Cycle 1
Health 2024-07-11 · Fire 2024-07-11
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Bluffton, OH
Willow Ridge Of Mennonite Home Communities Of Ohio
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
101 Willow Ridge Drive, Bluffton, OH
(419) 358-1015
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
19
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
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
0.79
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.60
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.28
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
5.38
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 15.63% |
8.2%
7.4 pts better
|
Numerator 5 · Denominator 32 |
| Staff flu vaccination coverage | 52.78% |
42%
10.8 pts better
|
Numerator 19 · Denominator 36 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.3% |
92.4%
20.1 pts worse
|
93.4%
21.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 72.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.3%
2.9 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
26.1%
26.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
6.2%
4.4 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
25.4%
6.1 pts better
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
11.5%
8.9 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.2% |
7.7%
12.5 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
6.2%
19.3 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.3% |
0.2%
4.1 pts worse
|
1.0%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
0.5%
1.1 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
21.7%
5.2 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.4% |
78.1%
56.7 pts worse
|
81.7%
60.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 21.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-25 · Fire 2022-01-25
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-05-02 · Fire 2019-05-02
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-27
F · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-27
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-27
E · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-27
F · Potential for more than minimal harm
2022-01-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-02-16
F · Potential for more than minimal harm
2022-01-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-16
F · Potential for more than minimal harm
2022-01-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-16
F · Potential for more than minimal harm
2019-05-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-06-20
F · Potential for more than minimal harm
2019-05-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-06-20
F · Potential for more than minimal harm
2019-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-11
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 2024-07-27
D · Potential for more than minimal harm
2024-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-27
G · Actual harm
2022-01-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-16
F · Potential for more than minimal harm
2022-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-16
E · Potential for more than minimal harm
2022-01-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-16
D · Potential for more than minimal harm
2022-01-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-02-16
D · Potential for more than minimal harm
2022-01-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-16
D · Potential for more than minimal harm
2022-01-25
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 2022-02-16
D · Potential for more than minimal harm
2022-01-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-02-16
E · Potential for more than minimal harm
2019-05-02
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-06-20
E · Potential for more than minimal harm
2019-05-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-02
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 2019-06-20
D · Potential for more than minimal harm
2019-05-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-02
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 2019-06-20
D · Potential for more than minimal harm
2019-05-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-06-20
Penalties and ownership
What sits behind the stars
Ownership
Brethren Retirement Community
5% Or Greater Direct Ownership Interest · Organization
Allread, Kara
Corporate Director · Individual
Arnold, Matthew
Corporate Director · Individual
Keller, Lori
Corporate Director · Individual
Kepler, David
Corporate Director · Individual
Maurer, Rebecca
Corporate Director · Individual
Nickles, Lance
Operational/Managerial Control · Individual
North, Steven
Corporate Director · Individual
Polhamus, Marjorie
Corporate Director · Individual
Shetler, David
Corporate Director · Individual
Subler, Jeff
Corporate Director · Individual
Warner, John
Corporate Director · Individual
Warner, John
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mennonite Memorial Home
Bluffton, OH
2-star overall rating with 3-star inspections with 13 recent health deficiencies
#2
Vancrest Of Ada
Ada, OH
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Autumn Court
Ottawa, OH
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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