Oaks At Bethesda The
OAKS AT BETHESDA THE in ZANESVILLE, OH — inspection on May 28, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of facility Notification of Change in Condition policy, dated [DATE], revealed the following were sample reasons to notify the physician immediately for a change in condition: a deterioration in health, mental, or psychosocial status un either life-threatening conditions or clinical complications, need to alter treatment significantly, or clinical complications such as development of a pressure area, onset of delirium or recurrent urinary tract infections.
Documentation of notification or notification attempts should be recorded in the electronic health record.
Review of facility Guidelines for Pain Observation and Management policy, dated [DATE], revealed the purpose of the policy is to ensure each resident's pain, including it's origin, location, severity, alleviating and exacerbating factors, current treatment, and response to treatment will be observed and documented according to the needs of each individual. If there is a change in pain indicators or verbalizations from resident, a pain event form will be completed to indicate changes and care plan update.
366413 05/28/2026
Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701
risk factors and implementpreventative measures.
Should the resident experience a fall the attending
circumstancessurrounding the fall to determine the cause of the episode, a reassessment to
bythe Interdisciplinary team (IDT) to evaluate thoroughness of the investigation andappropriateness of the interventions.
366413 05/28/2026
Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701
Based on observation, staff interview and review of facility policy, the facility failed to ensure
three residents (Resident #48, #51 and #71) of three residents reviewed for medication storage.
Facility census was 49.Findings include:1.
Review of the medical record for Resident # 48 revealed an admission date of 05/08/26 with diagnoses including encounter for surgical aftercare following surgery on the digestive system status post (s/p) colostomy, sepsis, chronic obstructive pulmonary disease (COPD) and asthma.
Review of the physician's orders for Resident # 48 revealed an order dated 05/08/26 for Ipratropium Bromide/Albuterol Sulfate 0.5mg/3mg per milliliter (ml) twice a day for COPD.
Review of the Medication Administration Record (MAR) for Resident # 48 dated May 2026 revealed the resident received Ipratropium Bromide/Albuterol Sulfate twice daily from 05/08/26 to 05/27/26.Observation and interview on 05/27/26 at 4:56 P.M. with RN # 140 of the medication cart on 100 hall revealed one box of Ipratropium Bromide/Albuterol Sulfate 0.5mg/3mg per milliliter (ml) for Resident #48, there was a yellow sticker attached to the foil packaging to enter an open date and discard after 14 days.
There was no open date on the package. RN #140 verified no open date on the medication.2.
Review of the medical record for Resident # 51 revealed an admission date of 10/23/23 with diagnoses including Type II Diabetes Mellitus with diabetic chronic kidney disease, hypertension and hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease.Review of the physician's orders for Resident # 51 revealed an order dated 05/12/26 and discontinued on 05/17/26 for insulin Lispro 100 unit/mL per sliding scale once daily.Observation and interview on 05/27/26 at 4:40 P.M. with Registered Nurse (RN) #128 during review of the medication cart for long 200 hall revealed, one vial of insulin Lispro with an open date of 04/11/26 and a yellow sticker that read expires after 28 days of opening.
During concurrent interview with RN #128 it was verified the insulin Lispro was expired.3.
Review of the medical record for Resident # 71 revealed an admission date of 05/15/26 with diagnoses including COPD and Diabetes Mellitus.
Review of the physician's orders for Resident # 71 revealed an order dated 05/15/26 for Levalbuterol aerosol solution 1.25 milligrams (mg) every four hours as needed and an order dated 05/19/26 through 05/21/26 for Levalbuterol aerosol solution 1.25 milligrams (mg) three times a day for wheezing.
Observation and interview on 05/27/26 at 4:40 P.M. with Registered Nurse (RN) #128 during review of the medication cart for long 200 hall, revealed one box of Levalbuterol aerosol solution 1.25 milligrams (mg) with no open date, there was a yellow sticker attached to the foil packaging to enter an open date and discard date after seven days , however the yellow sticker was blank.
During concurrent interview with RN #128 it was verified the the medication was not labeled with the open date.
Review of facility policy titled, Medication Storage, reviewed 11/01/22, revealed outdated or otherwise unusable medications must be immediately pulled from the active inventory and segregated to an area to prevent unintentional use.
366413 05/28/2026
Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701
Review of Resident #66's physician orders revealed an order dated 05/21/26 for contact precautions.
Review of the care plan dated 05/26/26 revealed resident had a need for contact isolation related to active infectious disease related to C-diff.
Interventions included use principles of infection control and universal/standard precautions.
Observation on 05/26/26 at 11:24 A.M. revealed Environmental Services Worker #154 entering contact isolation room for Resident #66 without donning proper PPE prior to entrance. A sign was posted outside of the room door to Resident #66's room indicated he was on contact precautions and a cart containing personal protective supplies was noted outside the resident's room door.
Interview on 05/26/26 at 11:24 A.M. with the Environmental Services Worker #154 verified she did not follow the guidance for contact isolation and should have put PPE on prior to entering Resident #66's room due to contact precautions.
Review of Center of Disease Control and Prevention (CDC) guidance for contact precautions, signage posted outside of Resident #66's room read Providers and Staff must also put on gloves before room entry.
Put on gown before room entry.
Review of facility policy titled Guidelines for Contact Precaution, reviewed 12/10/25 revealed wear a clean non-sterile, fluid resistant gown when entering the room if it is anticipated clothing will have substantial contact with the resident or environmental surface or when there is likelihood that organisms from blood, urine, stool, or wound drainage may be on surfaces or item's in the resident's rooms.
Post a sign at the resident's door that is appropriate according to Center for Disease Control and Prevention (CDC) guidance.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.