessment tool which forms the foundation of a comprehensive assessment and is used to guide care planning and monitoring for residents) reads: Section C: Cognitive Patterns, Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in many care planning decisions .Most residents are able to attempt the Brief Interview for Mental Status (BIMS). A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance . - Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. - Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care . Coding Tips: * Attempt to conduct the interview with ALL residents . * Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done. Section P: Restraints and Alarms, Intent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices, or an alarm was used, at any time during the day or night, during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories. - Bed rails used with residents who are immobile - If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. For residents who have no voluntary movement, the staff need to determine if there is an appropriate use of bed rails. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last revised 8/2021, included the following: 1. Upon admission, with significant changes in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements. In addition, a quarterly review assessment is completed. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently then once every 3 months. a. The facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care . The facility's Restraints Policy, last reviewed 6/2018, included the following: The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that: prohibits the use of physical restraints for discipline or convenience; prohibits the use of physical restrains to unnecessarily inhibit a resident's freedom of movement or activity; and limits physical restraint use to circumstances in which the resident had medical symptoms that may warrant the use of restraints .4. A physical restraint assessment must be completed a minimum of quarterly for the duration of restraint use and as otherwise indicated with significant change in condition or resolve of the medical symptoms that required the use of the restraint . 1. R16 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, anxiety, and depression. R16's Quarterly MDS assessment, dated 8/1/23, indicated R16's BIMS was not assessed. A progress note, dated 8/8/23, indicated R16 had a BIMs score of 7 out of 15 which indicated R16 had severely impaired cognition. On 8/28/23 at 10:18 AM, Surveyor interviewed R16 who was able to communicate and answer Surveyor's questions appropriately. Surveyor observed R16 sitting upright in bed with a tray table and personal items within reach. Surveyor also noted half rails on each side of R16's bed. From 8/28/23 through 8/30/23, Surveyor reviewed R16's medical record and noted the following: ~A Quarterly MDS assessment, dated 8/1/23, indicated R16's BIMS was not assessed. ~Quarterly MDS assessments, dated 5/4/23 and 11/8/22, indicated R16 was rarely/never understood. Staff assessments indicated R16 had moderately impaired cognition. ~An Annual MDS assessment, dated 2/2/23, indicated R16 was rarely/never understood. A staff assessment indicated R16 had moderately impaired cognition. A psychosocial note, dated 8/8/23, indicated an assessment was completed on 8/3/23 and R16's BIMS score was 7 (out of 15) (which indicated R16 had severely impaired cognition). R16's Quarterly MDS assessment, dated 8/1/23, also indicated R16 had a physical restraint of a bed rail that was used daily. R16's most recent occupational therapy assessment, dated 4/27/23, indicated R16 was able to turn/roll in bed using enabler bars (U-bars). R16's most recent therapy service screen, dated 7/24/23, indicated R16 was able to feed self, use enabler bars for positioning, and had no reported concerns of decreased range of motion since the last assessment. A bed rail assessment, dated 8/8/23, indicated R16 was not at risk for entrapment. On 8/30/23 at 9:32 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who indicated R16 is independent with bed mobility and can use the bed remote control to raise and lower the head of the bed. LPN-G also indicated R16 lifts R16's legs and is able to pull R16's body side-to-side using the bed rails. LPN-G indicated R16 requests to stay in bed for other health reasons, but is not immobile or bed bound. On 8/30/23 at 9:54 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who stated R16 is weak and does not walk, but is able to move in bed independently. CNA-H indicated R16 helps with care, but needs assistance from staff. R16 can activate the call light and communicate R16's needs to staff. On 8/30/23 at 12:38 PM, Surveyor interviewed LPN-J who verified R16 is interviewable. 2. R8 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, and dementia. R8's Quarterly MDS assessment, dated 7/7/23, indicated R8's BIMS was not assessed. On 8/28/23, Surveyor interviewed R8 who was able to communicate with Surveyor and make R8's needs known. During the interview, R8 was eating independently in a wheelchair. From 8/28/23 through 8/30/23, Surveyor reviewed R8's medical record and noted the following: ~A Quarterly MDS assessment, dated 4/7/23, contained a BIMS score of 5 out of 15 which indicated R8 had severely impaired cognition. 