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
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing
LPN hours / resident day
0.77
Licensed practical nurse staffing
Aide hours / resident day
3.04
Nurse aide staffing
Weekend hours
4.28
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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