Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oaks At Bethesda The during CMS and state inspections, most recent first.
A resident with impaired mobility, weakness, and a prior wrist fracture required supervision and touching assistance for showering and bathing, but a CRCA left her alone in the shower room. The resident fell in the bathroom and sustained a comminuted, intra-articular distal radius fracture of the right arm; witness statements and the facility investigation confirmed staff did not stay with her during the shower.
Medication storage was deficient when an RN found one resident’s inhaled med without an open date, another resident’s insulin vial past its 28-day expiration after opening, and a third resident’s aerosol solution with a blank open-date sticker. The affected residents had COPD/asthma or DM with CKD, and facility policy required outdated or unusable meds to be removed from active inventory.
A resident’s nephrology appointment was cancelled because required pre-appointment labs were not ordered or completed, and the DON later confirmed there was no evidence the provider was contacted to clarify the needed testing. In a separate event, another resident with severe cognitive impairment and multiple chronic conditions showed escalating distress, pain, hallucinations, and swallowing difficulty, but the provider was not notified until later and no other comfort measures or injectable meds were ordered before the resident was sent to the ER.
A staff member entered a resident’s contact isolation room without donning PPE first, despite the resident being on contact precautions for C-diff. The resident had orders and a care plan for contact isolation, and PPE supplies and signage were posted outside the room. The staff member confirmed the lapse, and CDC guidance plus facility policy required gloves and a gown before room entry.
A resident with multiple complex medical conditions developed deep tissue injuries to the buttocks, but wound treatment orders and documentation of protective cream application were not in place or recorded until after the resident developed Moisture Associated Skin Damage (MASD). The care plan and physician orders for pressure relief were not fully implemented, and facility policy for pressure ulcer prevention was not consistently followed.
The facility failed to implement proper infection control measures for laundering isolation linens, potentially affecting all 52 residents. Multiple cases of C-diff were recorded, and the facility lacked a specific policy for washing isolation linen. Laundry processes did not separate contaminated linens, relying on high-temperature washing without verifying temperatures reached the necessary 160°F. The isolation cycle with bleach was not used for personal items, leading to inadequate disinfection.
The facility failed to notify the physician and address a change in a resident's ability to chew and swallow, and did not implement compression stockings or unna boot dressings per order for another resident. One resident was observed holding pills in her mouth and coughing with meals, but the physician was not notified. Another resident did not receive prescribed compression treatments, resulting in red and swollen lower extremities. These deficiencies indicate a lack of communication and adherence to care protocols.
A facility failed to document care and ensure orders for a resident with a catheter. The resident, with a history of cerebral infarction and malnutrition, returned from the hospital with a new indwelling urinary catheter. Observations confirmed the catheter's presence, but interviews with nursing staff revealed no orders or care plans were in place. The LPN acknowledged the oversight and intended to address it.
A facility failed to implement timely pharmacy recommendations for a resident, affecting their medication management. The resident, with multiple diagnoses, did not have the month for Estring replacement added to their records, and a side effect monitoring order for Gabapentin was delayed. Additionally, an AIMS assessment for aripiprazole was not completed as required, contrary to facility policy.
A facility failed to monitor and document the pain management of a resident with multiple diagnoses, including dementia and anxiety disorder. Despite administering Hydrocodone-Acetaminophen multiple times, the facility did not document the severity, location, or nonpharmacological interventions for the resident's pain. The Director of Nursing confirmed the lack of documentation, which was required by the facility's policy.
A facility failed to justify the use of prophylactic antibiotics for a resident, as identified through medical record review and staff interviews. The resident, with a history of sepsis and other conditions, was prescribed levofloxacin and macrobid without meeting the criteria for antibiotic use. The facility's policy requires collaboration with pharmacy providers and documentation review, but these were not adequately followed, resulting in a deficiency.
