Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Ridge Of Mennonite Home Communities Of Ohio during CMS and state inspections, most recent first.
A facility failed to create a baseline care plan for a resident admitted with a surgical wound following knee joint prosthesis. Despite the resident's documented surgical wound with staples and sutures, the baseline care plan lacked interventions or goals for wound care. The DON confirmed the omission, which violated the facility's policy requiring care plans within 48 hours of admission.
The facility failed to ensure that the advance directive code status in the EMR matched the signed advanced directive form for two residents. One resident with severe cognitive impairment had a mismatch between the EMR and the DNR Order Form, while another cognitively intact resident also had a discrepancy. These errors were confirmed by the DON.
The facility failed to thoroughly investigate incidents of resident-to-resident sexual abuse involving three residents. A resident with a history of inappropriate behavior was involved in multiple incidents, and another resident with impaired cognition was also involved in an incident. Despite documentation of these events, the facility did not conduct comprehensive investigations, interviews, or staff education, leading to a deficiency.
The facility failed to develop comprehensive care plans for two residents, one on hospice care and another prescribed an antipsychotic medication. The care plan for a resident on hospice did not include necessary goals or interventions, while another resident's care plan omitted the use of prescribed Seroquel. These omissions were confirmed by the DON.
The facility failed to develop comprehensive care plans for two residents, omitting critical aspects such as code status, medication use, and management of medical conditions. One resident's plan did not address their DNR-CC status, blood thinner, or antipsychotic medication, while another's plan overlooked their DNR-CC Arrest status, hypertension, urinary incontinence, and pain management. The DON confirmed these deficiencies, which did not align with the facility's care planning policy.
A facility failed to assess a surgical wound upon admission for a resident with a knee joint prosthesis. The admission skin assessment noted a surgical wound with staples and sutures but lacked detailed description and measurements. This was confirmed by an RN, and the facility's policy required wound measurements, which were not completed.
A resident with essential hypertension was given crushed Aspirin Delayed Release, contrary to the physician's order, due to a failure in the facility's medication administration process. The RN confirmed the error, and the pharmacy was unaware of any need to crush the medication. The facility's policy did not address the proper handling of such medications.
The facility did not follow its Legionnaires policy, which required water systems to be maintained and documented. The Maintenance Director admitted to not testing water heater temperatures or treating shower heads, and there was no documentation of stagnant water prevention in empty rooms.
Failure to Develop Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to ensure a thorough baseline care plan was created for a resident who was admitted with a surgical wound following knee joint prosthesis. The resident, who was admitted with diagnoses including aftercare following knee joint prosthesis, Parkinsonism, and hypertension, had a surgical wound with 31 staples and two sutures documented in the admission skin assessment. However, the baseline care plan for the resident did not include any interventions or goals related to the surgical wound. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan should have addressed the resident's surgical wound. The facility's Baseline Care Policy requires that any services and treatments be developed within the first 48 hours of admission.
Discrepancy in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the advance directive code status in the Electronic Medical Record (EMR) matched the signed advanced directive form for two residents. Resident #5, who was admitted with unspecified dementia and severe cognitive impairment, had a discrepancy between the EMR and the DNR Order Form. The EMR indicated a Do Not Resuscitate - Comfort Care (DNR-CC) status, while the signed DNR Order Form indicated a Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) status. This inconsistency was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #18, who was cognitively intact and admitted with a pelvic fracture and hypertension, also had a mismatch between the EMR and the DNR Order Form. The EMR documented a DNR-CCA status, whereas the signed DNR Order Form indicated a DNR-CC status. This discrepancy was also verified by the DON. These errors affected the residents' documented wishes regarding their code status, as recorded in the facility's EMR.
