Cycle 1
Health 2024-06-13 · Fire 2024-06-13
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Springfield, OH
Wooded Glen
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2900 Bechtle Avenue, Springfield, OH
(937) 342-1460
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
54
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2018-02-15
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,427
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9897
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.95% · Performance 21.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.49
Baseline 7.33% · Performance 6.19% · Measure score 5.49 · Achievement 5.49 · Improvement 4.36
Total nurse turnover
6.64
Baseline 45.00% · Performance 36.54% · Measure score 6.64 · Achievement 6.64 · Improvement 3.7
Adjusted total nurse staffing
2.36
Baseline 2.31 hours · Performance 3.30 hours · Measure score 2.36 · Achievement 0.79 · Improvement 2.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.76% |
10.72%
3 pts worse
|
No Different than the National Rate · Eligible stays 210 · Observed rate 16.67% · Lower 95% interval 9.94% |
| Discharge to community | 64.27% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 203 · Observed rate 58.62% · Lower 95% interval 56.67% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 114 · Denominator 114 |
| Falls with major injury | 2.63% |
0.77%
1.9 pts worse
|
Numerator 3 · Denominator 114 |
| