Inspection·July 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dated 06/06/25 for LPN #301 indicated the nurse was discharged from employment due to advising CNA #300 to transport Resident #19 while tipped backwards in a wheelchair on two wheels and then assisting by holding the resident's legs which was observed on video. Review of a performance improvement form dated 06/06/25 for CNA #300 indicated the aide was discharged from employment due to tipping Resident #19 backwards in the wheelchair onto two wheels and transporting her back to her room which was observed on video. Interview on 07/22/25 at 1:03 P.M. with Administrator verified the above incident findings. The deficient practice was corrected on 06/06/25 when the facility implemented the following corrective actions: CNA #300 and LPN #301 were suspended on 06/02/25 by the Director of Nursing (DON). Staff statements from those involved were obtained by DON on 06/02/25. On 06/02/25 an order was written for psychiatric/psychological services to consult Resident #19 on next facility visit. Resident skin assessments were completed post incident by floor nurses with no new skin issues identified. Resident #19's responsible party and nurse practitioner were notified on 06/02/25 by the DON. Social service designee completed psychosocial visits with Resident #19 on 06/04/25, 06/05/25 and 06/06/25 with no changes from baseline. All residents were interviewed and those who could not be interviewed received comprehensive skin assessments by licensed nurses by 06/04/25 with no variances noted. A root cause analysis was completed on 06/05/25 by the interdisciplinary team (IDT). Police were notified by Regional Director of Clinical Services (RDCS) #303 on 06/05/25 and report completed. All staff were educated by RDCS or designee by 06/06/25 regarding facility abuse policy, including timely reporting, the abuse coordinator and removing residents immediately when abuse identified; resident rights; restraints; and caring for residents with behaviors. Beginning on 06/05/25, online education was assigned entitled, Abuse Prevention, Dealing with Difficult Behaviors, which all staff members completed by 06/06/25. All facility staff completed questionnaires on 06/06/25 to validate learning of abuse reporting and prevention with immediate education provided by DON or designee if incorrect answers were submitted. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held on 06/06/25 with the interdisciplinary team to ensure compliance with facility abuse policy, timely reporting and resident rights. CNA #300 and LPN #301 were terminated from employment on 06/06/25 by the Administrator and DON. Beginning 06/06/25, the DON or designee audited two staff members daily on various shifts using visual audit to validate resident rights were honored, correct actions in response to resident refusals of care, and residents were free from abuse for four weeks Beginning 06/06/25, the DON or designee interviewed two staff members daily on various shifts on response to resident abuse or denial of rights, and when to notify the abuse coordinator of suspected abuse with immediate education if incorrect responses received for four weeks. Beginning 06/06/25, the DON or designee interviewed 15 residents weekly for four weeks regarding abuse and resident rights being followed. Results of audits were reviewed in a one-month follow-up QAPI Committee meeting with revisions to the plan or changes made in monitoring as deemed by the QAPI committee. This deficiency was an incidental finding identified during the complaint investigation. Event ID: Facility ID: 365718 If continuation sheet Page 2 of 8 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and review of the facility policy, the facility failed to maintain a clean and sanitary environment. This affected two (Residents #6 and #67) of 14 residents reviewed for environment and had the potential to affect all residents residing in the facility. The facility census was 70. Findings include: 1. Observation on 07/21/25 at 9:54 A.M. revealed Resident #6 in a wheelchair next to the bed watching television. The room had a distinct odor of urine. The bed covers were pulled away which exposed a wet soiled incontinence pad. The edges of the soiled area were dried and yellowish-brown in color. There were six gnats crawling upon the wet part of the soiled area and two gnats flying above it. Nearby on the floor just outside the bathroom was a small pile of wet soiled clothes. Across the room from the bed near the wall was soiled linen including a towel and washcloth. Interview with Resident #6 at the time of the observation who complained about the bed and indicated having been up in the wheelchair for a long time without it being cleaned up. Interview on 07/21/25 at 10:01 A.M. with Certified Nursing Assistant (CNA) #214 confirmed the observation in Resident #6's room and verified night shift had gotten Resident #6 up and left it that way but had not had an opportunity to fix it yet although it had been a few hours since then. Review of the medical record for Resident #6 revealed an admission date of 07/25/19 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, congestive heart failure and diabetes mellitus type two. The Annual Minimum Data Set (MDS) assessment completed 06/10/25 indicated no cognitive impairment. The plan of care reviewed 06/27/25 specified Resident #6 required one to two staff assistance with all activities of daily living (ADL) and was incontinent of bowel and bladder. 