Inspection·January 22, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showers/ bathing activities were scheduled based on a resident's room number. Resident #5 was to be showered on the evening shift every Tuesday and Friday. A review of Resident #5's Point of Care History report from 12/12/23 to 01/18/23 revealed the resident's bathing activities were being documented when they occurred. It documented the date/ time the activity was provided and the type of bathing activity that was received. The resident was documented as not receiving any showers during the week of 12/17/23 through 12/23/23. Partial bed baths were provided daily with one complete bed bath being provided on 12/20/23. The week of 12/24/23 through 12/30/23 the resident was provided only one shower on 12/25/23. A complete bed bath was documented as having been provided on 12/28/23. They other bathing activities provided during that week were partial bed baths. The week of 01/07/24 through 01/13/24 revealed the resident was not documented as having received any showers during that week. There was one bathing activity marked as other bath that occurred on 01/09/24 and the others were partial bed baths. A review of Resident #5's nurses' progress notes did not reveal any evidence of the resident refusing to be showered on her scheduled shower days to explain when a shower had not been provided. There was also no explanations given as to why a complete bed bath or other bath were given in place of a shower. On 01/16/24 at 1:52 P.M., an initial interview with Resident #5 revealed she did not always get her showers twice a week as per her preference. She felt twice a week would be adequate for her if she received them. On 01/18/24 at 8:58 A.M., an interview with State Tested Nursing Assistant (STNA) #73 revealed Resident #5 required total assistance with her ADL's and believed the resident's preference was to receive showers. She indicated the showers were done on the evening shift. She had not known the resident to refuse any showers when offered. On 01/18/24 at 12:42 P.M., further interview with Resident #5 confirmed it was her preference to get a shower on her scheduled shower days. She denied she had ever refused to be showered on her scheduled shower day or requested a different type of bathing activity to be provided on her scheduled shower days. She stated she liked to be showered and did not feel a complete or partial bed bath was enough. She indicated the staff would just come in and do a bed bath without offering her a shower on her scheduled shower days. On 01/18/24 at 1:05 P.M., findings were verified by the facility's Administrator. She was asked to provide any additional evidence to support Resident #5 was being provided two showers a week per her preference. No additional information was provided. A review of the facility's policy on Guidelines for Bathing Preference revised 05/11/16 revealed the purpose of the policy was to establish a personal preference bathing routine. The procedures included advising the resident of the facility's guidelines for them to self-determine their plan of care and schedule during their stay in the facility. The residents should determine their preference for bathing upon admission to include the day of the week, time of the day, and type of bathing (tub bath, bed bath, or shower). Bathing shall occur at least twice a week unless the resident's preference stated otherwise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 2 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to timely notify the registered dietitian, physician, or resident representative of one resident's (#298) significant weight loss. The affected one resident (#298) of one resident reviewed for notification of change. The facility census was 51. Findings Include: Review of the medical record for Resident #298 revealed an admission date on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of right femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 weighed 123 pounds (lbs) with no noted weight loss or gain in the last month or six months. Resident #298 was on a therapeutic diet. Resident #298 did not have any unhealed pressure ulcers or injuries. Review of weights dated from 12/22/23 to 01/15/24 revealed Resident #298 weighed 123 lbs on 12/22/23 at 10:15 P.M., 116 lbs on 01/05/24 at 3:53 P.M. (a seven lb weight loss), and 111 lbs on 01/15/24 at 9:57 A.M. (an additional five lb weight loss and a total weight loss of 12 lbs in less than 30 days). Review of the Nutrition - Weight/Wound Note, dated 01/10/24 at 11:13 A.M. revealed Resident #298's current weight was 116 lbs taken on 01/05/24 (five days earlier). A significant weight loss of seven lbs or 5.7% in two weeks was noted. Recommended weekly weights for four weeks. Increased metabolic demands related to skin impairment. Loss may be related to recent acute care events. Consider diet liberalization to maximize nutritional support in advanced age setting. Intakes were 51-100%. Recommend changing diet to Fortified diet, regular texture, thin liquids to offer additional calories and protein. Monitor weights with nutritional interventions as recommended. There was no documentation the Registered Dietitian (RD), physician, or resident representative were notified of the significant weight loss. Interview on 01/17/24 at 2:41 P.M. with RD #102 revealed she was on-site at the facility one time per week to review resident weights. RD #102 stated if a resident was weighed after she was on-site that week and revealed a significant weight change, she would not know until the following week unless the facility staff notified her of the change. RD #102 confirmed she had not been notified of Resident #298's significant weight loss identified on 01/05/24 until 01/10/24 when she was on-site at the facility and reviewed the weights (five days later). Interview on 01/18/24 at 3:51 P.M. with the Administrator confirmed there was no evidence Resident #298's physician, registered dietitian, or resident representative were notified of the resident's significant weight loss when it was identified on 01/05/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 3 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0580 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Physician-Provider Notification Guidelines, reviewed 12/31/22, revealed the policy stated, The purpose of the policy was to ensure the resident's physician