Inadequate Investigation of Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into incidents of resident-to-resident sexual abuse, affecting three residents. Resident #16, who had a history of affectionate behavior towards females, was involved in multiple incidents where he inappropriately touched staff and other residents. Despite being on 15-minute checks, Resident #16 was observed engaging in inappropriate behavior with other residents and staff over several days. Resident #15, with impaired cognition, was also involved in an incident where he touched and kissed another resident, Resident #7, who had severely impaired cognition. These incidents were documented in progress notes and self-reported incidents (SRI), but the facility did not conduct comprehensive investigations. The facility's response to these incidents was inadequate, as no interviews with other residents were conducted, and no staff statements or education were provided following the incidents. The Administrator and Director of Nursing (DON) were unaware of the documented behaviors prior to the incidents, as they were not employed at the time. The facility's policy on abuse, neglect, and exploitation required investigations of allegations, but this was not followed. The lack of thorough investigation and response to the incidents led to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for two residents, leading to deficiencies in addressing their specific needs. Resident #9, who was admitted with diagnoses including unspecified dementia, anxiety, depression, and senile degeneration of the brain, was placed on hospice care. Despite this significant change in her care requirements, the facility did not update her care plan to include goals or interventions related to hospice care. This oversight was confirmed by the Director of Nursing (DON) during an interview, who acknowledged the absence of a hospice care plan for the resident. Similarly, Resident #5, who was admitted with unspecified dementia and other related conditions, was prescribed Seroquel, an antipsychotic medication. However, the resident's care plan did not address the use of this medication, which is crucial for managing her condition. The DON confirmed this omission during an interview, indicating a failure to incorporate the medication into the resident's care plan. These deficiencies highlight the facility's failure to develop and implement comprehensive care plans that meet the residents' needs.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for two residents, affecting their care management. Resident #5, who was admitted with severe cognitive impairment and required various levels of assistance, had a care plan that did not address critical aspects such as code status, the use of a blood thinner, or the use of an antipsychotic medication. This oversight was identified through a review of the resident's medical records, which included orders for a Do Not Resuscitate - Comfort Care (DNR-CC) directive, Apixaban for blood thinning, and Seroquel for managing dementia-related symptoms. Similarly, Resident #18, who was cognitively intact but required assistance with mobility and personal care, had a care plan that failed to address essential medical conditions and treatments. The resident's medical records indicated a DNR-CC Arrest code status, hypertension managed with Aspirin and Metoprolol, urinary incontinence treated with Myrbetriq, and pain managed with Tramadol. The Director of Nursing confirmed these deficiencies, acknowledging that the care plans were not comprehensive and did not meet the facility's policy requirements for person-centered care planning.
Failure to Assess Surgical Wound Upon Admission
Penalty
Summary
The facility failed to properly assess a surgical wound upon admission for a resident who was admitted with a knee joint prosthesis, Parkinsonism, and hypertension. The admission skin assessment documented the presence of a surgical wound with 31 staples and two sutures but lacked further description and measurements of the wound. This deficiency was confirmed during an interview with a registered nurse who verified the absence of measurements or a detailed description of the surgical wound in the admission assessment. The facility's policy on Wound and Skin Care Treatment Program required that measurements of a wound be completed, which was not adhered to in this case.
Improper Crushing of Delayed-Release Medication
Penalty
Summary
The facility failed to ensure that medications that should not be crushed were administered correctly, affecting a resident who was cognitively intact and required assistance with various activities of daily living. The resident had a physician's order for Aspirin Delayed Release 81 mg to be taken orally once a day for essential hypertension. However, during an observation, it was noted that a registered nurse crushed and administered the delayed-release aspirin to the resident, which was confirmed by the nurse. Further interviews revealed that the pharmacy was unaware of any need for the resident's medications to be crushed and confirmed that the delayed-release aspirin should not be crushed. The Director of Nursing also confirmed that the medication should not have been crushed. A review of the facility's medication administration standards showed that the policy did not address the issue of crushing medications that are not supposed to be crushed.
Failure to Follow Legionnaires Policy
Penalty
Summary
The facility failed to adhere to its Legionnaires policy, which was intended to apply to all water systems, including shower heads, hoses, ice machines, and infrequently used equipment. The policy required that cold water be heated to 140 degrees Fahrenheit by water heaters in each house, and that relevant procedures and record-keeping related to the program be maintained and reviewed as necessary. However, the Maintenance Director confirmed that in the seven months of his employment, he had not tested the temperature of the water heaters, nor was there documentation that shower heads had been treated or that stagnant water prevention was completed when a resident room was empty. Additionally, there was no documentation to show that the facility was following its policy of checking water heaters.
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Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bluffton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mennonite Memorial Home | 1.4 mi | ★★★★★ | 0 | 0 |
| Vancrest Of Ada | 8.4 mi | ★★★★★ | 2 | 0 |
| Autumn Court | 11.3 mi | ★★★★★ | 0 | 0 |
| Lost Creek Rehabilitation And Nursing Center | 12.2 mi | ★★★★★ | 0 | 0 |
| Meadows Of Ottawa The | 12.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.