Resident Left Unsupervised During Shower and Fell
Penalty
Summary
The facility failed to ensure a resident was not left alone in the shower, and the resident fell in the bathroom and sustained a comminuted, intra-articular distal radius fracture of the right arm. Resident #2 was admitted with diagnoses including Type II Diabetes Mellitus with hyperglycemia, overactive bladder, pain, cognitive communication deficit, generalized muscle weakness, difficulty walking, and a prior Colles' fracture of the right radius. The care plan identified impaired mobility, unsteady gait, impaired posture, generalized weakness, dyspnea on exertion, incontinence, hypertension, Diabetes Mellitus, and polypharmacy as fall-related concerns, and the profile care guide documented the resident needed one-person assistance for transfers and use of a platform walker. The quarterly MDS assessment showed the resident was alert and oriented and required supervision and touching assistance with tub/shower transfers, showering, and bathing. The facility investigation stated the resident was assisted into the bathroom to shower, but the CRCA exited the shower room and left the resident to shower herself; the root cause analysis documented that staff did not stay with the resident to assist with the shower and the aide was outside the building when the fall occurred. Witness statements indicated the resident was found on the bathroom floor and the spouse reported that staff left her in the bathroom and did not come in to help. The resident later stated she was reaching for something, lost her balance, and fell.
Medication Storage Lapses
Penalty
Summary
The facility failed to ensure medications were dated when opened and expired medications were removed from active storage. During observation and interview, one box of Ipratropium Bromide/Albuterol Sulfate for a resident with COPD and asthma had a yellow sticker for an open date and discard date, but no open date was written on the package. The resident had received the medication twice daily from the admission date through the day of observation, and the RN verified the package was not dated. A second resident with Type II DM and chronic kidney disease had an insulin Lispro vial in the medication cart with an open date of 04/11/26 and a sticker indicating it expired after 28 days of opening; during interview, the RN verified the insulin was expired. A third resident with COPD and DM had a box of Levalbuterol aerosol solution in the medication cart with no open date, and the attached sticker for the open and discard dates was blank; the RN verified the medication was not labeled with the open date. Facility policy stated outdated or otherwise unusable medications must be immediately pulled from active inventory and segregated to prevent unintentional use.
Missed nephrology testing and delayed response to resident decline
Penalty
Summary
The facility failed to complete laboratory orders related to a nephrology consultation for one resident and failed to ensure the resident was able to attend the medical appointment as scheduled. The resident was cognitively intact, had multiple diagnoses including osteomyelitis, sepsis, acute kidney failure, bacteremia, rheumatoid arthritis, atrial fibrillation, and hypertension, and her AVS stated that testing should be completed one week before the nephrology appointment so results would be available for review. The record showed no laboratory orders entered or completed for that consultation, and no laboratory results were found related to the appointment. The resident’s nephrology appointment was later cancelled the morning it was scheduled to occur. The resident stated she did not cancel the appointment and said staff told her that morning it had to be cancelled because the needed testing had not been done. Her representative also confirmed the appointment was cancelled before she attended and expressed concern that the resident needed the appointment. The DON initially stated the resident cancelled the appointment, then later confirmed there was an order for testing to be completed before the appointment, that there was no evidence it was ordered or completed, and that there was no evidence the provider was contacted to clarify what orders were needed before the appointment. The facility also failed to provide timely comfort care during a change in condition for another resident with severe cognitive impairment and multiple chronic illnesses, including chronic respiratory failure with hypoxia, pulmonary hypertension, heart disease, diabetes, COPD, and chronic pain syndrome. Progress notes documented escalating distress, restlessness, crying, yelling, hallucination-like behavior, pain, and difficulty swallowing over several hours, but the provider was not notified until later in the morning. After notification, laboratory tests were ordered and the provider discontinued PRN Percocet because the resident was spitting it out and was having trouble swallowing. The record and interviews showed no other pain or psychotropic medications were ordered during the period of decline, and the resident was later sent to the emergency room for continued decline, inability to swallow, and family refusal of hospice services.
Failure to Use PPE Before Entering Contact Isolation Room
Penalty
Summary
The facility failed to ensure staff donned personal protective equipment prior to entering Resident #66’s room while the resident was on contact precautions for sepsis due to Clostridioides difficile (C-diff). Resident #66 was admitted with diagnoses including sepsis due to C-diff, and the physician orders included contact precautions. The care plan identified a need for contact isolation related to active infectious disease related to C-diff and included interventions for infection control and standard precautions. During observation, an Environmental Services Worker entered Resident #66’s contact isolation room without putting on the required PPE before entry. A sign outside the room indicated the resident was on contact precautions, and a cart with personal protective supplies was placed outside the room. In interview, the Environmental Services Worker confirmed she did not follow contact isolation guidance and should have put PPE on before entering the room. The report also notes CDC guidance and facility policy requiring gloves and gown before room entry for contact precautions.