or practitioner is aware of a change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner. Residents Affected - Few Review of the facility policy, Guidelines for Responsible Party Notification, reviewed 12/31/22, revealed the policy stated, the purpose of the policy was to ensure the resident's responsible party is aware of all diagnostic testing results or change in condition in a timely manner. The responsible party should be notified of change in condition or diagnostic testing results immediately. Documentation of notification attempts should be recorded in the Electronic Health Record (EHR). Review of the facility policy, Guidelines for Weight Tracking, reviewed 12/31/22, revealed the policy stated, the physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 4 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident's oral hypoglycemic medication that was put on hold per physician's orders was evaluated or resumed timely, after the resident started eating, in accordance with the physician's orders. This affected one resident (#12) of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Type 2 (adult onset) diabetes mellitus. A review of Resident #12's physician's orders revealed she had an order for the use of Metformin (an oral hypoglycemic used to lower blood glucose levels) 1,000 milligrams (mg) by mouth twice a day for diabetes mellitus. The order originated on 10/24/23. The physician's orders also included an order to hold the Metformin until the resident started eating. That order was given on 10/30/23 and was an open ended order. A review of Resident #12's medication administration record (MAR) for December 2023 and January 2024 revealed the nurses were holding the resident's Metformin 1,000 mg that was ordered by mouth twice a day. The MAR indicated the order remained on hold from 10/30/23. The MAR also included the order to hold the Metformin until the resident started eating. A review of Resident #12's laboratory test results in her electronic medical record (EMR) revealed she had not had a Hemoglobin A1C ( a blood test that calculates the average blood glucose level over a three month period) test performed since 08/31/23. That Hemoglobin A1C result was elevated at 7.4% (normal levels below 5.7%). A review of Resident #12's meal intakes for the past 30 days (12/17/23 to 01/17/24) revealed the resident had a fair appetite. She was noted to have only refused meals five times during that 30 day period. She ate between 1-25% 24 times, 26-50% 27 times, 51-75% 10 times, and 76-100% 20 times. Further review of Resident #12's EMR revealed it was absent for any documented evidence that the facility staff had followed up with Resident #12's physician regarding the order to hold her Metformin as previously ordered when Resident #12 was documented on the meal intake records as having consumed some of all of her meals. Furthermore, there was no evidence of the facility staff clarifying the previous order to hold the Metformin until the resident started eating to determine if there was any certain percentage amount the resident needed to consistently eat for the Metformin to be resumed. Findings were verified by the Director of Nursing (DON). On 01/17/24 at 3:40 P.M., an interview with the DON confirmed Resident #12's Metformin remained on hold, as per the physician's order given on 10/30/23. She acknowledged the order was to hold the Metformin until the resident was eating and her meal intakes for the past 30 days revealed she had been eating. She further acknowledged the order was not clear on how much the resident needed to be eating before the Metformin could be resumed. She confirmed the last time the resident had her Hemoglobin A1C checked was on 08/31/23 and her Hemoglobin A1C was elevated at that time. She stated the physician would be in the facility in the morning and she would clarify the order to hold the Metformin until the resident was eating to see if it should have been resumed when the resident had been known (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 5 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0684 to be eating. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #12's nurses' progress notes revealed a nurse's note dated 01/17/24 at 4:05 P.M. that indicated the resident's physician was contacted and ordered for a complete metabolic panel (CMP) and a Hemoglobin A1C to be drawn. The lab tests were obtained and sent to the lab for processing. Residents Affected - Few A review of the lab results for the CMP that had been collected on 01/17/24 at 6:02 P.M. and results reported on 01/17/24 at 7:06 P.M. revealed Resident #12's glucose level was elevated at 160 milligrams/ deciliter (mg/dl). The normal range for glucose was 65-100 mg/dl. The Hemoglobin A1C was still pending at that time. The physician was notified of the lab results when she visited the facility the morning of 01/18/24. The physician did not give any new orders at that time and was awaiting the results of the Hemoglobin A1C. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 6 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, review of skin assessments, and facility policy review, the facility failed to prevent, comprehensively assess and timely treat a pressure ulcer and failed to prevent the pressure ulcer from worsening for Resident #298. This affected one resident (#298) of three residents reviewed for skin impairments. The facility census was 51. Residents Affected - Few Actual Harm occurred on 01/05/24 when a new, facility-acquired, skin area was identified on Resident #298's left heel that developed within 30 days of the resident's admission. The area was assessed as a purple-black bruise without swelling and measured 3.5 centimeters (cm) long by 2.5 cm wide. The facility failed to notify the physician or implement any treatment to the left heel until 01/09/24 (five days after the skin injury was identified) resulting in the wound worsening to an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) deep tissue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) measuring four cm long and three cm wide and covered by necrotic (dead) tissue. Findings Include: Review of the medical record for Resident #298 revealed an admission date on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of left femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 did not have any unhealed pressure ulcers or injuries. Skin