Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview, and policy review the facility failed to ensure residents who required
assistance with showers received them based on their preference. This affected two residents (#72 and
#78) of three residents reviewed for activities of daily living (ADL). The facility census was 88.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #72 revealed an admission date of 01/08/21. Diagnoses
included Multiple Sclerosis, morbid obesity, gastro-esophageal reflux disease (GERD), and hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was
cognitively intact. She required total assistance of two people for transfers and toilet use, extensive
assistance of two people for bed mobility and dressing and extensive assistance of one person for hygiene.
It was very important for her to choose between a bed bath, tub bath, and shower.
Review of the physician's orders for July 2023 revealed Resident #72 was to receive a shower based on
preference, on Wednesday and Saturday, in the morning and refusals were to be documented.
Review of the shower schedule revealed Resident #72 was supposed to receive a shower on Wednesdays
and Saturdays on first shift.
Review of the State Tested Nurse's Aide (STNA) tasks dated 07/08/23 through 07/31/23 revealed Resident
#72 had a shower on 07/08/23. Review of the shower sheets revealed Resident #72 had a shower on
07/12/23 and a bed bath on 07/01/23, 07/05/23, 07/19/23, 07/22/23, and 07/29/23. She refused a shower
and/or bed bath on 06/28/23.
Interview on 07/31/23 at 11:31 A.M. with Resident #72 revealed she would like to have a shower twice a
week. She knew her shower days were Wednesday and Saturday, but she does not always get them.
Observation at the time of the interview revealed Resident #72's hair was greasy and unkempt.
2. Review of the medical record for Resident #78 revealed an admission date of 12/18/21. Diagnoses
included pulmonary embolism, pulmonary fibrosis, respiratory failure, and muscle weakness.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #78 was severely cognitively
impaired. He required extensive assistance of one person for toilet use, limited assistance of one person for
transfers, dressing and hygiene and supervision of one person for bed mobility. It was somewhat important
for him to choose between a bed bath, tub bath, and shower.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365795
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
365795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oasis Center for Rehabilitation and Healing
850 East Midlothian Blvd
Youngstown, OH 44507
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the physician's orders for July 2023 revealed Resident #78 was supposed to receive a shower
based on preference, on Monday, Wednesday, and Friday on night shift, and refusals were to be
documented.
Review of the shower schedule revealed Resident #78 was supposed to receive a shower on Monday,
Wednesday, and Friday on night shift.
Review of the STNA tasks dated 07/04/23 through 07/28/23 revealed no documented evidence Resident
#78 received a shower during the time frame.
Review of the shower sheets revealed Resident #78 had a shower on 07/19/23 and 07/24/23, a bed bath
on 07/03/23, 07/17/23, 07/26/23, and 07/28/23. He refused on 06/30/23, 07/05/23, 07/07/23, and 07/14/23.
Resident #78 was in the hospital on [DATE] through 07/12/23 and again on 07/19/23 through 07/23/23.
Interview on 07/31/23 at 9:16 A.M. with Resident #78 revealed he does not get showers, he only got
washed up and could not recall when it last occurred. He stated sometimes he would prefer a shower to a
bed bath.
Interview on 07/31/23 at 2:10 P.M. with STNA's #208 and #209 revealed they asked the resident if they
preferred a shower or a bed bath. If a bed bath was preferred over a shower on any given day, they would
document such in the medical record, as well as document any shower or bed bath refusals. STNA #208
confirmed Resident #72 preferred a shower over a bed bath. She also confirmed she knew Resident #78
had been in the hospital a few times recently, but she was unsure if she preferred a shower or a bed bath.
Interview with Administrator on 08/01/23 at 9:54 A.M. verified resident preferences for type and frequency
of showers was assessed on admission. He confirmed showers were not provided to Residents #72 and
#78 based on preference or schedule.
Review of the facility policy titled Activities of Daily Living (ADL), supporting, dated March 2018, revealed
residents who were unable to carry out ADL independently would receive services necessary to maintain
good hygiene.
This deficiency represents non-compliance investigated under Complaint Number OH0014779.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365795
If continuation sheet
Page 2 of 7
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
365795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oasis Center for Rehabilitation and Healing
850 East Midlothian Blvd
Youngstown, OH 44507
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 0800
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
Based on observation, record review, interview, and facility policy review the facility failed to ensure a
variety of foods were offered and failed to honor resident preferences for meals. This affected five residents
(#22, #5, #61, #62, and #78) and had the potential to affect all residents, except for seven residents (#10,
#11, #12, #14, #16, #27 and #73) who received no food by mouth. The facility census was 88.
Findings include:
Review of the medical record for Resident #22 revealed an admission date of 12/18/22. Diagnoses included
sepsis, diabetes, malnutrition, and kidney failure.
Review of the diet orders and preferences provided by the facility revealed Resident #22 requested meat
with her meal each morning.
Review of the menu for the month of July 2023 revealed scrambled eggs were served 15 of 30 days.
