Cycle 1
Health 2025-04-04 · Fire 2025-04-04
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lexington, KY
The Willows at Fritz Farm
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2710 Man O War Boulevard, Lexington, KY
(859) 273-0088
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 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
2017-03-08
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
1.18
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,706
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.11% · Performance 23.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.88
Baseline 7.62% · Performance 5.78% · Measure score 6.88 · Achievement 6.88 · Improvement 6.52
Total nurse turnover
4.98
Baseline 43.64% · Performance 43.33% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Adjusted total nurse staffing
2.24
Baseline 3.39 hours · Performance 3.72 hours · Measure score 2.24 · Achievement 2.24 · Improvement 0.88
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.68% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 247 · Observed rate 12.15% · Lower 95% interval 9.91% |
| Discharge to community | 73.27% |
50.57%
22.7 pts better
|
Better than the National Rate · Eligible stays 233 · Observed rate 70.82% · Lower 95% interval 68.3% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 135 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 65.42% |
53.69%
11.7 pts better
|
Numerator 70 · Denominator 107 |
| Discharge mobility score | 62.62% |
50.94%
11.7 pts better
|
Numerator 67 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 1.48% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 135 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 2.9% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 68.61% |
42%
26.6 pts better
|
Numerator 94 · Denominator 137 |
| Discharge function score | 66.36% |
56.45%
9.9 pts better
|
Numerator 71 · Denominator 107 |
| Transfer of health information to provider | 98.67% |
95.95%
2.7 pts better
|
Numerator 74 · Denominator 75 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 53.85% |
25.2%
28.7 pts better
|
Numerator 35 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.5% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.8%
0.5 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 3.6% · Q4 3.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.2%
15.2 pts better
|
11.4%
11.4 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 who lose too much weight | 6.7% |
6.7%
About the same
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.5% · Q3 8.3% · Q4 0.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
29.6%
3.6 pts better
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 23.1% · Q3 25.0% · Q4 25.0% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
17.6%
7.8 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 9.1% · Q3 4.5% · Q4 7.1% · 4Q avg 9.8% · 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 ability to walk independently worsened | 11.8% |
17.3%
5.5 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
15.6%
4.3 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 16.7% · Q3 13.0% · Q4 3.7% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · 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 | 24.0% |
19.8%
4.2 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 16.4% · Q3 34.6% · Q4 23.7% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.5%
0.7 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.7% · Q3 8.4% · Q4 4.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
83.8%
14.9 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 98.6% · Q3 99.4% · Q4 98.7% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
13.9%
2.7 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 9.6% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.8%
0.2 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.0% |
83.6%
12.4 pts better
|
79.7%
16.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
24.5%
2.8 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 22.8% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-16 · Fire 2020-01-16
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-02-07 · Fire 2019-02-07
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-08
D · Potential for more than minimal harm
2019-02-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-02-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-04
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 2025-05-07
E · Potential for more than minimal harm
2025-04-04
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 2025-05-07
D · Potential for more than minimal harm
2025-04-04
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 2025-05-07
D · Potential for more than minimal harm
2025-04-04
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 2025-05-07
D · Potential for more than minimal harm
2025-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-07
E · Potential for more than minimal harm
2020-01-16
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 2020-02-10
E · Potential for more than minimal harm
2019-02-07
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 2019-03-22
D · Potential for more than minimal harm
2019-02-07
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 2019-03-23
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
Barney, Leigh
Corporate Officer · Individual
Blair, Elizabeth
Operational/Managerial Control · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Mehaffey, Todd
Corporate Officer · Individual
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Pietrowski, Cristina
Corporate Officer · Individual
Prosky, Danny
Corporate Officer · Individual
Regions Bank
5% Or Greater Mortgage Interest · Organization
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
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
Nearby options
Other facilities in reach
#1
Sayre Christian Village Nursing Home
Lexington, KY
2-star overall rating with 3-star inspections with $7,901 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Mayfair Manor
Lexington, KY
1-star overall rating with 1-star inspections with abuse icon flag with $33,602 in total fines with 5 recent health deficiencies
#3
Hartland Park Health & Rehabilitation
Lexington, KY
1-star overall rating with 2-star inspections with $12,925 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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