2. Observation on 07/21/25 at 10:13 A.M. of the hallway approximately ten feet from and approaching Resident #67's room revealed a strong unpleasant odor of urine. The resident was not in the room and the odor was more pungent within it. Upon walking on the floor of the room, it was sticky as the sound of adherence and the resistance as shoes pulled away from the floor was felt. The bed covers were pulled back which exposed an incontinence pad with a large, dried area of urine yellowish-brown and dried smudges of feces. The bedside table was sticky with dried spills and a large number of crumbs and debris. Interview at the time of the observation with Licensed Practical Nurse (LPN) #246 verified the observation and indicated Resident #67 had a urinary catheter but would empty the urine bag without assistance and spill it on the floor and/or bed sheets. The resident also had behaviors including refusal of housekeeping or personal care, so staff had to reapproach or clean the room after the resident left the room. Interview on 07/21/25 at 10:56 A.M. with Administrator and Director of Nursing (DON) revealed Resident #67 was considered by staff as a focus resident because of the behaviors, so the staff had to check on the resident more frequently. Review of the medical record for Resident #67 revealed an admission date of 08/23/19 with diagnoses including Alzheimer's disease, dementia, sensorineural hearing loss, urethral stricture, congestive heart failure and diabetes mellitus type two. The Annual MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment and a urinary catheter. The plan of care reviewed 06/10/25 specified Resident #67 required cues and assist as needed to accomplish daily tasks and was known to empty the urinary catheter bag without assistance. Review of the facility policy, Handling Soiled Linen, revised 12/20/23, revealed soiled linen was collected at the bedside or point of use and placed into a linen bag or designated lined receptacle when task was completed. The soiled linen was not kept in a resident's room, bathroom or other care areas. Review of the facility policy, Safe and Homelike Environment, revised 01/01/22, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 3 of 8 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm facility provided and maintained bed and bath linens that were clean and in good condition, and minimized odors by disposing of soiled linens promptly and reporting lingering odors to housekeeping. This deficiency represents non-compliance investigated under Master Complaint Number 2570725 and Complaint Number 1342408 (OH00166879). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 4 of 8 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of Self-Reported Incident (SRI) #261204, and facility policy review, the facility failed to protect Resident #3 from verbal abuse by a staff member. This affected one (Resident #3) of four residents reviewed for abuse, neglect, misappropriation and exploitation. The facility census was 70. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/21/20 with diagnoses including Alzheimer's disease with late onset, dementia, diabetes mellitus type two, congestive heart failure, violent behavior, mood affective disorder, major depressive disorder, and nicotine dependence. Review of Resident #3's plan of care reviewed 04/25/25 revealed the resident had behaviors of increased agitation towards others, often unprovoked, verbal aggression and profanity. Review of the Annual Minimum Data Set (MDS) assessment completed 05/06/25 revealed no cognitive impairment. Review of a nursing progress note dated 05/31/25 revealed Resident #3 left outside the therapy room door. When Registered Nurse (RN) #302 asked the resident to stop, she replied shut up. Resident #3 was asked to stop letting ducks in and refused to leave the therapy room. Review of nursing progress notes dated 06/01/25 revealed RN #302 documented while on the phone with the Director of Nursing (DON) residents were in the therapy area and asked to leave but Resident #3 refused. RN #302 informed the resident she could have a police escort out if refusals continued because of safety, letting ducks into the building and administration's request to get all residents out of the therapy area. Resident #3 responded by calling RN #302 a [expletive] and stated, the nurse should make her get out. Resident #3 eventually left the therapy area. While RN #302 was at the medication cart counting narcotics in the nurses' station area, Resident #3 approached RN #302 and informed the nurse she did not want RN #302 in her room or taking care of her anymore. Resident #3 continued to state to RN #302, she don't want no [expletive] in her room, and you are a [expletive]. RN #302 told the resident it was inappropriate talk and furthermore if the resident crossed through the therapy area to the courtyard for any reason including smoking, it would be a direct infarct of the smoking rules and could result in losing smoking privileges. Resident #3 responded to RN #302 to kiss her [expletive] [expletive] and threatened to call her lawyer because RN #302 had no right to take away her smoking privileges because it was her right to do and say what she wanted, then left the nurses' station. Review of SRI tracking #261204 dated 06/04/25 revealed an allegation of verbal abuse was reported to administration via a company compliance hotline by Licensed Practical Nurse (LPN) #301 who reported she witnessed RN #302 on 05/31/25 abuse Resident #3 by calling the resident a hillbilly [expletive], and the DON witnessed it being on the phone at the time. Regional Director of Clinical Services (RDCS) #303 reviewed video evidence and found the incident occurred at approximately 7:30 P.M. to 7:40 P.M. when RN #302 and LPN #248 were seen at the medication cart near the nurses' station closest to the therapy room doors. Resident #3 approached RN #302, stated something, then walked away to the opposite end of the nurses' station nearest the therapy area by 300 hall. RN #302 then reacted by throwing both hands up in the air and pointing at Resident #3 while walking towards her, still using hand gestures continuing to point and reflecting excitability. Next, LPN #257 intervened by redirecting Resident #3 away from RN #302 out of the area toward the resident's room. As Resident #3 walked away, RN #302 continued to point at and use hand gestures but there was no audio as to what was said to the resident. RN #302 then picked up the telephone to make a call while standing at the medication cart with LPN #248. Review of the written witness statement by the DON dated 06/04/25 indicated receiving a phone call at the time of the incident from RN #302 who complained residents had exited out the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 5 of 8 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy room doors to smoke which let ducks into the facility, and refused to listen when told to shut the door, leave the area and allow the ducks to exit the building. RN #302 reported Resident #3 was chasing after the ducks and would not listen, but eventually the residents did leave the therapy area and shut the door. RN #302 complained of both Residents #3 and #56 yelling and swearing at her about smoking and it being their right to smoke but Resident #56 did later apologize to her. RN #302 continued to complain about Resident #3 who called her a lesbian and told her they had rights to go smoke. RN #302 reported telling Resident #3 to move away from her and go to her room to defuse the situation. DON denied hearing any verbal interactions between RN #302 and Resident #3 over the telephone. Review of the written telephone interview between RDCS #303 and witness LPN #248 dated 06/04/25 indicated RN #302 was very upset, crying and talking about the workload while they were both counting narcotics at the medication cart when Resident #3 approached and told RN #302, she could not take care of her because of what was said, then called RN #302 a [expletive]. RN #302 informed LPN #248 the resident was calling her a lesbian then RN #302 said to Resident #3, I'm [expletive] married and have seven [expletive] kids. I bet you don't have a [expletive] husband. RN #302 then called Resident #3 a [expletive], so LPN #248 responded to RN #302, hey, hey, hey when it stopped, and Resident #3 then walked away. RN #302 called the DON to report what happened but did not tell the DON she had called Resident #3 names. Review of the written telephone interview between RDCS #303 and witness LPN #243 dated 06/04/25 indicated discussing the schedule and call-offs with RN #302 who was upset about it at the time. It was near smoke break for residents, so they were told it had to wait while the nurses were trying to call the DON to discuss the schedule. Then quacking was heard, and ducks were seen in the therapy area where the door had been propped open, so the residents were told to close the doors and not use them, but the residents replied they were just waiting for their smoke break. The nurses then informed them it may be some time before there was a smoke break. Resident #3 became upset yelling at them and called RN #302 a [expletive]. RN #302 was stern with Resident #3 telling the resident to leave the area. After the ducks got out of the facility, RN #302 went to the medication cart at the nurses' station when Resident #3 approached her and called her a lesbian [expletive]. RN #302 did not take it well and responded to Resident #3, I'm [expletive] married and have seven [expletive] kids. I bend over for every [expletive] in here, and you have the nerve to call me names. Resident #3 responded to RN #302, yep, yep. RN #302 then called the DON and reported Resident #3 was calling her names. The DON tried to talk to Resident #3 but the resident threw the phone down when LPN #243 handed it to her. RN #302 was crying and very upset. Review of the written telephone interview between RDCS #303 and witness LPN #257 dated 06/04/25 indicated RN #302 was trying to get two residents (#3 and #56) to exit the therapy area, shut the doors and redirect ducks out of the building. Resident #3 was calling RN #302 names then called the DON to discuss it and get assistance with getting residents to comply. While RN #302 was on the phone with the DON she called Resident #3 hillbilly [expletive]. Review of the written telephone interview between RDCS #303 and alleged perpetrator RN #302 dated 06/04/25 indicated Residents #3 and #56 were exiting the facility through the therapy doors which allowed ducks into the building. RN #302 asked them to close the doors to let the ducks exit, but Resident #3 started calling her names, calling her a [expletive] and telling her to kiss her [expletive] [expletive] all while attempting to get residents to come in. RN #302 denied calling Resident #3 any names only that the resident called her names. RN #302 reported working on the day after the incident and received report from other staff that Resident #3 had continued to talk about her, calling her names, so RN #302 approached the resident and asked her to stop speaking of the incident and calling her inappropriate names, but there were no further interactions. Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 6 of 8 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the written telephone interview between RDCS #303 and witness LPN #301 (undated) indicated not being present during the incident on 05/31/25 but on 06/01/25 while working with RN #302 at the nurses' station, RN #302 informed her, and the other staff present there what had occurred the previous evening with Resident #3. RN #302 told them the resident had called her names, so she reciprocated. It was also relayed that the DON was on the phone at the time of the event, so LPN #301 called the compliance hotline (on 06/04/25).Review of a performance improvement form dated 06/06/25 for RN #302 indicated the nurse was discharged from employment due to being observed by staff being disrespectful to Resident #3 which was confirmed by review of video showing RN #302 pointing at the resident appearing to be aggressive. Review of the state nursing board complaint filed by the Administrator dated on 06/11/25 revealed a complaint made against RN #302 who was witnessed calling Resident #3 a [expletive], saying I'm [expletive] married and have seven [expletive] kids, was seen on video pointing at the resident while approaching her repeatedly shaking her arms, and was reported to the state agency for verbal abuse against Resident #3. Interview on 07/22/25 at 1:03 P.M. with the Administrator verified the above incident findings and confirmed the abuse investigation, SRI #261204, was substantiated. Interview on 07/22/25 at 3:00 P.M. with RDCS #303 confirmed the above findings of the incident and described the video findings as the nurses had come in at the start of the shift. RN #302 was there and probably was discussing the schedule. Another staff member saw ducks in the therapy gym, so everyone migrated over to them and then returned. RN #302 and LPN #248 were at the medication cart with Resident #3 at the other side of the nurses' station. The resident walked up to RN #302, said some things, supposedly calling the nurse a [expletive] and walked away. The altercation then occurred with RN #302 making a statement to the resident, pointing hands going toward her before returning to the medication cart to call the DON. Another nurse directed Resident #3 away from RN #302 back to her room. Review of the written interview between Social Services Designee (SSD) #275 and Resident #3 dated 06/04/25 indicated the resident got upset with a nurse, called her a [expletive] and then the staff member called the resident a [expletive]. Review of the facility policy, Abuse, Neglect and Exploitation, revised 01/10/24, revealed the facility implemented written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after an investigation. All alleged violations were to be reported to the Administrator. The deficient practice was corrected on 06/06/25 when the facility implemented the following corrective actions:The DON and RN #302 were suspended on 06/04/25 immediately when the incident was reported via the company compliance hotline on 06/04/25 by LPN #301.Staff statements from those involved were obtained by RDCS #303 on 06/04/25.Resident #3 refused a skin assessment on 06/06/25 and then reattempted and allowed with no skin alterations noted.Resident #3 was observed via camera footage by RDCS #303 as being removed from the situation by LPN #257 on 05/31/25 and redirect to her room.Resident #3's responsible party and nurse practitioner were notified on 06/04/25 by RDCS #303.SSD #275 completed psychosocial visits with Resident #3 daily for 72 hours with no changes from baseline.The DON and RN #302 were suspended by RDCS #303 on 06/04/25 and after the investigation identified the DON was not on the phone at the time of the incident, and RN #302 displayed inappropriate behavior and cursing at Resident #3 which resulted in termination of employment on 06/06/25.A root cause analysis was completed on 06/05/25 by the interdisciplinary team (IDT).RN #302 was reported to the state board of nursing by the Administrator at the conclusion of the investigation.A PHQ9 assessment (measures depressive symptoms) was completed for Resident #3 and the resident was referred to psychiatric/psychological services on 06/06/25 by SSD #275.Police were notified by RDCS #303 on 06/05/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365718 If continuation sheet Page 7 of 8 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and a report was completed.All residents were interviewed and those who could not be interviewed received comprehensive skin assessments by licensed nurses by 06/04/25 with no variances noted.All staff were educated by RDCS #303 or designee by 06/06/25 regarding facility abuse policy, including timely reporting, the abuse coordinator and removing residents immediately when abuse identified; resident rights; and caring for residents with behaviors.Beginning on 06/05/25, online education was assigned entitled, Abuse Prevention, Dealing with Difficult Behaviors, which all staff members completed by 06/06/25.All facility staff completed questionnaires on 06/06/25 to validate learning of abuse reporting and prevention with immediate education provided by DON or designee if incorrect answers were submitted.Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held on 06/06/25 with the interdisciplinary team to ensure compliance with facility abuse policy, timely reporting and resident rights.Beginning 06/06/25, the DON or designee audited two staff members daily on various shifts using visual audit to validate resident rights were honored, correct actions in response to resident refusals of care, and residents were free from abuse for four weeks.Beginning 06/06/25, the DON or designee interviewed two staff members daily on various shifts on response to resident abuse or denial of rights, and when to notify the abuse coordinator of suspected abuse with immediate education if incorrect responses received for four weeks.Beginning 06/06/25, the DON or designee interviewed 15 residents weekly for four weeks regarding abuse and resident rights being followed.Results of audits were reviewed in a one-month follow-up QAPI Committee meeting with revisions to the plan or changes made in monitoring as deemed by the QAPI committee.This deficiency was an incidental finding identified during the complaint investigation. Event ID: Facility ID: 365718 If continuation sheet Page 8 of 8