Cycle 1
Health 2025-06-26 · Fire 2025-06-26
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lexington, KY
The Willows At Citation
4-star overall rating with 3-star inspections with 2 recent health deficiencies
1376 Silver Springs Drive, Lexington, KY
(859) 277-0320
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-06-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
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
1.08
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
2.07
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,120
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9941
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.87% · Performance 22.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.66
Baseline 7.14% · Performance 5.85% · Measure score 6.66 · Achievement 6.66 · Improvement 5.53
Total nurse turnover
7.57
Baseline 37.50% · Performance 32.73% · Measure score 7.57 · Achievement 7.57 · Improvement 3.27
Adjusted total nurse staffing
2.25
Baseline 3.73 hours · Performance 3.72 hours · Measure score 2.25 · Achievement 2.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.52% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 13.23% · Lower 95% interval 9.48% |
| Discharge to community | 71.59% |
50.57%
21 pts better
|
Better than the National Rate · Eligible stays 173 · Observed rate 67.63% · Lower 95% interval 65.76% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 130 · Denominator 130 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 130 |
| Discharge self-care score | 77.55% |
53.69%
23.9 pts better
|
Numerator 76 · Denominator 98 |
| Discharge mobility score | 58.16% |
50.94%
7.2 pts better
|
Numerator 57 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 130 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 3.51% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 71.74% |
42%
29.7 pts better
|
Numerator 99 · Denominator 138 |
| Discharge function score | 65.31% |
56.45%
8.9 pts better
|
Numerator 64 · Denominator 98 |
| Transfer of health information to provider | 98.59% |
95.95%
2.6 pts better
|
Numerator 70 · Denominator 71 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 51.52% |
25.2%
26.3 pts better
|
Numerator 34 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.2
0.4 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
96.2%
0.5 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.8%
0.6 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.3% · Q4 6.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
15.2%
10.1 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.0% · Q3 3.6% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
6.7%
5.7 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
29.6%
3.1 pts better
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 26.1% · Q3 28.0% · Q4 25.9% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
17.6%
8.6 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 9.1% · Q3 13.0% · Q4 4.8% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
15.6%
8.2 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 8.3% · Q4 12.0% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
19.8%
2.5 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 15.2% · Q3 24.1% · Q4 20.6% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.5%
3.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.8% · Q3 1.9% · Q4 1.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
83.8%
14.5 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 98.8% · Q3 98.7% · Q4 95.9% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
13.9%
10.9 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 2.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.8%
1.8 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
83.6%
11.8 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
24.5%
4.2 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 25.9% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-04 · Fire 2021-11-04
7 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 3
Health 2019-05-09 · Fire 2019-05-09
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2025-06-26
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 2025-07-17
D · Potential for more than minimal harm
2025-06-26
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-17
E · Potential for more than minimal harm
2021-11-04
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 2021-12-15
E · Potential for more than minimal harm
2021-11-04
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 2021-12-15
D · Potential for more than minimal harm
2021-11-04
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 2021-12-15
D · Potential for more than minimal harm
2021-11-04
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-15
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Adam
Operational/Managerial Control · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
Operational/Managerial Control · Individual
Fightmaster, Lisa
Operational/Managerial Control · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Pietrowski, Cristina
Operational/Managerial Control · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wiemann, Charlotte
Operational/Managerial Control · Individual
Nearby options
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#2
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3-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Cardinal Hill Skilled Rehabilitation Unit
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4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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