Cycle 1
Health 2024-12-18 · Fire 2024-12-18
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Harrodsburg, KY
The Willows at Harrodsburg
3-star overall rating with 2-star inspections with $12,529 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
180 Lucky Man Way, Harrodsburg, KY
(859) 734-2953
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
1990-08-31
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
0.91
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,636
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.34
Baseline 21.56% · Performance 20.81% · Measure score 1.34 · Achievement 1.34 · Improvement 1.16
Healthcare-associated infections
3.22
Baseline 5.83% · Performance 6.87% · Measure score 3.22 · Achievement 3.22 · Improvement 0
Total nurse turnover
5.90
Baseline 61.29% · Performance 39.58% · Measure score 5.90 · Achievement 5.90 · Improvement 5.46
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.45% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 151 · Observed rate 11.26% · Lower 95% interval 8.61% |
| Discharge to community | 65.8% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 125 · Observed rate 68.8% · Lower 95% interval 58.46% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 96 · Denominator 96 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 96 |
| Discharge self-care score | 66.22% |
53.69%
12.5 pts better
|
Numerator 49 · Denominator 74 |
| Discharge mobility score | 51.35% |
50.94%
0.4 pts better
|
Numerator 38 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 1.04% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 96 · Adjusted rate 0.88% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 5.1% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 21.14% |
42%
20.9 pts worse
|
Numerator 26 · Denominator 123 |
| Discharge function score | 52.7% |
56.45%
3.8 pts worse
|
Numerator 39 · Denominator 74 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 60 · Denominator 60 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 3 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 96.8% |
96.2%
0.6 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.8%
1.3 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.2% · Q3 3.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 37.4% |
15.2%
22.2 pts worse
|
11.4%
26 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 33.3% · Q3 43.8% · Q4 33.3% · 4Q avg 37.4% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.7%
3.6 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 3.8% · Q4 4.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
29.6%
10.6 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.2% · Q3 18.5% · Q4 20.0% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
17.6%
10.1 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.7% · Q3 4.0% · Q4 8.7% · 4Q avg 7.5% · 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 | 6.0% |
15.6%
9.6 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 13.0% · 4Q avg 6.0% · 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 | 5.1% |
19.8%
14.7 pts better
|
19.8%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 0.0% · Q3 7.1% · Q4 4.0% · 4Q avg 5.1% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
5.5%
5 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
83.8%
13.6 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 98.0% · Q3 96.3% · Q4 95.3% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
13.9%
2.4 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.8%
0.1 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.4% · Q3 0.0% · Q4 1.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
83.6%
15.4 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
24.5%
About the same
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 20.8% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-26 · Fire 2019-09-26
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-12-20 · Fire 2018-12-20
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-22
Inspection history
Recent health citations
G · Actual harm
2024-12-18
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 2024-11-06
F · Potential for more than minimal harm
2024-12-18
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 2025-01-22
E · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-18
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 2025-01-22
D · Potential for more than minimal harm
2024-12-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-22
E · Potential for more than minimal harm
2018-12-20
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-01-31
D · Potential for more than minimal harm
2018-12-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-01-31
D · Potential for more than minimal harm
2018-12-20
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 2019-01-31
Penalties and ownership
What sits behind the stars
$4,017
2024-12-18
Fine
Fine · fine $4,017
Fine
$8,512
2024-12-18
Fine
Fine · fine $8,512
Fine
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
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
Operational/Managerial Control · Individual
Duncan, James
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
Hettinger, Rachel
Operational/Managerial Control · Individual
Pietrowski, Cristina
Operational/Managerial Control · Individual
Thacker, Jessica
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 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
Harrodsburg Health & Rehabilitation Center
Harrodsburg, KY
4-star overall rating with 4-star inspections with $6,682 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Danville Centre for Health & Rehabilitation
Danville, KY
2-star overall rating with 1-star inspections with $12,444 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Henson Park Health & Rehabilitation
Danville, KY
1-star overall rating with 1-star inspections with $369,133 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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