treatments included a pressure reducing device for chair and bed. Review of the physician orders revealed Resident #298 had the following orders in place: Oxycodone 5 milligrams (mg) every six hours as needed (PRN) for pain dated 12/22/23 and a Wound Care (WC) order for left heel to cleanse wound with wound cleanser or normal saline, apply Betadine, and cover with foam (gentle or life) dressing every five days dated 01/09/24 (four days after the wound was identified). Review of progress notes dated from 12/22/23 through 01/18/24 revealed on 01/05/24 at 10:25 P.M., Licensed Practical Nurse (LPN) #61 noted the aide reported Resident #298 was requesting pain medication. LPN #61 spoke with Resident #298 who reported left heel pain rated a seven (out of ten) and stated, it usually only hurts at night. LPN #61 looked at bilateral heels and a dark, boggy, intact area with no drainage, approximately 3.5 cm long by 2.5 cm wide was noted to her left heel. LPN #61 assisted to reposition and elevated her feet on a pillow to help with reducing pressure. Resident #298 was educated on the importance of elevating her feet as much as possible. PRN pain medication was given. On 01/09/24 at 10:53 A.M. (four days later), the physician was notified of a left heel deep tissue injury (DTI) and new order was received to apply Betadine and cover with foam daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 7 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of the Medication Administration Record (MAR) dated January 2024 revealed Resident #298 received PRN Oxycodone on 01/05/24 at 9:56 P.M. for pain to her left heel. The pain level was an eight out of ten where ten was the worst possible pain. Review of the Treatment Administration Record (TAR) dated January 2024 revealed Resident #298 received a weekly skin assessment on 01/02/24, 01/09/24, and 01/16/24. None of the assessments noted a 1 for a new impairment. Review of the care plan, dated 12/22/23, revealed Resident #298 had a pressure ulcer to left heel with a start date of 01/12/24. Interventions included assess and record the condition of the skin surrounding the pressure ulcer, observe for and report signs of pain related to the pressure ulcer, treatment per physician order and notify physician if treatment was not effective, and weekly skin assessment, measurement, and observation of the pressure ulcer and record. Review of the Skin Integrity Event - Bruise Event, created on 01/05/24 at 10:34 P.M. and completed at 10:36 P.M. by LPN #61 revealed Resident #298 had facility-acquired bruise on her left heel, approximately 3.5 cm long by 2.5 cm wide. The bruise was purple-black without swelling. Resident #298 reported a pain level of seven out of ten (where ten is the worse possible pain), and described as severe, horrible, intense pain. The immediate intervention was to make sure the resident had an appropriate treatment implemented. The physician and resident representative were notified. This event was invalidated by LPN #61 on 01/09/24 at 10:41 A.M. with a reason of incorrect data. However, the progress note was not invalid. Review of the Skin Integrity Event - Pressure, Stasis, Diabetic Wound Event, created on 01/05/24 at 10:25 P.M. (nine minutes prior to the Bruise Event was opened) but not completed until 01/09/24 at 10:43 A.M. (four days after the event was initially created) by LPN #61 revealed Resident #298 had a facility-acquired left heel wound measuring approximately 3.5 cm long by 2.5 cm wide. The wound was not staged and did not include a comprehensive assessment of the wound bed or the surrounding skin of the area. New interventions included to utilize transfer/draw sheets/trapeze to decrease friction and avoid positioning resident directly on skin breakdown. Treatment orders was marked yes. Physician and resident representative were noted to be notified on 01/09/24 at 10:44 A.M. Review of the Wound Management Detail Report dated 01/12/24 at 10:00 A.M. and completed by LPN #50 revealed Resident #298 had a facility acquired pressure ulcer to her left heel that measured four cm long by three cm wide. The wound was staged as an unstageable, deep tissue injury with necrotic tissue. The wound was 100% covered by eschar tissue (dead tissue that sheds or falls off from the skin, typically tan, brown, or black, and may be crusty. When a wound has eschar on top of it, the wound cannot be classified because it makes it difficult to see the wound underneath). The surrounding skin had redness and was blanchable (can make it go away by pressing on it). Interview on 01/17/24 at 5:10 P.M. with Resident #298 revealed the resident's left heel was still sore. Resident #298 stated she thought she caused the wound while trying to turn over in bed one night. The resident stated the wound was not seeping and she thought it was closed. Resident #298 stated the physician looked at the wound yesterday, 01/16/24. Resident #298 stated the wound was being covered with a dressing. A request to interview LPN #61 was made however according to the Administrator, the nurse was attending a funeral and unavailable to be interviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 8 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0686 An interview with Medical Director (MD) #47 was attempted via telephone however no return contact was received. Level of Harm - Actual harm Residents Affected - Few Interview on 01/18/24 at 9:08 A.M. with LPN #96 revealed she was not wound certified but based off of her nursing experience and education, if a wound had necrotic tissue, it would typically be staged at least as an unstageable pressure ulcer, not a deep tissue injury, because the professional would not be able to see the wound bed to determine an appropriate stage. Observation and interview on 01/18/24 at 9:12 A.M. of Resident #298 in her room with LPN #96 revealed the resident was laying in bed at the time of the observation with a blanket covering her. Resident #298 agreed to allow this surveyor and LPN #96 to look at her feet. LPN #96 raised the blanket and confirmed the resident's heels were not elevated off the mattress. Both heels were laying directly on the mattress. Resident #298's left heel was observed with a clean dressing in place dated 01/14/24. LPN #96 offered to place a pillow under the resident's heels. Resident #298 stated, there is supposed to be one under my heels but the aide had been busy and must have