Cycle 1
Health 2025-01-29 · Fire 2025-01-29
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Okemos, MI
The Willows At Okemos
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4830 Central Park Drive, Okemos, MI
(517) 349-3600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-09-25
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
1.27
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.30
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.30
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,513
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9926
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.75
Baseline 20.07% · Performance 19.23% · Measure score 4.75 · Achievement 4.75 · Improvement 2.26
Healthcare-associated infections
2.25
Baseline 5.01% · Performance 7.16% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Total nurse turnover
6.72
Baseline 36.36% · Performance 36.21% · Measure score 6.72 · Achievement 6.72 · Improvement 0
Adjusted total nurse staffing
2.13
Baseline 3.44 hours · Performance 3.68 hours · Measure score 2.13 · Achievement 2.13 · Improvement 0.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 10.88% · Lower 95% interval 7.87% |
| Discharge to community | 65.78% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 143 · Observed rate 64.34% · Lower 95% interval 57.72% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 68.97% |
53.69%
15.3 pts better
|
Numerator 40 · Denominator 58 |
| Discharge mobility score | 56.9% |
50.94%
6 pts better
|
Numerator 33 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 51.09% |
42%
9.1 pts better
|
Numerator 70 · Denominator 137 |
| Discharge function score | 51.72% |
56.45%
4.7 pts worse
|
Numerator 30 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 37.84% |
25.2%
12.6 pts better
|
Numerator 14 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
95.0%
0.5 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 100.0% · Q3 97.5% · Q4 93.5% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.0%
0.3 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.1%
1.2 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
4.1%
0.6 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 2.7% · Q3 2.5% · Q4 3.2% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.5%
2.3 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.2% · Q3 0.0% · Q4 3.8% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
19.6%
7.5 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 6.5% · Q3 6.7% · Q4 11.5% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
16.5%
12.2 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 0.0% · Q3 3.3% · Q4 4.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 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 | 39.7% |
13.9%
25.8 pts worse
|
16.3%
23.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.0% · 4Q avg 39.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
11.7%
10.3 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 29.0% · Q3 6.7% · Q4 3.8% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 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 | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
20.4%
2 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 18.5% · Q3 16.6% · Q4 5.9% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.6%
1.4 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.9% · Q3 3.1% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
82.8%
0.8 pts better
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.2% · Q2 83.3% · Q3 85.0% · Q4 83.0% · 4Q avg 83.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
11.5%
5.1 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 16.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
79.5%
3 pts better
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
24.2%
1.5 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 23.8% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-10-04 · Fire 2022-10-04
5 health deficiencies
Top issue: Administration (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-01-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-13
F · Potential for more than minimal harm
2022-10-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-10-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-26
E · Potential for more than minimal harm
2022-10-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-26
Inspection history
Recent health citations
G · Actual harm
2025-05-07
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 2025-05-28
D · Potential for more than minimal harm
2025-05-07
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 2025-05-28
E · Potential for more than minimal harm
2025-01-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-29
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 2025-02-27
D · Potential for more than minimal harm
2025-01-29
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 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-01-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-13
D · Potential for more than minimal harm
2024-01-04
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 2024-02-13
D · Potential for more than minimal harm
2024-01-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-13
C · Minimal harm
2024-01-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-13
D · Potential for more than minimal harm
2023-09-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-08-23
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-05-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-20
F · Potential for more than minimal harm
2022-10-04
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 2022-10-26
D · Potential for more than minimal harm
2022-10-04
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 2022-10-26
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
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
Ermiger, Joseph
Operational/Managerial Control · 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
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Prosky, Danny
Corporate Officer · Individual
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
Medilodge of Okemos
Okemos, MI
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Ingham County Medical Care Facility
Okemos, MI
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Medilodge of Campus Area
East Lansing, MI
2-star overall rating with 2-star inspections with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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