Failure to Ensure Wound Treatment Orders and Documentation for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that wound treatment orders were in place for a resident with multiple medical conditions, including surgical aftercare, heart disease, respiratory failure, chronic kidney disease, and diabetes. The resident was admitted with deep tissue injuries (DTIs) to the bilateral buttocks, which were documented as dark reddish purple, hard areas. Although the care plan included the application of barrier cream after each incontinent episode, and physician orders were in place for pressure relief interventions, there was no documented evidence that protective cream was applied to the affected areas from the time of admission until several days later. Further review revealed that an order for protective cream to the bilateral buttocks was not obtained until after the resident developed Moisture Associated Skin Damage (MASD). The Treatment Administration Record did not show documentation of barrier cream application prior to this order, and the DON confirmed that there was no documentation or order for barrier cream until after MASD was identified. Facility policy required measures to maintain skin integrity and prevent pressure ulcers, but these were not consistently implemented for this resident.
Inadequate Infection Control in Laundry Procedures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for laundering isolation linens and clothing, which could potentially affect all 52 residents. The infection control logs revealed multiple cases of Clostridium difficile (C-diff) over a period of three months, indicating a possible ongoing issue with infection control. The Director of Environmental Service (DES) #149 confirmed that the facility did not have a specific policy for washing isolation linen or clothing, and the current practice involved treating all laundry items as contaminated without special handling for those from residents with C-diff. Observations and interviews revealed that the laundry process did not include separating contaminated linens from non-contaminated ones, relying instead on high-temperature washing to kill organisms. However, the facility's washing machine temperatures were not verified to reach the necessary 160 degrees Fahrenheit to ensure the elimination of C-diff spores. Additionally, the isolation cycle, which included bleach, was not used for personal items due to concerns about damaging colored fabrics, leading to the use of a cycle without bleach for these items. The facility's infection prevention and control program policy, revised in 2021, required annual reviews of departmental policies for adherence to infection control principles, but there was no evidence of such a review for the laundry procedures. The CDC guidelines emphasize the importance of using chlorine-based disinfectants or high-concentration hydrogen peroxide formulations to kill C-diff spores, and the need for proper handling and separation of soiled linens to prevent contamination. The facility's failure to adhere to these guidelines and ensure proper laundering procedures contributed to the deficiency.
Failure to Notify Physician and Implement Treatment Orders
Penalty
Summary
The facility failed to notify the physician and address a change in a resident's ability to chew and swallow, and failed to implement compression stockings or unna boot dressings per order for another resident. Resident #11, who was cognitively intact, had no initial concerns related to chewing or swallowing. However, progress notes indicated that the resident was holding pills in her mouth and not swallowing them, and later was observed coughing and gagging with meals and drinks. Despite these observations, there was no evidence that the physician or family was notified, and the issue was not followed up on or discussed with the resident until much later. Resident #9, who had diagnoses including venous insufficiency and congestive heart failure, was readmitted to the facility with orders for compression stockings and unna boot dressings. However, there was no evidence that these treatments were applied as ordered. Observations revealed that the resident did not have the prescribed compression stockings or unna boot in place, and the resident's lower extremities were red and swollen. Interviews with the DON and ADON confirmed that the orders were not properly implemented, and there was no evidence of the unna boot treatments being completed as required. The facility's policy on 'Notification of Change of Condition' requires informing the resident, consulting with the physician, and notifying the resident's legal representative of significant changes in the resident's status. However, this policy was not adhered to in the case of Resident #11. Similarly, the facility's policy on 'General Wound and Skin Care' was not followed for Resident #9, as the necessary treatments to promote and maintain good skin integrity were not provided. These deficiencies highlight a failure in communication and adherence to care protocols, affecting the quality of care for the residents involved.