forgotten. Resident #298 was observed with facial grimacing when LPN #96 raised her left heel off the mattress and placed it on the pillow. Resident #298 confirmed her left heel hurts a little bit. Interview on 01/18/24 at 10:13 A.M. with Assistant [NAME] President (AVP) #101 confirmed a wound treatment for Resident #298's left heel wound that was identified on 01/05/24 was not initiated until 01/09/24 (four days later). AVP #101 confirmed a treatment should have been implemented immediately upon identification of a new skin area. AVP #101 stated the information included in the Bruise Event by LPN #61 was accurate as far as the description of the area. LPN #61 was not wound certified so she was unable to officially stage the area. Interview on 01/18/24 at 10:35 A.M. with LPN #50 revealed she had completed the wound assessment on 01/12/24 (seven days after the wound was first identified) for Resident #298 and had staged the wound as an unstageable, deep tissue injury. LPN #50 confirmed Resident #298's left heel wound had not been officially staged prior to 01/12/24. LPN #50 stated she did not know why the area was documented as a deep tissue injury on 01/09/24 because the area had not been officially staged yet. LPN #50 confirmed she was not wound certified but had some experience with wounds from a previous job. LPN #50 stated LPN #61 requested she look at the resident's left heel wound. LPN #50 stated the area was small and may heal fairly quickly if Resident #298's heels were off-loaded. Interviews on 01/18/24 at 10:43 A.M. and 11:37 A.M. with Assistant Director of Health Services (ADHS) #84 confirmed she was the facility's designated wound nurse and she completed wound rounds weekly. ADHS #84 stated Resident #289's left heel wound was identified while she was off from work due to COVID-19 on 01/05/24 but she was just informed of the wound yesterday, 01/17/24 (12 days after the wound was identified). ADHS #84 stated she returned to work on 01/11/24 and she did not know why she was not notified of the new wound area upon her return or why another nurse completed the wound assessment on 01/12/24. ADHS #84 stated she assessed Resident #289's left heel wound for the first time on 01/17/24 but had not entered the assessment into the resident's record yet. ADHS #84 confirmed the wound was unstageable because it was covered with necrotic tissue and she could not see the wound bed. ADHS #84 also stated it appeared to be a deep tissue injury, not a bruise. ADHS #84 confirmed the area should have been comprehensive assessed and staged by a wound certified nurse prior to 01/12/24 (seven days later). ADHS #84 stated the facility did not have a wound physician who made rounds on the resident and if a resident needed more extensive wound care the facility would need to refer them to a local wound clinic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 9 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy, Guidelines for General Wound and Skin Care, date 05/10/17, revealed the policy stated, the following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. Use pillows or wedges for positioning to avoid skin on skin contact. Evaluate the need for heel floats/boots. Document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, periwound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet. Notify the wound care nurse/nurse supervisor for all new stage II-IV pressure ulcers or if you have any questions. Event ID: Facility ID: 366413 If continuation sheet Page 10 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to timely address or implement effective nutritional interventions for Resident #298 who experienced a significant weight loss. This affected one resident (#298) of three residents reviewed for nutrition. The facility census was 51. Residents Affected - Few Actual Harm occurred on 01/05/24 when Resident #298's weight revealed a significant weight loss of 5% in less than 30 days. The Registered Dietitian (RD) was not notified and did not address the significant weight loss until 01/10/24 (five days later) to make nutritional recommendations. The facility did not implement the nutritional recommendations from the RD that were made on 01/10/24 until 01/12/24 (seven days after the significant weight loss was identified). The nutritional interventions were not properly monitored by the facility staff for effectiveness. Resident #298 was weighed again on 01/15/24 (ten days following the initial identification of a significant weight loss) which showed an additional 4% weight loss. Resident #298's total weight loss was 9% in less than 30 days. Findings Include: Review of the medical record for Resident #298 revealed an admission date on 12/22/23. Medical diagnoses included displaced intertrochanteric fracture of left femur, polymyalgia rheumatica, and Type II Diabetes mellitus without complications. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #298 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #298 had an impairment to her lower extremity and used a walker or wheelchair for mobility. Resident #298 required substantial/maximal assistance from staff to complete bed mobility and partial/moderate assistance with transfers. Resident #298 weighed 123 pounds (lbs) with no noted weight loss or gain in the last month or six months. Resident #298 was on a therapeutic diet. Resident #298 did not have any unhealed pressure ulcers or injuries. Review of weights dated from 12/22/23 to 01/15/24 revealed Resident #298 weighed 123 lbs on 12/22/23 at 10:15 P.M., 116 lbs on 01/05/24 at 3:53 P.M. (a seven lb weight loss), and 111 lbs on 01/15/24 at 9:57 A.M. (an additional five lb weight loss and a total weight loss of 12 lbs in less than 30 days). Review of meal intakes dated from 12/22/23 through 01/18/24 revealed Resident #298's intakes varied from 1-25% to 76-100%. From 12/22/23 to 01/05/23 (15 days), the resident's intake was documented as 50% or less 13 times. Review of the care plan dated 12/22/23 revealed Resident #298's Profile Care Guide included a regular diet, regular texture, thin liquids, and fortified foods. The care plan noted Resident #298 did not like cottage cheese. Review of the progress notes dated from 12/22/23 through 12/27/23 revealed on 12/22/23 at 5:37 P.M., Resident #298 was admitted to the facility. Vital signs were within normal limits. The resident had three surgical incisions to her lower left extremity from hip fracture surgery. Resident #298's abdomen was noted to be distended (bloating or swelling in the belly area) was noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 11 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0692 On 12/23/23 at 10:54 A.M., Resident #298 was noted to have non-pitting (does not indent when pressure is applied) swelling to her left lower leg as well as abdominal distension. Level of Harm - Actual harm Residents Affected - Few On 12/24/23 at 11:54 P.M., 12/25/23 at 11:26 A.M., and 12/27/23 at 11:48 P.M., Resident #298 was noted without any swelling to either leg and abdominal distension was noted. Review of the admission Nutrition assessment dated [DATE] at 8:13 A.M., revealed Resident #298's current body weight on 12/22/23 was 123 lbs. with a hospital weight of 124 lbs. The resident was noted for a risk of weight/fluid variances post surgery and post intravenous fluids (IVF) at hospital. Monitor weights as available. Increased metabolic demands related to hip fracture and surgery. Edema (swelling) noted per nursing masking actual weight and/or potential weight changes. Malnutrition risk related to edema masking actual weight and/or potential weight changes. Diet: Controlled Carbohydrate (CCHO). The diet was adequate to meet Resident #298's calculated needs. Intakes ranged from 26% to 100%. No dietary recommendations were made. Monitor weights, labs, physical parameters to evaluate diet and intakes meet actual needs with current interventions. Honor food preferences within ordered diet. Review of progress notes dated from 12/28/23 through 01/01/24, 01/03/24 through 01/05/24 through 01/09/24 revealed Resident #298 did not have any edema or abdominal distension noted. Review of the progress notes dated 01/02/24 at 7:35 A.M. and 01/09/24 at 7:10 A.M. by Medical Director (MD) #47 revealed there was no edema noted in the physician's assessments. Review of the progress note dated 01/05/24 at 10:25 P.M. revealed Licensed Practical Nurse (LPN) #61 identified a new dark, boggy intact area with no drainage measuring approximately 3.5 centimeters (cm) long by 2.5 cm wide to Resident #298's left heel. There was no documentation of the identified significant weight loss when Resident #298's weight was 116 lbs on 01/05/24. There was no documentation the Registered Dietitian (RD), physician, or resident representative were notified of the significant weight loss. There was no documentation a re-weight had been completed. Review of the Nutrition - Weight/Wound Note, dated 01/10/24 at 11:13 A.M. revealed Resident #298's current weight was 116 lbs taken on 01/05/24 (five days earlier). A significant weight loss of seven lbs or 5.7% in two weeks was noted. Recommended weekly weights for four weeks. Increased metabolic demands related to skin impairment. Loss may be related to recent acute care events. Consider diet liberalization to maximize nutritional support in advanced age setting. Intakes were 51-100%. Recommend changing diet to Fortified diet, regular texture, thin liquids to offer additional calories and protein. Monitor weights with nutritional interventions as recommended. Review of the Metabolic/Nutrition Event dated 01/10/24 and completed by Registered Dietitian (RD) #102 revealed the dietitian recommended to change diet to fortified diet, regular texture, thin liquids (discontinue controlled carbohydrate diet) and weekly weights for four weeks. The physician and resident representative were notified on 01/12/24 (seven days after a significant weight loss was identified). Review of the care plan for Resident #298 revealed the care plan had been revised on 01/10/24 and indicated the resident had experienced a significant weight loss within 30 days. Interventions included offer encouragement and assistance with eating as needed (PRN), provide diet, supplements, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 12 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0692 Level of Harm - Actual harm medications, adaptive equipment, and snacks as ordered, and weigh as ordered. Additionally, Resident #298 required increased caloric, protein, and/or nutrient needs related to presence of impaired skin integrity. Interventions included encourage fluids, obtain weight as ordered or as needed, provide diet as ordered, and provide supplements, vitamins, and/or minerals as ordered. Residents Affected - Few Review of an Interdisciplinary Team Note (IDT) dated 01/12/24 at 4:51 P.M. (two days after recommendations were made and seven days after a significant weight loss was initially identified) revealed the dietitian recommends to add fortified foods to diet. MD #47 notified and agreed. Review of the physician's orders revealed Resident #298 had the following diet order: Controlled Carbohydrate, regular texture, fortified food, and thin liquids dated 01/12/23. An order for weekly weights had not been implemented as recommended. Review of the progress note dated 01/16/24 at 6:45 A.M. by MD #47 noted Resident #298's weight on 01/15/24 at 9:57 A.M. was 111 lbs (an additional five lb loss). Review of the Nutrition - Weight Note, dated 01/17/24 at 10:29 A.M., revealed Resident #298's current weight on 01/15/24 was 111 lbs. An additional weight loss of five lbs in ten days was noted and a significant weight loss of 12 lbs in 24 days or 9.5% weight loss was noted with decreased meal intakes. Monitor weights as available. Fortified diet as ordered. Recommend to discontinue CCHO diet in advanced age setting with poor meal intakes. Intakes ranged from 26-75%. May benefit from an appetite stimulant. Consider consulting with the physician for an appetite stimulant such as Remeron. Monitor oral intakes and weight trends with recommended interventions. Review of the Fortified Foods List revealed the options included: yogurt parfait, power shake, cheese and cracker plate, peanut butter crackers, and cottage cheese plate. Observation and interview on 01/17/24 at 1:00 P.M. with Resident #298 in her room revealed the resident had the lunch meal in front of her. The meal consisted of baked chicken, mashed potatoes, peas, Jello dessert, a chef's salad, and grapes. There was not a fortified food noted on the resident's meal tray. Interview on 01/17/24 at 2:41 P.M. with RD #102 revealed she was on-site at the facility one time per week to review resident weights. RD #102 stated if a resident was weighed after she was on-site that week and