Lexington, KY

The Willows at Hamburg

3-star overall rating with 2-star inspections with $61,627 in total fines with 2 recent health deficiencies

2531 Old Rosebud Road, Lexington, KY

(859) 543-0337

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 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

64

Certified beds

Average residents

57

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

2012-12-14

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

0.69

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

1.22

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.98

Nurse aide staffing · state 2.43 · national 2.35

Total nurse hours

4.90

All reported nurse hours · state 4.01 · national 3.89

Licensed hours

1.92

RN + LPN hours · state 1.58 · national 1.54

Weekend hours

4.65

Weekend nurse staffing · state 3.50 · national 3.43

Weekend RN hours

0.52

Weekend registered nurse coverage · state 0.52 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.62

CMS adjusted RN staffing hours

Adjusted total hours

4.40

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

18%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,552

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.80

Composite VBP score used to determine payment impact.

Payment multiplier

0.9894

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.83

Baseline 18.08% · Performance 20.12% · Measure score 2.83 · Achievement 2.83 · Improvement 0

Healthcare-associated infections

0

Baseline 6.10% · Performance 8.16% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

6.37

Baseline 45.07% · Performance 37.66% · Measure score 6.37 · Achievement 6.37 · Improvement 3.16

Adjusted total nurse staffing

5.12

Baseline 3.38 hours · Performance 4.54 hours · Measure score 5.12 · Achievement 5.12 · Improvement 4.32

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.73%	10.72% About the same	No Different than the National Rate · Eligible stays 217 · Observed rate 10.14% · Lower 95% interval 7.31%
Discharge to community	69.02%	50.57% 18.4 pts better	Better than the National Rate · Eligible stays 183 · Observed rate 65.03% · Lower 95% interval 62.37%
Medicare spending per beneficiary	0.91	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 142 · Denominator 142
Falls with major injury	1.41%	0.77% 0.6 pts worse	Numerator 2 · Denominator 142
Discharge self-care score	40.54%	53.69% 13.1 pts worse	Numerator 45 · Denominator 111
Discharge mobility score	64.86%	50.94% 13.9 pts better	Numerator 72 · Denominator 111
Pressure ulcers or injuries, new or worsened	0.7%	2.29% 1.6 pts better	Numerator 1 · Denominator 142 · Adjusted rate 0.53%
Healthcare-associated infections requiring hospitalization	8.16%	7.12% 1 pts worse	No Different than the National Rate · Eligible stays 132 · Observed rate 8.33% · Lower 95% interval 5.48%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 114
Staff flu vaccination coverage	72.73%	42% 30.7 pts better	Numerator 112 · Denominator 154
Discharge function score	61.26%	56.45% 4.8 pts better	Numerator 68 · Denominator 111
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 55 · Denominator 55
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 68 · Denominator 68
Resident COVID-19 vaccinations up to date	32.89%	25.2% 7.7 pts better	Numerator 25 · Denominator 76

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.9 0.4 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.2 0.5 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.6%	94.3% 4.3 pts better	93.4% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 97.4% · 4Q avg 98.6%
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	3.4%	3.8% 0.4 pts better	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 2.9% · Q4 7.9% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	14.9%	15.2% 0.3 pts better	11.4% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 24.2% · Q3 15.6% · Q4 13.9% · 4Q avg 14.9%
Percentage of long-stay residents who lose too much weight	3.8%	6.7% 2.9 pts better	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.9% · Q3 5.9% · Q4 0.0% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.3%	29.6% 4.7 pts worse	19.6% 14.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 35.3% · Q3 35.3% · Q4 29.4% · 4Q avg 34.3%
Percentage of long-stay residents who received an antipsychotic medication	16.7%	17.6% 0.9 pts better	16.7% About the same	Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 20.8% · Q3 14.8% · Q4 6.5% · 4Q avg 16.7% · 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	17.6%	17.3% 0.3 pts worse	16.3% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.5%	15.6% 2.9 pts worse	14.9% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 22.6% · Q3 15.6% · Q4 22.6% · 4Q avg 18.5% · 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	27.4%	19.8% 7.6 pts worse	19.8% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 30.5% · Q3 25.3% · Q4 29.3% · 4Q avg 27.4%
Percentage of long-stay residents with pressure ulcers	0.0%	5.5% 5.5 pts better	5.1% 5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine	91.8%	83.8% 8 pts better	81.7% 10.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 91.0% · Q3 93.7% · Q4 91.1% · 4Q avg 91.8%
Percentage of short-stay residents who had an outpatient emergency department visit	16.7%	13.9% 2.8 pts worse	12.0% 4.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 15.3% · Expected 10.3% · 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	89.3%	83.6% 5.7 pts better	79.7% 9.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.7%	24.5% 3.8 pts better	23.9% 3.2 pts better	Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 19.4% · Expected 22.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-08 · Fire 2025-08-08

