Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, and staff interview, the facility failed to provide access to the remote control
to change position of an electric recliner chair for one for one (#200) of one resident reviewed for
accommodation of needs. The facility census was 51.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #200 revealed the resident was admitted on [DATE]. Diagnoses
included unspecified fracture of T11-T12 vertebra, low back pain, hypertensive chronic kidney disease
stage 3, heart failure, atrial fibrillation, hyperlipidemia, insomnia, osteoarthritis, history of falling, and
hypertension.
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/27/19, revealed the resident
had no cognitive issues. The resident required extensive assistance with bed mobility, transfer, locomotion,
dressing, toilet use, and personal hygiene.
Interview on 12/26/19 at 9:36 A.M., Resident #200 revealed she was not able to access the remote control
to her electric recliner chair. Resident #200 stated the facility does not want her to get out of her chair
without assistance.
Observation on 12/26/19 at 9:38 A.M. revealed Resident #200 was reclined in the electric recliner chair in
the resident's room. The recliner chair had a remote control, which was attached to a cord, and located in
the side pocket of the recliner chair. The remote controlled the back and foot rest. On the remote was taped
a handwritten note reading Remote to stay in side pocket. Resident #200 was unable to access the remote
to make adjustments to the chair for comfort.
Additional observations on 12/27/19 at 9:26 A.M. and 3:29 P.M. revealed the remote control to the recliner
was located in the side pocket of the recliner.
Interview on 12/26/19 at 11:45 A.M., State Tested Nurse Aide (STNA) #600 verified Resident #200 was
unable to reach the remote control to the recliner. STNA #600 stated about three to four weeks ago there
was a note to keep the remote control in the side pocket of the recliner. Resident #200 was to use the call
light when needed.
Interview on 12/27/19 at 10:56 A.M., STNA #650 verified Resident #200 was not to have access to the
remote control for the recliner and the remote was to be kept in the side pocket. STNA #650 stated the
resident was to use the call light when needed.
(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 4
Event ID:
366365
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
366365
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Bellevue
101 Auxiliary Drive
Bellevue, OH 44811
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Review of facility policy titled Resident Rights Guidelines, revised May 2017, verified the residents have the
right to be given the information to participate in decisions which affect them both individually and
corporately.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366365
If continuation sheet
Page 2 of 4
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
366365
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Bellevue
101 Auxiliary Drive
Bellevue, OH 44811
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications
were secured from unauthorized access when a medication cart was left unlocked and unattended by staff.
This affected one (#50) resident the facility identified as the only independently mobile and cognitively
impaired resident residing on the 300 Hall. The census was 51.
Findings include:
Observation on 12/27/19 at approximately 3:30 P.M. revealed Registered Nurse (RN) #375 administering
medications to residents on the 300 Hall from the 300 Hall medication cart. At 3:38 P.M., RN #375 removed
medications from the 300 Hall medication cart, prepared them for administration, and walked away from the
medication cart without locking it. RN #375 walked down the 300 Hall and entered a resident's room to
administer the medications, leaving the unlocked medication cart out of her sight. At 3:42 P.M., RN #375
walked back to the 300 Hall medication cart, prepared another resident's medications for administration,
and again, walked away from the medication cart without locking it. RN #375 walked down the 300 Hall and
entered another resident's room to administer the medications, leaving the unlocked medication cart out of
her sight.
Interview on 12/27/19 at 3:47 P.M. with RN #375 verified she did not lock the 300 Hall medication cart for
two different resident medication administrations in a row. RN #375 stated the medication cart should be
locked every time a nurse steps away from the cart.
Review of a facility policy titled Medication Storage in the Facility, revised August 2014, revealed
medications and biologicals are stored safely, securely, and properly, following manufacturer's
recommendations or those of the supplier. Only licensed nurses, pharmacy personnel and those lawfully
authorized to administer medications (such as medication aides) are permitted to access medications.
Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized
access.
The facility identified Resident #50 as the only resident residing on the 300 Hall who was cognitively
impaired and independently mobile.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366365
If continuation sheet
Page 3 of 4
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
366365
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Bellevue
101 Auxiliary Drive
Bellevue, OH 44811
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed
to ensure a resident's urinary catheter collection bag was kept off the ground. This affected one (#48) of
one residents reviewed for urinary catheters. The facility identified two residents in the facility with urinary
catheters. The census was 51.
Findings include:
Review of Resident #48's medical record revealed and admission date of 06/17/15. Diagnoses included
hemiplagia and hemiparesis, vascular dementia with behavioral disturbances, anxiety, insomnia, retension
of urine, neuromuscular dysfunction of bladder, and muscle wasting and atrophy.
Review of the most recent Minimum Data Set (MDS) assessment, dated 12/04/19, revealed Resident #48
was assessed with an indwelling urinary catheter.
Review of a care plan dated 12/10/19 for Resident #48's urinary catheter, revealed an intervention to
maintain a closed system with the urinary collection bag below the resident's bladder and keep the bag
covered.
Observation on 12/26/19 at 01:27 PM revealed Resident #48 sitting in a wheelchair in the dining room with
his urinary catheter collection bag suspended from under his wheelchair and the bag resting on the floor.
Subsequent observations on 12/27/19 at 10:20 A.M. and 5:26 P.M., revealed Resident #48's urinary
catheter collection bag remained suspended from under his wheelchair with the bag resting on the floor.
Observations on 12/27/19 at 10:26 A.M. and 12:49 P.M., revealed Resident #48 was propelling himself in
his wheelchair and his urinary catheter collection bag could be heard and seen dragging on the floor as
Resident #48 moved down the hallway. Observation on 12/28/19 at 7:56 A.M., revealed Resident #48 sitting
in his wheelchair in his room with his urinary catheter collection bag resting on the floor.
Interview on 12/28/19 at 8:00 A.M., Licensed Practical Nurse (LPN) #480 verified Resident #48's urinary
catheter collection bag was on the floor and stated it should not be touching the ground at anytime. LPN
#480 stated Resident #480 would not be able to reach under his wheelchair and move the placement of his
urinary catheter collection bag on his own.
Resident #48 was observed once again on 12/28/19 at 11:34 A.M. sitting in the dining room with his urinary
catheter collection bag suspended from underneath his wheelchair and resting on the floor.
Review of a facility policy titled Urinary Catheter Care, dated 05/11/16, revealed staff should be sure the
catheter tubing and drainage bag are kept off the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366365
If continuation sheet
Page 4 of 4
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Back to topCitations
10 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
- 0001GeneralS&S Fpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0133GeneralS&S Fpotential for harm
Install a two-hour-resistant firewall separation.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the December 28, 2019 survey of WILLOWS AT BELLEVUE?
This was a inspection survey of WILLOWS AT BELLEVUE on December 28, 2019. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WILLOWS AT BELLEVUE on December 28, 2019?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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.