revealed a significant weight change, she would not know until the following week unless the facility staff notified her of the change. RD #102 confirmed she had not been notified of Resident #298's significant weight loss identified on 01/05/24 until 01/10/24 when she was on-site at the facility and reviewed the weights (five days later). RD #102 stated she made recommendations to add fortified foods and weekly weights as interventions on 01/10/24 and informed the staff. RD #102 stated a re-weight would be suggested when a significant weight loss or gain was indicated to confirm the weights are accurate. RD #102 confirmed the diet recommendation was not implemented until 01/12/24 (two days later and seven days following the identification of a significant weight loss). RD #102 confirmed an order for weekly weights had not been implemented by the facility. Resident #298 was weighed again on 01/15/24 and revealed an additional five lb weight loss. The most recent weight was just reviewed by RD #102 today, 01/17/24, with additional recommendations made. Observations and interviews on 01/17/24 at 5:10 P.M. and 5:25 P.M. with Resident #298 in her room. During the interview, discussion with the resident included the list of fortified foods. Resident #298 stated she did not like yogurt or cottage cheese. Observed the resident's dinner tray had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 13 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0692 Level of Harm - Actual harm Residents Affected - Few placed in front of her and included: a Ritz cracker and cottage cheese plate, turkey, dressing, green beans, mashed potatoes, and a piece of cake with fruit topping. Resident #298 stated she would not eat the cottage cheese. Review of the meal ticket for the dinner meal on 01/17/24 revealed the meal ticket stated fortified food, no sweets, wants small portions, and decaf coffee. There were not any dislikes listed. Interview on 01/17/24 at 5:45 P.M. and 5:57 P.M. with the Director of Food Services (DFS) #86 confirmed the fortified food offered with the dinner meal was a cracker and cottage cheese plate. DFS #86 stated the list of fortified foods was not reviewed with the residents for preferences. DFS #86 stated the kitchen staff picked a fortified food for the meal and if a resident requested another option, the kitchen would provide it. DFS #86 stated she was not aware Resident #298 did not like yogurt or cottage cheese. DFS #86 stated she did not know who was responsible for monitoring the acceptance of the fortified food. DFS #86 stated the kitchen staff did not provide education to the residents regarding the importance of eating the additional fortified food and did not explain to the resident why the additional fortified food was added to the meal trays. DFS #86 offered Resident #298 another fortified food option following surveyor intervention and the resident accepted peanut butter crackers. Interview on 01/17/24 at 6:20 P.M. with the Administrator and Assistant [NAME] President (AVP) #101 confirmed the facility had not been monitoring the acceptance of the fortified food options and had only been monitoring resident intakes of the whole meal tray. The Administrator and AVP #101 confirmed the fortified foods list did not meet the selection indicated in the facility's policy. The Administrator and AVP #101 confirmed resident preferences should have been addressed with the residents related to the fortified food options. Review of the facility policy, Nutrition Recommendation Guideline, reviewed 12/01/21, revealed the policy stated, the dietitian reviews recommendations with the Director of Health Services (DHS) and Director of Food Services (DFS) if possible or a copy of the recommendations is provided for the Executive Director (ED), DHS, and DFS to review. Suggested discipline follows up on recommendations in a timely manner. Review of the facility policy, Guidelines for Weight Tracking, reviewed on 12/31/22, revealed the policy stated, residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight. The physician, resident representative, and dietitian shall be notified of a weight variance of 5% in 30 days. Review of the facility policy, Fortified Foods, reviewed 10/02/23, revealed the policy stated, The Fortified Foods program focuses on provided a greater variety of food choices to better meet the unique nutritional needs and preferences of each resident. The Fortified Foods selection includes shakes, desserts, breakfast items, soups, and savory foods. When placed on Fortified Foods, a resident will receive a fortified food item of choice in addition to the regular menu meal. The Director of Food Services (DFS) will talk with residents to decide on what fortified food is preferred. At least two fortified food options should be available per meal, with one option to always be a fortified shake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 14 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, review of the dialysis contract, and review of the facility policy, the facility failed to adequately communicate with the dialysis center to ensure proper coordination of care for one resident (#42). This affected one resident (#42) of one resident reviewed for dialysis services. The facility census was 51. Residents Affected - Few Findings Include: Review of the medical record for Resident #42 revealed an admission date on 10/25/23. Medical diagnoses included chronic kidney disease-Stage 3, congestive heart failure, and cognitive communication deficit. Review of the physician orders revealed Resident #42 had the following orders: Dialysis port: monitor for signs and symptoms of infection dated 11/25/23 and To Davita dialysis on Monday, Wednesday, and Friday at 2:45 P.M. Complete Dialysis Center Communication Observation under Other Clinical Observation and send with resident dated 01/12/24. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #42 required set up or clean up assistance to supervision or touching assistance to complete Activities of Daily Living (ADLs). The resident did not have a significant weight loss or gain. Resident #42 received dialysis services. Review of the Dialysis Center Communication Forms dated from 11/27/23 to 01/15/24 revealed the communication forms were consistently not fully completed by either the facility, the dialysis center, or both providers. The communications from the dialysis center to the facility section was not completed. The facility did not monitor Resident #42's vital signs upon returning to the facility from the dialysis center. There were not any additional dialysis communications included in the resident's record. Review of the progress notes dated from 10/25/23 through 01/18/24 revealed on 01/17/24 at 8:04 A.M., Licensed Practical Nurse (LPN) #61 spoke with the dialysis center who stated a new order for Resident #42 to only go to dialysis twice a week and would not need to go today. On 01/17/24 at 2:23 P.M., Registered Dietitian (RD) #102 noted an attempt to contact the dialysis RD but was unavailable at the dialysis clinic. Requested lab work. Dialysis unit stated will send labs to the facility. Interventions included to coordinate with dialysis RD for nutritional interventions as needed. There was not an updated dialysis order for Resident #42 indicating the resident only needed to attend dialysis Mondays and Fridays. Observation and interview on Wednesday, 01/17/24 at 10:52 A.M. with Resident #42 in her room revealed she had a recent change in her dialysis schedule and only needed to go to dialysis on Mondays and Fridays from 10:30 A.M. to 2:15 P.M. now instead of Mondays, Wednesdays, and Fridays. Resident #42 stated she just started dialysis a couple of months ago. Resident #42 stated the facility sent a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 15 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few form with her to dialysis. The resident gave the form to the dialysis center and then the dialysis center sent the form back with her to the facility. Resident #42 then gave the forms to the nurse. Resident #42 stated, I don't know why they give it to me because it doesn't get filled out. Interview on 01/17/24 at 2:41 P.M. with Registered Dietitian (RD) #102 revealed she had not been able to reach the RD at the dialysis center yet to discuss Resident #42's nutritional status and any recommendations the dialysis dietitian may have. RD #102 stated she attempted to reach the RD at the dialysis today, 01/17/24, and was unsuccessful but the dialysis center had agreed to fax lab results to the facility. RD #102 stated she had not received any lab results for Resident #42 at all from the dialysis center since the resident started attending the dialysis center. Interview on 01/18/24 at 5:07 P.M. with Licensed Practical Nurse (LPN) #43 revealed the dialysis communication forms were documented under the observation tab in Resident #42's electronic health record. LPN #43 stated the forms were sent to the dialysis center via email, however, the facility did not usually receive the completed forms back from the dialysis center. LPN #43 was not aware of a change in Resident #42's dialysis schedule and would need to follow up with the dialysis center to confirm the change. LPN #43 confirmed the communication forms for Resident #42 were not completed and the resident's vital signs were not being documented upon returning to the facility from the dialysis center. Interview on 01/18/24 at 5:23 P.M. with LPN #50 revealed the dialysis center just faxed dialysis running sheets to the facility on [DATE]. The running sheets were dated from 12/18/23 to 01/15/24. LPN #50 confirmed none of the running sheets had been uploaded to the resident's medical record. Interview on 01/18/24 at 5:28 P.M. with the Administrator confirmed the facility and the dialysis center had not been in regular communication to coordinate Resident #42's care. The Administrator stated the dialysis center had not been responsive to the facility's attempted contacts. Review of the dialysis contract dated 10/29/13 revealed the contract stated, the dialysis center would provide to Care Facility from time to time all appropriate information and guidance regarding the renal condition of Residents who are patients of Dialysis Center, including administration of medications, directions for handling medical and nonmedical emergencies such as bleeding or hemorrhage, bacterial infection, and septic shock, and the care of shunts and fistulas. The Care Facility will provide to Dialysis Center, upon initial referral and from time to time thereafter, the same information relating to any Resident accepted for dialysis services which is necessary or useful in connection with the provision of dialysis services to such Resident. Review of the facility policy, Guidelines for Dialysis, reviewed 12/31/22, revealed the policy stated, the purpose of the policy was to provide communication to Dialysis Providers and monitoring of resident receiving dialysis. A report (may be written or verbal) shall be requested from the Dialysis that will alert the facility regarding: tolerance to procedure, vital signs, medications administered, and other information deemed necessary for the ongoing provision of care. Upon return from the Dialysis Provider the facility shall: provide ongoing monitoring of the shunt site for signs of complications and review the Dialysis Provider paperwork for any necessary follow up requirements. Notify attending physician, dialysis center and responsible party of adverse findings are noted. Document notifications in medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 16 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a lunch meal was delivered timely to one resident (#42). This affected one resident (#42) of three residents reviewed for nutrition. The facility census was 51. Findings Include: Review of the medical record for Resident #42 revealed an admission date on 10/25/23. Medical diagnoses included chronic kidney disease-Stage 3, congestive heart failure, and cognitive communication deficit. Review of the physician orders revealed Resident #42 had the following order: To Davita dialysis on Monday, Wednesday, and Friday at 2:45 P.M. Review of the meal times revealed lunch meal was open dining in the dining room from 11:30 A.M. to 1:00 P.M. and the nursing facility hall trays were delivered starting at 12:00 P.M. Observation and interview on Wednesday, 01/17/24 at 10:52 A.M. with Resident #42 in her room revealed she had a recent change in her dialysis schedule and only needed to go to dialysis on Mondays and Fridays from 10:30 A.M. to 2:15 P.M. now instead of Mondays, Wednesdays, and Fridays. Resident #42 stated the facility usually provided a lunch to take with her to the dialysis center. Today, the kitchen staff provided chicken strips