Interviews on 07/31/23 at 7:16 A.M. with Residents #5, #61, #62, and #78 revealed the same food was
always served, especially eggs at breakfast. They didn't eat when they got tired of the same thing being
served.
Interview and observation on 07/31/23 at 9:16 A.M. revealed Resident #62 had a meal consisting of two
muffins and scrambled eggs for breakfast. Observation at the time of the interview of Resident #62's tray
ticket revealed he asked for meat for breakfast but did not receive any.
Review of the menu for breakfast on 08/01/23 revealed a menu of oatmeal or cold cereal, ham, egg, and
cheese breakfast omelet muffin and toast.
Observation of breakfast on 08/01/23 at 8:40 A.M. revealed scrambled eggs and toast were served.
Observation of Resident #22's breakfast revealed she did not receive meat with her meal. Interview at the
time of the observation with Resident #22 confirmed the observation.
Interview on 08/01/23 at 8:48 A.M. with Certified Dietary Manager (CDM) #204 confirmed no substitutions
were made to the meal for breakfast on 08/01/23. He confirmed he was not aware scrambled eggs were
served in place of the ham, egg, and cheese breakfast omelet. He also confirmed some residents received
meat at their request but was not aware Resident #22 did not receive the meat she had requested each
morning at breakfast.
Review of the facility policy titled Food and Nutrition Services dated October 2017 revealed residents would
be provided with a well-balanced and consider meal preferences.
This deficiency represents non-compliance investigated under Complaint Number OH00144779.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365795
If continuation sheet
Page 3 of 7
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
365795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oasis Center for Rehabilitation and Healing
850 East Midlothian Blvd
Youngstown, OH 44507
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, record review and interview, the facility failed to ensure the menu was followed as
written. This had the potential to affect all residents, with the exception of seven residents (#10, #11, #12,
#14, #16, #27 and #73) who received no food by mouth. The facility census was 88.
Findings include:
Review of the menu for breakfast on 08/01/23 revealed a menu of oatmeal or cold cereal, ham, egg, and
cheese breakfast omelet muffin and toast.
Observation of breakfast on 08/01/23 at 8:40 A.M. revealed scrambled eggs and toast were served.
Observation on 08/01/23 at 8:45 A.M. of the menu substitution log revealed no evidence of a substitution to
the breakfast meal.
Interview on 08/01/223 at 8:48 A.M. with Certified Dietary Manager (CDM) #204 confirmed no substitutions
were made to the meal for breakfast on 08/01/23. He confirmed he was not aware scrambled eggs were
served in place of the ham, egg, and cheese breakfast omelet.
This deficiency represents non-compliance investigated under Complaint Number OH00144779.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365795
If continuation sheet
Page 4 of 7
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
365795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oasis Center for Rehabilitation and Healing
850 East Midlothian Blvd
Youngstown, OH 44507
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview, and review of the facility policy the facility failed to ensure Resident #78's medical
record was updated to reflect his most current care needs. This affected one resident (#78) of three
residents reviewed for general care and services. The facility census was 88.
Findings include:
Review of the medical record for Resident #78 revealed an admission date of 12/18/21. Diagnoses included
pulmonary embolism, pulmonary fibrosis, respiratory failure, and muscle weakness.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was
severely cognitively impaired. He required extensive assistance of one person for toilet use, limited
assistance of one person for transfers, dressing, and hygiene, and supervision of one person for bed
mobility.
Review of the physician's orders for July 2023 revealed Resident #78 required the use of a Hoyer
(mechanical) lift with the assistance of two people for transfers.
Interview on 07/31/23 at 9:16 A.M. with Resident #78 revealed he had a fall while getting on the scale. He
denied using a Hoyer lift and said he could transfer himself.
Review of the fall investigation dated 07/16/23 revealed Resident #78 was standing on the scale when he
fell. He was assessed and no injuries were noted. As part of the fall investigation completed on 07/16/23,
he was referred to therapy for bilateral extremity weakness.
Interview on 08/01/23 at 7:50 A.M. with State Tested Nurse Aide (STNA) #208 and STNA #210 revealed
Resident #78 required limited assistance of one person for transfers. Neither STNA had any knowledge of
Resident #78 ever using a Hoyer lift.
Review of the physical therapy (PT) progress notes dated 07/28/23 revealed Resident #78 performed
transfers with moderate assistance.
Interview on 08/01/23 at 8:30 A.M. with the Administrator revealed Resident #78 was made a Hoyer lift for
transfers as a result of the fall investigation completed 07/16/23 until he could be evaluated by therapy, as a
precaution. He confirmed the order for Hoyer use for transfers was inaccurate and should have been
discontinued upon evaluation from therapy.
Review of the facility policy titled Charting and Documentation, dated July 2017, revealed any changes in
the residents' condition would be documented in the medical record.
This deficiency is an incidental finding discovered during the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365795
If continuation sheet
Page 5 of 7
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
365795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oasis Center for Rehabilitation and Healing
850 East Midlothian Blvd
Youngstown, OH 44507
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 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview, and facility policy review the facility failed to ensure Hoyer (mechanical) lifts were
functioning appropriately. This affected two residents (#72 and #90) of three residents reviewed for
accidents and had the potential to affect 23 additional residents (#8, #11, #13, #15, #16, #20, #21, #25,
#26, #27, #30, #39, #41, #50, #54, #60, #63, #64, #65, #66, #68, #78, and #80) identified by the facility as
requiring the use of a Hoyer lift for transfers. The facility census was 88.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #72 revealed an admission date of 01/08/21. Diagnoses
included Multiple Sclerosis, morbid obesity, gastro-esophageal reflux disease (GERD), and hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was
cognitively intact. She required total assistance of two people for transfers and toilet use, extensive
assistance of two people for bed mobility and dressing, and extensive assistance of one person for hygiene.
Review of the physician's orders for July 2023 revealed Resident #72 required the assistance of two people
using a Hoyer lift for transfers.
Review of the progress note dated 07/03/23 revealed Resident #72 was lowered to the floor while being
transferred with the Hoyer lift. She sustained an injury to her right calf which was treated with a bandage.
Interview on 07/31/23 at 11:31 A.M. with Resident #78 revealed staff was using the Hoyer lift with her when
the lift dropped slightly. She denied hitting the floor and was not injured. She revealed the incident occurred
sometime around the Fourth of July holiday.
Review of the fall investigation dated 07/04/23 revealed Resident #72 was lowered to the floor while using
the Hoyer lift. She was assessed for injury and her right calf was bandaged. The investigation revealed the
leg of the Hoyer lift moved during the lift, despite the legs being locked prior to transfer.
The lift was immediately taken out of service and inspected by the Director of Nursing (DON) and the
Maintenance Director. It was revealed the leg spring was worn and needed replaced as well as a leg handle
groove being worn. Both other Hoyer lifts in the facility were inspected with no abnormalities found. Hoyer
lift competency was provided to all State Tested Nurse Aides (STNAs).
2. Review of the medical record for Resident #90 revealed an admission date of 08/30/22. Diagnoses
included muscle weakness, diabetes, morbid obesity, and chronic obstructive pulmonary disease (COPD).
Review of the quarterly MDS assessment dated [DATE] revealed Resident #90 was cognitively intact. He
was totally dependent on two people for transfers, required extensive assistance of two people for bed
mobility, and extensive assistance of one person for dressing, toilet use, and hygiene.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365795
If continuation sheet
Page 6 of 7
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
365795
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oasis Center for Rehabilitation and Healing
850 East Midlothian Blvd
Youngstown, OH 44507
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 0908
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the physician's orders for July 2023 revealed Resident #90 required the assistance of two people
using a Hoyer lift for transfers.
Review of the progress noted dated 07/08/23 revealed Resident #90 tipped over in the Hoyer lift while two
STNAs were attempting to transfer him into the shower chair. The Hoyer lift was observed with the legs
inverted. Resident #90 was assessed, and no injuries were noted.
Interview on 07/31/23 at 7:16 A.M. with Resident #90 revealed he fell to the floor when staff was using the
Hoyer lift and the legs of the lift inverted. He could not recall exactly when the incident occurred.
Review of the fall investigation dated 07/11/23 revealed Resident #90 tipped over while being transferred
with the Hoyer lift while two STNAs were attempting to transfer him into the shower chair. Resident #90 was
assessed for injury, and no injuries were found. The investigation revealed the leg of the Hoyer lift inverted
during transfer to the shower chair, causing Resident #90 to be lowered to the floor. The Hoyer lift was
inspected by maintenance and no issues were found.
Interview on 08/01/23 at 8:06 A.M. with the Director of Nursing (DON) revealed the Hoyer lifts involved in
the incidents with Residents #78 and #90 were two different Hoyer lifts. The one involving Resident #78 was
taken out of service after the incident and replaced with a rental, and eventually a new unit. He revealed the
lift needed a new spring and the handle to open the legs was worn. The Hoyer involving Resident #90 was
repaired by maintenance. The DON revealed maintenance checked the functionality of the lifts monthly.
Review of the inspection log for Hoyer lifts for 2023 provided by the facility revealed the facility used four
Hoyer lifts, and each one was inspected monthly with no issues being noted.
Review of the facility policy titled Safe Lifting and Movement of Residents, dated December 2013, revealed
maintenance would perform routine checks of mechanical (Hoyer) lifts to ensure they remained in good
working order.
This deficiency represents non-compliance investigated under Complaint Number OH0014779.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365795
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the August 1, 2023 survey of OASIS CENTER FOR REHABILITATION AND HEALING?
This was a inspection survey of OASIS CENTER FOR REHABILITATION AND HEALING on August 1, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at OASIS CENTER FOR REHABILITATION AND HEALING on August 1, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and speci..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.