7. On 8/30/23, Surveyor reviewed R53's medical record. R53 was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, transient ischemic attack, psychoactive substance induced mood disorder, frontal lobe and executive functional deficit. On 8/28/23, Surveyor toured the facility and interviewed R53 who indicated things are going well and staff treat R53 well. R53 was able to make R53's needs known and ambulated on the unit independently. R53's admission MDS assessment, dated 4/25/23, contained a BIMS score of 8 out of 15 which indicated R53 had moderately impaired cognition. Surveyor reviewed R53's Quarterly MDS assessment, dated 7/26/23, and noted R53's BIMS was not assessed. On 8/30/23 at 10:30 AM, Surveyor interviewed MDS Coordinator (MDSC)-E who stated MDSC-E was under the impression side rails should be coded as physical restraints. MDSC-E indicated most of the resident who use half side rails use them to get up to the bathroom, assist themselves out of bed, and for bed mobility. MDSC-E did not feel the side rails met the description of a physical restraint. On 8/30/23 at 11:15 AM, Surveyor interviewed Social Services Director (SSD)-I who stated SSD-I was trained that if a resident's BIMS assessment takes place after the MDS ARD (assessment reference date), SSD-I should mark Not Assessed and make sure the assessment is entered in the resident's medical record for reference. When Surveyor asked SSD-I to provide BIMS assessments for all sampled residents marked as Not Assessed on their MDS', SSD-I was unable to provide BIMS assessments for those marked as Not Assessed. On 8/30/23 at 1:22 PM, Surveyor again interviewed SSD-I regarding why residents' BIMS are documented inconsistently from quarter to quarter such as a BIMS of 15 one quarter, rarely/never understood the next quarter and then a BIMS of 7 or not assessed the next quarter. SSD-I indicated some residents refuse the assessment depending on their mood, and SSD-I completes the BIMS assessment after completion of the MDS. SSD-I then documents the BIMS score in a progress note in the resident's medical record. SSD-I was unclear why rarely/never understood was selected when residents refused an assessment rather than not assessed as the resident was not assessed due to refusal or inability of the resident to participate in the assessment at that time.

Based on record review, staff interview and resident representative interview, the facility did not document or make prompt efforts to resolve grievance for 1 Resident (R) (R306) of 18 sampled residents. Social Worker (SW)-J and Registered Nurse (RN)-L heard R306's Power of Attorney (POA)-M's verbal grievance regarding lack of activities and request for activity calendar but did not document, resolve or report the grievance to grievance official, SW-J. Findings include: The facility's Policy titled Grievance Policy-Bayshore Village revised on 09/2022. Policy: . each Resident has the right to voice grievances to the facility. Definitions: Voice grievances are not limited to a formal, written grievance process but may include a Resident's verbalized complaint to facility staff. Prompt efforts to resolve include facility acknowledgment of complaint/grievances and actively working toward resolution of that complaint/grievances. Grievance Official is an individual who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions. Procedures: H. Response 1. Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate the complaint to their supervisor and the facility Grievance Official. 1.On 09/07/22 at 11:05 a.m., Surveyor interviewed POA-M, who expressed R306's psychosocial needs are not being met due to lack of activities and desired to see what activities are being offered. POA-M verbalized POA-M had requested an activity calendar on two different occasions. First occasion from Social Worker (SW)-J via e-mail on 8/22/22. and second occasion from Registered Nurse (RN)-L via telephone on 8/29/22. POA-M has not received any further follow-up from the facility. Surveyor reviewed the facility's Grievance Notebook and noted R306's Representative's request for activity calendar grievance was not documented. 2. On 09/08/22 8:01 a.m., Surveyor interviewed SW-J who confirmed the e-mail dated 8/22/22 from POA-M with the following message R306 says there is nothing to do activity-wise. I am wondering if there is an activity calendar or anything like that or an activity director so we can give him/find him things to do. SW-J's replied to POA-M did not address the activity calendar. SW-J verbalized the e-mail was not clear in requesting an activity calendar. 3. On 09/08/22 at 2:26 p.m., Surveyor interviewed RN-L, who confirmed speaking with POA-M regarding activity calendars. RN-L did not realize POA-M wanted a copy of the activity calendar. RN-L confirmed RN-L did not inform POA-M where activity calendars were posted and did not offer POA-M any activity calendar. 4. On 09/08/22 at 12:06 p.m., Surveyor interviewed SW-K who confirmed role as facility Grievance Official. SW-K did not think the request for an activity calendar was considered a grievance, however SW-K would have reviewed the e-mail and would have given POA-M a more formal response. Surveyor reviewed POA-M's e-mail with SW-K and SW-K agreed the e-mail was considered a concern grievance. SW-K was not aware until 9/8/22 and verified there was no documentation regarding POA-M's grievance.

Based on staff interview and record review, the facility did not implement the abuse prevention policy requiring background checks for 1 (Facility Worker (FW)-F) of 8 sampled staff. Facility did not obtain a response from Department of Health Services (DHS) Integrated Background Information System (IBIS) information prior to hiring FW-F. Findings include: Wisconsin (WI) Caregiver Program Manual, revision dated January 2020, documents At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents: .3. A 'Response to the Caregiver Background Check' letter from DHS that reports the person's status, including administrative finding or licensing restrictions. Facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property Policy, revision dated 3/2022, Employee Screening and Training. B. Prospective employees will need to have a successful completion of criminal background checks. On 9/6/22 and 9/8/22, Surveyor observed FW-F working in facility. On 9/7/22, Surveyor selected sample of 8 staff to review for background checks. Surveyor noted FW-F did not have a DHS response with paperwork and payment receipt which usually documents $7.00 for Department of Justice (DOJ) check and $3.00 for DHS check ($10.00 total) documented $7.00 instead of $10.00 paid. On 9/7/22 at 11:25 AM, Director of Nursing (DON)-B verified DHS response was not with FW-F's background check paperwork. DON-B indicated background checks were completed by off-site Human Resources (HR) department. On 9/7/22 at 11:30 AM, Surveyor interviewed HR-G, a generalist at the HR office, via telephone. HR-G indicated another person typically runs background checks for employees with FW-F's work classification. At 1:07 PM, HR-G explained to Surveyor via telephone that FW-F's file was reviewed by HR on 9/7/22 and FW-F's DHS check was not run. FW-F indicated an oversight must have occurred.

Based on staff interviews and record review, the facility did not ensure a Resident (R) prescribed a high risk medication had a care plan developed to monitor for possible side effects for 3 (R19, R42, and R47) of 18 sampled residents. The facility did not develop a care plan to monitor for possible side effects of R19's opioid (narcotic pain relief) and diuretic (commonly referred to as a water pill) medications. The facility did not develop a care plan to monitor for possible side effects of R42's antidepressant and opioid medications. The facility did not develop a care plan to monitor for possible side effects of R47's antipsychotic medication. 1. From 9/6/22 through 9/8/22, Surveyor reviewed R19's medical record which documented R19's prescriptions included tramadol (opioid medication) twice per day and up to two additional times per day as needed. R19's prescriptions also included hydrochlorothiazide (diuretic medication) daily. Surveyor noted R19's medical record did not contain monitoring for possible negative side effects for opioid (such as respiratory depression) and diuretic use (such as dehydration). On 9/8/22 at 11:22 AM, Surveyor interviewed Registered Nurse (RN)-H, who verified being responsible for minimum data set information and contributing to nursing care plan development. RN-H confirmed side effect monitoring was not in place for R19's opioid and diuretic medications. 2. From 9/6/22 through 9/8/22, Surveyor reviewed R42's medical record which documented R42's prescriptions included duloxetine (antidepressant medication) daily and morphine sulfate (opioid medication) four times per day and up to four additional times per day as needed. Surveyor noted R42's medical record did not contain monitoring for possible negative side effects for antidepressant (such as dizziness and insomnia) and opioid medications. On 9/8/22 at 11:08 AM, Director of Nursing (DON)-B verified to Surveyor that R42 did not have a care plan to monitor for possible negative side effects related to R42's opioid and antidepressant medication use. 3. From 9/6/22 through 9/8/22, Surveyor reviewed R47's medical record which documented R47's prescriptions included Seroquel (antipsychotic medication) daily. Surveyor noted Tardive Dyskinesia (TD) monitoring was completed every six months and no other monitoring for possible negative side effects for antipsychotic medication (such as dizziness and sedation) was in place. On 9/8/22 at 10:06 AM, DON-B indicated to Surveyor that DON-B would review R47's medical record for monitoring plans. Only TD monitoring was submitted to survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, record review and staff interview, the facility did not ensure 2 Residents (R) (R16 and R34) of 5 sampled residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers (injuries) from developing. R16 was observed sitting in chair with cushion and towel over cushion for two days of survey. R34 was observed sitting in recliner without cushion in recliner for 2 of the survey days. Findings include: Facility follows AHRQ (Agency for Healthcare Research and Quality) as a guide for Pressure Injury (PI) prevention. R34 was admitted to facility on 6/18/22 with the diagnosis of dementia, muscle weakness, difficulty walking, Alzheimer and failure to thrive. R34's MDS (Minimum Data Set) assessment dated [DATE] indicated that R34 required extensive assistance with bed mobility, transfers, dressing and hygiene. R34's skin condition record dated 6/18/22 indicated that R34 had an opening on left buttock measuring 9 cm (Centimeters) long and 0.5 cm wide. Opening was resolved on 6/29/22. R34's Braden Risk Assessment scale dated 6/18/22 indicated R34 had moderate risk for the development of PI and the Braden Risk assessment dated [DATE] indicated R34 was at risk for the development of PI. R34's care plan dated 7/15/22 indicated pressure relieving cushion in wheelchair or recliner to protect skin in wheelchair or recliner. On 8/7/22 at 9:26 AM Surveyor observed R34 in recliner sitting on a cloth pad with no cushion in chair. On 8/7/22 at 10:22 AM Surveyor observed R34 sitting in recliner on a cloth pad with no cushion in recliner. On 8/8/22 at 9:22 AM Surveyor observed R34 sitting in recliner on a cloth pad with no cushion in chair. On 8/8/22 at 10: 02 AM Surveyor observed R34 sitting in recliner on a cloth pad with no cushion in chair. On 8/8/22 at 10:06 AM Surveyor interviewed R34 and R34 indicated they sit in recliner most of the day and also sleeps in recliner at night. R34 was not aware whether there was a cushion under them. On 8/8/22 at 10:52 AM Surveyor and the DON (Director of Nursing)-B went into R34's room to observe R34. DON-B verified there was no cushion in R34's recliner and only a cloth pad. DON-B verified that R34 should have a cushion in the recliner where R34 is sitting. 2. R16 was admitted to facility on 7/28/15 with the diagnosis of dysphasia, urinary incontinence, anemia, chronic kidney disease and osteoarthritis. R16's MDS assessment dated [DATE] indicated that R16 required extensive assistance with bed mobility, transfers, toileting, dressing and hygiene and R16 was at risk for the development of PI. The most recent care plan for R16 documented the following interventions: pressure reducing device in chair (cushion), pressure reducing device in bed, turn and reposition program On 09/06/22 at 10:57 AM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 09/06/22 at 12:19 PM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 09/07/22 at 08:32 AM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 09/07/22 at 09:52 AM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 9/8/22 at 10:42 AM Surveyor interviewed DON-B. DON-B verified that a towel should not be over cushion in R16's wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the resident environment was free of accident hazards for 1 Resident (R) (R42) of 4 sampled residents reviewed for fall safety. R42 was not appropriately secured into R42's wheelchair with the seat belt while unsupervised as assessed and care planned. Findings Include: R42 was admitted in 2019 with congestive heart failure (CHF), chronic osteomyelitis, diabetes mellitus type 2, unspecified displaced fracture of second cervical vertebra, major depressive disorder, and dementia without behavioral disturbance. R42's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated R42's Brief Interview for Mental Status (BIMS) was unable to be completed, indicating, No (resident is never/rarely understood.) On 9/7/22 at 7:45 AM, Surveyor interviewed R42's legal guardian (LG)-E . LG-E stated R42 had a seat belt that needed to be applied while R42 is in R42's wheelchair. LG- stated R42 had two irreparable breaks in R42's neck and is ordered to wear a cervical collar. LG-E stated when LG-E was visiting on Saturday, 9/3/22, LG-E needed to remind staff to put R42's seat belt on. R42 stated the facility does not leave R42's door opened per care plan. On 9/6/22, Surveyor reviewed R42's record which included a provider note dated 7/25/2022 3:37 PM which stated, [R42] utilizes a seatbelt while seated in [R42's] wheelchair. The seatbelt is indicated for use by the following information: Per [named clinic and provider], there is an old fracture that has not healed properly. There likely is a fibrous non union of two pieces of bone of C2 (second cervical vertebrae.) Options given were to continue in the Cervical Collar for the rest of [R42's] life, or fusion of C1/C2. It has been decided to remain wearing the Cervical Collar due to the dangers of fusion at C1/C2. Per [named provider], any injury to the neck or wrong movement of the neck could result in a devastating spinal cord injury, including death. Therefore, it is imperative that [R42] utilize the seatbelt at all times while in [R42's] wheelchair. On 9/6/22 at 4:04 PM, Surveyor observed Certified Nursing Assistants (CNA)-C and CNA-D transfer R42 from bed into R42's wheelchair. R42 was provided a call-light and staff and Surveyor exited R42's room. On 9/6/22 at 4:26 PM, Surveyor interviewed CNA-C regarding R42's seat belt. CNA-C stated R42's seat belt was on. Surveyor requested to observe and verify that R42's seat belt was properly secured. R42's door was opened approximately four to six inches, not allowing R42 to be in direct supervision. CNA-C lifted R42's blanket and the seat belt was not fastened. CNA-C fastened R42's seat belt. CNA-C stated R42's seat belt needed to be on most of the time. R42's therapy note dated 7/13/22 stated R42's wheelchair positioning included the use of a seat belt. R42's care plan related to seat belt use included: Seat belt may be removed under direct staff supervision when [R42] is up in W/C (wheelchair.) On 9/6/22 at 4:45 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R42's seat belt. DON-B stated R42's seat belt should be on while R42 is in R42's wheelchair and not under direct supervision. yes it should have been on while he was in his wheelchair and not in direct supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure food was prepared, stored, and served under sanitary conditions. Outdated and undated products were stored for 5 Residents (R) (R15, R27, R35, R54, and R157) of 60 residents. Staff did not date or did not discard food and beverages after seven days of constitution or opening for community use beverages and R15, R27, R35, R54, and R157's individually labeled items. Kitchenette ovens had baked food debris, in varying amounts, in the interior of oven. Findings include: On 9/6/22 at 8:36 AM, Surveyor interviewed Dietary Manager (DM)-I who indicated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. Undated and Outdated Beverages FDA Food Code 2017 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in ¶¶ (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 On 9/6/22, following initial tour of main kitchen beginning at 8:36 AM, Surveyor and DM-I entered [NAME] Way unit where Surveyor observed and DM-I verified the refrigerator held one 64 ounce (oz) container of cranberry juice cocktail was open and undated. DM-I expressed uncertainty regarding how quickly the unit used a container of cranberry juice cocktail, verified cranberry juice cocktail should have been dated upon opening, and directed a staff member to discard cocktail. Refrigerator also contained approximately a quarter of a sandwich labeled for R54 with no date. DM-I verified the sandwich required a date. On 9/6/22 at 9:24 AM, Surveyor and DM-I proceeded to Clover unit where Surveyor observed and DM-I verified a 64 oz container of orange juice was open and undated in the refrigerator. Surveyor and DM-I proceeded to [NAME] unit which where Surveyor observed and DM-I verified the refrigerator contained an open, undated 64 oz container of orange juice. On 9/6/22 at 9:37 AM, Surveyor and DM-I entered Stony unit where Surveyor observed and DM-I verified the refrigerator held a container of nectar thickened flavored water labeled as constituted for R35's use on 8/28/22, a container of nectar thickened coffee labeled as constituted for R35's use on 8/29/22, a container of honey thickened chocolate milk labeled as constituted for R15's use on 8/28/22, a container of pudding thickened chocolate milk labeled as constituted for R27's use on 8/29/22, and a container of soy milk, open and undated, labeled for R157's use. DM-I verified all alternate thickness beverages should have been discarded after day 7 from date of constitution and R157's soy milk should have been open dated. Soiled Ovens FDA Food Code 2017 documents at 4-601.11(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 9/6/22 from 8:36 AM through 9:37 AM, Surveyor observed and DM-I toured unit kitchenettes. Surveyor and DM-I entered Clover unit. Surveyor observed black, baked on food in bottom of unit oven. DM-I confirmed the oven was not clean and explained the oven was seldom used and kitchenette ovens were not on a cleaning schedule. Surveyor and DM-I entered [NAME] unit. Surveyor proceeded to open oven and felt handle was sticky to touch. DM-I then touched handle and confirmed handle was sticky. Surveyor observed crumbs in bottom of oven. DM-I confirmed oven was not clean and identified activities department as the only oven user. Surveyor and DM-I entered Stony unit. Surveyor observed Stony unit oven had aluminum foil stuck to the racks with what DM-I described as pizza drippings hanging from racks; black baked food residue was in bottom of oven. Surveyor and DM-I entered [NAME] unit. Surveyor observed and DM-I verified the oven bottom was soiled.