in a container for the resident to take with her this morning. Resident #42 stated she informed the dietary aide that she did not have to go to dialysis today because her schedule changed and requested chicken noodle soup for lunch instead. The dietary aide informed Resident #42 the kitchen staff were preparing the regular lunch meal for the day but would provide Resident #42 with chicken noodle soup as requested when the lunch meal was delivered in approximately an hour. The resident stated she spoke with the dietary aide at approximately 10:00 A.M. Interview on 01/17/24 at 12:45 P.M. and 1:49 P.M. with Resident #42 in her room revealed the resident stated she had not received any chicken noodle soup yet as requested. The resident could not recall the name of the dietary aide she spoke to this morning. Resident #42 stated she would still like to have chicken noodle soup because she was hungry. The resident stated she had not eaten anything since breakfast that morning. Interview on 01/17/24 at 1:53 P.M. with [NAME] #93 revealed she was aware Resident #42 requested chicken noodle soup but she thought the kitchen had followed up with her because the kitchen only had the kind of soup that had carrots in it and the resident typically did not like it. [NAME] #93 asked if Resident #42 had just returned from dialysis and was not aware of Resident #42's dialysis schedule change. Observation and interview on 01/17/24 at 1:55 P.M. with Resident #42 and [NAME] #93 in the resident's room revealed [NAME] #93 explained the kind of chicken noodle soup the kitchen had in stock to the resident and offered to make it for her if the resident still wanted it. Resident #42 accepted the chicken noodle soup and requested it be made for her again. [NAME] #93 informed the resident the soup was in small cans and offered two cans of the soup to the resident. Resident #42 agreed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 17 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 01/17/24 at 2:01 P.M. of [NAME] #93 with a meal tray and a bowl of soup walking towards Resident #42's room to deliver the soup to the resident (two hours after the regularly scheduled lunch meal time). Interview on 01/17/24 at 2:04 P.M. with [NAME] #93 confirmed she delivered the chicken noodle soup to the resident and the resident accepted it. Review of the facility policy, Meal Service, revised 01/2023, revealed the policy stated, meals will be served at the following hours Lunch Dining room [ROOM NUMBER]:30 A.M. and Tray Service after dining rooms have been served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 18 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and record review, the facility failed to properly store and date foods, dispose of expired foods, and complete proper hand hygiene during lunch meal service. This had the potential to affect 51 residents who received meals from the kitchen. The census was 51. Findings include: 1. The following concerns were noted during the main initial kitchen tour conducted on 01/16/24 between 9:38 A.M. and 10:07 A.M. Observation of the main fridge revealed 12 undated containers of moldy strawberries, 13 undated containers of moldy blackberries, an undated opened bag of fresh carrots and an opened large package of cream cheese with a use by date of 12/26/23. Observation of main dry storage area revealed an open container of vinegar with an open date of 03/08/23 with a best by date of 12/23/23. Interview on 01/16/24 between 9:42 A.M. and 9:48 A.M., Dietary Manager (DM) #86 verified there were 12 undated moldy containers of strawberries, 13 undated containers of moldy blackberries, an undated opened bag of fresh carrots and a large opened package of cream cheese with a use by date of 12/26/23 in the kitchens main refrigerator. Interview on 01/16/24 at 10:00 A.M., DM #86 confirmed an opened container of vinegar with an open date of 03/08/23 and a best by date of 12/23/23 was in the main kitchens' dry storage area. Review of the undated document titled Food labeling and Dating Policy states food removed from its original container, has a broken seal, has been processed in any way must have .Item Name, Date and Time the food was labeled, and Use by date. 2. The following observations were noted during meal service on 1/17/24 between 11:45 A.M. and 11:53 A.M. Observation of meal preparation on 01/17/24 at 11:45 A.M. revealed [NAME] #93 touched the outside of a plastic bag of hamburger buns with bare hands, then plated a hamburger for a resident. [NAME] #93 inserted their right hand under the chef's coat, walked around the kitchen, and then put on clean gloves without handwashing. Observation on 1/17/24 at 11:50 A.M. revealed [NAME] #93 exited the cooler with bare hands, carrying empty cardboard boxes and an unopened package of French fries; after laying them down, [NAME] #93 put on clean gloves without handwashing. [NAME] #93 walked to the fryer to plate meal items, touching fries with the contaminated gloved hands before placing the food on the plate. Observation on 01/17/24 at 11:53 A.M. revealed [NAME] #93 straightened their apron with bare hands before returning to the stove to check the soup's temperature with a thermometer. [NAME] #93 put on clean gloves without hand hygiene after taking food temperatures. [NAME] #93 walked to the grill to serve a hamburger, where staff handled a resident's bun with the contaminated gloved hands. Interview on 01/17/24 at 12:56 A.M. with DM #86 verified that staff are expected to wash their hands before putting on gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 19 of 20 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 366413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Bethesda The 2971 Maple Avenue Zanesville, OH 43701 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 0812 Level of Harm - Minimal harm or potential for actual harm Interview on 01/17/24 at 1:00 P.M. with Executive Director #54 verified that staff are expected to wash their hands before putting on gloves. Interview on 01/17/24 at 1:10 P.M. with [NAME] #93 confirmed observations to be accurate, stated they forgot to wash hands before putting on gloves. Residents Affected - Many Review of the Single- Use Gloves policy dated 01/23 revealed staff should wash hands before putting on gloves and after discarding gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366413 If continuation sheet Page 20 of 20