Lack of Documentation and Orders for Resident's Catheter
Penalty
Summary
The facility failed to ensure that an order was in place and care was documented for a resident with a catheter. Resident #154, who had a history of cerebral infarction, dysphagia, and severe protein-calorie malnutrition, was admitted with a moderately impaired cognition. On December 24, 2024, the resident was sent to the emergency room due to a distended abdomen and returned with a new indwelling urinary catheter. However, upon review on January 7, 2025, there were no physician orders or care plans documented for the catheter. Observations on January 6, 2025, confirmed that the resident had a urinary catheter in place. Interviews with a registered nurse and an LPN on January 7, 2025, verified the absence of orders or a care plan for the catheter. The LPN acknowledged the oversight and mentioned the intention to check the catheter size and input the necessary orders. This deficiency affected one of the two residents reviewed for catheters in a facility with a census of 52.
Failure to Implement Timely Pharmacy Recommendations
Penalty
Summary
The facility failed to implement pharmacy recommendations in a timely manner for a resident, affecting their medication management. The resident, who was cognitively intact, had diagnoses including bipolar II, type 2 diabetes, anxiety disorder, and major depressive disorder. The pharmacy recommended adding the month for Estring replacement to the resident's records for better monitoring, which was accepted but not implemented. Additionally, a recommendation to add a side effect monitoring order set for Gabapentin was delayed by 27 days before being addressed. Furthermore, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for the resident, who was receiving aripiprazole, an antipsychotic medication. The last AIMS assessment was completed several months prior, and the recommendation for a new assessment was not acted upon until after the deficiency was identified. The Director of Health Services confirmed these oversights, which were contrary to the facility's policy requiring timely action on pharmacy recommendations to ensure residents maintain the highest practicable level of functioning.
Failure to Monitor and Document Pain Management
Penalty
Summary
The facility failed to adequately monitor and document the pain management of a resident who was receiving as-needed pain medication. The resident, who had a history of unspecified dementia, chronic obstructive pulmonary disease, anxiety disorder, esophageal obstruction, depression, anxiety, dysphagia, and mixed receptive expressive language disorder, was noted to have moderately impaired cognition. The resident's care plan included interventions for pain management, such as observing and recording verbal and nonverbal signs of pain, notifying the physician of increased pain, administering medications as ordered, and attempting non-pharmacological interventions. However, the facility did not document the severity, location, or nonpharmacological interventions for the resident's pain, despite administering Hydrocodone-Acetaminophen on multiple occasions. The Medication Administration Record (MAR) indicated that the as-needed Hydrocodone was administered several times between December 19, 2024, and January 1, 2025, with only one instance of pain being rated as six out of ten for knee pain. There was no further documentation of pain levels, descriptions, or nonpharmacological interventions attempted. The Director of Nursing confirmed the lack of documentation during an interview. The facility's policy on pain observation and management required documentation of each resident's pain, including its origin, location, severity, and response to treatment, which was not adhered to in this case.
Deficiency in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to provide justification for the use of prophylactic antibiotics for a resident, which was identified during a review of medical records, staff interviews, and facility policy. The resident, who was admitted with diagnoses including sepsis, acute cystitis with hematuria, polyneuropathy, and a history of prostate cancer, was prescribed levofloxacin and macrobid as prophylactic antibiotics. However, the orders for these antibiotics did not meet the criteria for antibiotic use, and there was no statement from the physician justifying their use. The facility's Plan of Care for the resident included interventions related to the use of long-term prophylactic antibiotics, but the antibiotics did not meet the McGeer criteria for use. During an interview, the Director of Health Service and the Infection Control Nurse confirmed that the antibiotics prescribed to the resident did not meet the necessary criteria for use. The facility's Infection Prevention and Control Program policy, revised in 2021, requires collaboration with the campus pharmacy provider and Medical Director regarding antibiotic stewardship. The policy also mandates that documentation within the resident's Electronic Health Record be reviewed to determine if the infection meets the McGeer Criteria. Despite these requirements, the facility failed to justify the prophylactic use of antibiotics for the resident, leading to a deficiency in antibiotic stewardship practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Zanesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Healthcare At Willow Haven | 0.7 mi | ★★★★★ | 58 | 0 |
| Adams Lane Healthcare And Rehabilitation Center | 1.2 mi | ★★★★★ | 0 | 0 |
| The Oaks Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Continuing Healthcare At Cedar Hill | 1.6 mi | ★★★★★ | 4 | 0 |
| Altercare Zanesville Inc. | 2.1 mi | ★★★★★ | 0 | 0 |
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