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-05-06 · Fire 2022-05-06

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2019-08-22 · Fire 2019-08-22

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2022-05-06

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-06-03

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-08

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 2025-09-12

D · Potential for more than minimal harm 2025-08-08

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 2025-09-12

J · Immediate jeopardy 2024-07-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-07-11

J · Immediate jeopardy 2024-07-03

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-07-11

F · Potential for more than minimal harm 2022-05-06

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 2022-06-05

E · Potential for more than minimal harm 2022-05-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-06-05

E · Potential for more than minimal harm 2019-08-22

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 2019-09-20

Penalties and ownership

What sits behind the stars

$61,627 2024-07-03

Fine

Fine · fine $61,627

Fine

Ownership

Trilogy Opco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 62 facilities 2021-10-01

American Healthcare Reit Holdings LP

5% Or Greater Indirect Ownership Interest · Organization

0% 65 facilities 2021-10-01

American Healthcare Reit Inc

5% Or Greater Indirect Ownership Interest · Organization

0% 66 facilities 2021-10-01

Barney, Leigh

Corporate Officer · Individual

0% 69 facilities 2019-11-01

Bryant, William

Corporate Officer · Individual

0% 49 facilities 2016-01-05

Bufford, Randall

Corporate Officer · Individual

0% 35 facilities 2019-11-01

Conner, Gregory

Corporate Officer · Individual

0% 34 facilities 2021-06-03

Continental Merger Sub LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 50 facilities 2021-10-01

Corbin, Kathy

W-2 Managing Employee · Individual

0% 72 facilities 2011-01-10

Davis, David

Corporate Officer · Individual

0% 71 facilities 2017-08-21

Fightmaster, Lisa

W-2 Managing Employee · Individual

0% 60 facilities 2015-12-01

Frazier, Samuel

Operational/Managerial Control · Individual

0% 1 facilities 2017-03-06

Gahc3 Trilogy Jv LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 62 facilities 2021-10-01

Gahc4 Trilogy Jv LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 62 facilities 2021-10-01

Keybank National Association

5% Or Greater Mortgage Interest · Organization

0% 44 facilities 2018-09-11

Northstar Healthcare Income Inc

5% Or Greater Indirect Ownership Interest · Organization

0% 50 facilities 2021-10-01

Northstar Healthcare Income Operating Partnership LP

5% Or Greater Indirect Ownership Interest · Organization

0% 50 facilities 2021-10-01

Prosky, Danny

Corporate Officer · Individual

0% 51 facilities 2015-12-01

Streiff, Mathieu

Corporate Officer · Individual

0% 47 facilities 2015-12-01

Trilogy Healthcare Holdings Inc

5% Or Greater Indirect Ownership Interest · Organization

0% 63 facilities 2021-10-01

Trilogy Holdings Nt-Hci, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 48 facilities 2021-10-01

Trilogy Investors LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 61 facilities 2021-10-01

Trilogy Management Services LLC

Operational/Managerial Control · Organization

0% 56 facilities 2021-10-01

Trilogy Real Estate Investment Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 61 facilities 2021-10-01

Trilogy Reit Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 61 facilities 2021-10-01

Nearby options

Other facilities in reach

#1

Lexington Premier Nursing & Rehab

Lexington, KY

1-star overall rating with 1-star inspections with $240,331 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

Overall: 1 / 5
Health: 1 / 5
Staffing: 1 / 5
Fines: $240,331

#2