Bluffton, OH

Mennonite Memorial Home

2-star overall rating with 3-star inspections with 13 recent health deficiencies

410 W Elm Street, Bluffton, OH

(419) 358-1015

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1997-08-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.60

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.03

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.36

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.00

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.64

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.47

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.76

CMS adjusted RN staffing hours

Adjusted total hours

5.04

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,836

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

42.48

Composite VBP score used to determine payment impact.

Payment multiplier

0.9954

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.59

Baseline 20.18% · Performance 18.84% · Measure score 5.59 · Achievement 5.59 · Improvement 3.76

Healthcare-associated infections

1.83

Baseline 5.85% · Performance 7.29% · Measure score 1.83 · Achievement 1.83 · Improvement 0

Total nurse turnover

5.98

Baseline 100.00% · Performance 51.32% · Measure score 5.98 · Achievement 3.02 · Improvement 5.98

Adjusted total nurse staffing

3.59

Baseline 5.01 hours · Performance 4.1 hours · Measure score 3.59 · Achievement 3.59 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.35%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 6.38%
Discharge to community	49.82%	50.57% 0.8 pts worse	No Different than the National Rate · Eligible stays 60 · Observed rate 50% · Lower 95% interval 41.84%
Medicare spending per beneficiary	0.88	1.02 0.1 pts better
Drug regimen review with follow-up	71.43%	95.27% 23.8 pts worse	Numerator 25 · Denominator 35
Falls with major injury	5.71%	0.77% 4.9 pts worse	Numerator 2 · Denominator 35
Discharge self-care score	66.67%	53.69% 13 pts better	Numerator 18 · Denominator 27
Discharge mobility score	62.96%	50.94% 12 pts better	Numerator 17 · Denominator 27
Pressure ulcers or injuries, new or worsened	2.86%	2.29% 0.6 pts worse	Numerator 1 · Denominator 35 · Adjusted rate 3.73%
Healthcare-associated infections requiring hospitalization	7.29%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.83%
Staff COVID-19 vaccination coverage	5.71%	8.2% 2.5 pts worse	Numerator 6 · Denominator 105
Staff flu vaccination coverage	38.54%	42% 3.5 pts worse	Numerator 37 · Denominator 96
Discharge function score	55.56%	56.45% 0.9 pts worse	Numerator 15 · Denominator 27
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.8 About the same	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.0 · Expected 1.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.1	1.8 0.3 pts worse	1.8 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.4 · Expected 1.1 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	87.7%	92.4% 4.7 pts worse	93.4% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 80.4% · Q3 95.7% · Q4 88.0% · 4Q avg 87.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.2%	94.5% 1.7 pts better	95.5% 0.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2%
Percentage of long-stay residents experiencing one or more falls with major injury	6.7%	3.3% 3.4 pts worse	3.3% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.8% · Q3 6.5% · Q4 12.0% · 4Q avg 6.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.3%	26.1% 23.8 pts better	11.4% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3%
Percentage of long-stay residents who lose too much weight	6.7%	6.2% 0.5 pts worse	5.4% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 11.4% · Q3 0.0% · Q4 7.3% · 4Q avg 6.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.2%	25.4% 8.2 pts better	19.6% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 21.3% · Q3 16.2% · Q4 16.7% · 4Q avg 17.2%
Percentage of long-stay residents who received an antipsychotic medication	14.9%	11.5% 3.4 pts worse	16.7% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 20.6% · Q3 15.4% · Q4 10.0% · 4Q avg 14.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	2.1%	0.1% 2 pts worse	0.1% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 2.2% · Q4 2.0% · 4Q avg 2.1%
Percentage of long-stay residents whose ability to walk independently worsened	21.7%	7.7% 14 pts worse	16.3% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 27.1% · Q3 12.8% · Q4 8.1% · 4Q avg 21.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	20.9%	6.2% 14.7 pts worse	14.9% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.7% · Q3 8.6% · Q4 22.5% · 4Q avg 20.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	5.0%	0.2% 4.8 pts worse	1.0% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.1% · Q3 3.8% · Q4 1.6% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.2%	0.5% 3.7 pts worse	1.7% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.2% · Q3 2.2% · Q4 4.1% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.1%	21.7% 6.4 pts worse	19.8% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 27.3% · Q3 30.6% · Q4 25.9% · 4Q avg 28.1%
Percentage of long-stay residents with pressure ulcers	2.5%	3.7% 1.2 pts better	5.1% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 3.1% · Q4 2.4% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.8%	78.1% 0.3 pts worse	81.7% 3.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 68.8% · Q2 71.4% · Q3 84.4% · Q4 87.2% · 4Q avg 77.8%
Percentage of short-stay residents who had an outpatient emergency department visit	11.8%	12.5% 0.7 pts better	12.0% 0.2 pts better	Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.1% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.4%	1.2% 3.2 pts worse	1.6% 2.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q3 4.3% · Q4 4.5% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	47.2%	75.6% 28.4 pts worse	79.7% 32.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 47.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.6%	25.1% 1.5 pts worse	23.9% 2.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 19.4% · Expected 17.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-18 · Fire 2024-11-18

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-08-08 · Fire 2022-08-08

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-08-29 · Fire 2019-08-29

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-06-03

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-06-18

D · Potential for more than minimal harm 2025-06-03

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-06-18

F · Potential for more than minimal harm 2024-11-18

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-02-18

D · Potential for more than minimal harm 2024-11-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-18

C · Minimal harm 2024-11-18

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-12-16

E · Potential for more than minimal harm 2024-04-15

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-05-06

E · Potential for more than minimal harm 2024-04-15

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-05-06

E · Potential for more than minimal harm 2024-04-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-06

F · Potential for more than minimal harm 2023-11-14

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-09-21

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-05-09

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-09

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-06-09

D · Potential for more than minimal harm 2022-08-08

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-08-25

D · Potential for more than minimal harm 2022-08-08

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-08-25

D · Potential for more than minimal harm 2022-08-08

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-08-25

D · Potential for more than minimal harm 2022-08-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-08-25

D · Potential for more than minimal harm 2022-08-08

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-08-25

D · Potential for more than minimal harm 2022-08-08

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2022-08-25

D · Potential for more than minimal harm 2019-08-29

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-10-18

D · Potential for more than minimal harm 2019-08-29

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-10-18

D · Potential for more than minimal harm 2019-08-29

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2019-10-18

D · Potential for more than minimal harm 2019-08-29

F758 · Pharmacy Service Deficiencies

Health

Corrected 2019-10-18

D · Potential for more than minimal harm 2019-08-29

F761 · Pharmacy Service Deficiencies

Health

Corrected 2019-10-18

Penalties and ownership

What sits behind the stars

Ownership

Brethren Retirement Community

5% Or Greater Direct Ownership Interest · Organization

100% 2 facilities 2024-12-31

Allread, Kara