Cycle 1
Health 2025-07-11 · Fire 2025-07-11
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cincinnati, OH
Triple Creek Retirement Community
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
11230 Pippin Road, Cincinnati, OH
(513) 851-0601
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
56
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2008-09-15
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,474
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 21.95% · Performance 20.43% · Measure score 2.60 · Achievement 2.17 · Improvement 2.60
Healthcare-associated infections
0
Baseline 7.58% · Performance 8.58% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.12
Baseline 57.78% · Performance 50.91% · Measure score 3.12 · Achievement 3.12 · Improvement 1.59
Adjusted total nurse staffing
2.38
Baseline 2.33 hours · Performance 3.32 hours · Measure score 2.38 · Achievement 0.85 · Improvement 2.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 12.5% · Lower 95% interval 7.9% |
| Discharge to community | 60.99% |
50.57%
10.4 pts better
|
Better than the National Rate · Eligible stays 133 · Observed rate 57.14% · Lower 95% interval 52.01% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.01% |
95.27%
3.7 pts better
|
Numerator 100 · Denominator 101 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 101 |
| Discharge self-care score | 59.15% |
53.69%
5.5 pts better
|
Numerator 42 · Denominator 71 |
| Discharge mobility score | 63.38% |
50.94%
12.4 pts better
|
Numerator 45 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 2.97% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 101 · Adjusted rate 1.83% |
| Healthcare-associated infections requiring hospitalization | 8.58% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 11.11% · Lower 95% interval 4.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 47.26% |
42%
5.3 pts better
|
Numerator 69 · Denominator 146 |
| Discharge function score | 63.38% |
56.45%
6.9 pts better
|
Numerator 45 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 10.26% |
25.2%
14.9 pts worse
|
Numerator 4 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
92.4%
6.6 pts worse
|
93.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 94.4% · Q3 94.1% · Q4 80.0% · 4Q avg 85.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.5%
2.9 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.4% |
26.1%
10.7 pts better
|
11.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 21.2% · Q3 13.8% · Q4 7.1% · 4Q avg 15.4% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
6.2%
1.5 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 7.7% · Q3 7.1% · Q4 0.0% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
25.4%
12.9 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 11.5% · Q3 10.7% · Q4 12.0% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.6% |
11.5%
8.9 pts better
|
16.7%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 4.8% · 4Q avg 2.6% · 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 | 10.4% |
7.7%
2.7 pts worse
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
6.2%
0.9 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 7.7% · Q4 4.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.2%
0.4 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 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 | 28.3% |
21.7%
6.6 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 25.7% · Q3 18.1% · Q4 30.5% · 4Q avg 28.3% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
3.7%
0.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 2.1% · Q4 2.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.5% |
78.1%
0.4 pts better
|
81.7%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.1% · Q2 81.7% · Q3 97.0% · Q4 62.7% · 4Q avg 78.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
12.5%
4 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 9.5% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.2%
1.1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 2.2% · Q4 2.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
75.6%
11.9 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
25.1%
0.8 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 31.0% · Expected 28.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-07-03 · Fire 2019-07-03
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-08-11
E · Potential for more than minimal harm
2025-07-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-11
F · Potential for more than minimal harm
2022-08-18
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-18
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-18
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-09-25
F · Potential for more than minimal harm
2022-08-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-25
E · Potential for more than minimal harm
2022-08-18
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 2022-09-25
F · Potential for more than minimal harm
2019-07-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-15
F · Potential for more than minimal harm
2019-07-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-08-15
F · Potential for more than minimal harm
2019-07-03
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2019-08-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-11
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 2025-08-11
D · Potential for more than minimal harm
2025-07-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-11
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-11
D · Potential for more than minimal harm
2024-05-28
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 2024-06-12
D · Potential for more than minimal harm
2024-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-07
D · Potential for more than minimal harm
2022-08-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-09-25
B · Minimal harm
2022-08-18
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 2022-09-12
B · Minimal harm
2022-08-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-09-12
F · Potential for more than minimal harm
2019-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-03
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 2019-08-15
D · Potential for more than minimal harm
2019-07-03
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 2019-08-15
D · Potential for more than minimal harm
2019-07-03
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 2019-08-15
D · Potential for more than minimal harm
2019-07-03
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-08-15
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
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
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
Marzec, Karen
Operational/Managerial Control · Individual
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
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
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4-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Veranda Gardens & Assisted Living
Cincinnati, OH
2-star overall rating with 1-star inspections with $30,715 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Burlington House Rehab & Alzheimer's Care Center
Cincinnati, OH
3-star overall rating with 2-star inspections with $85,205 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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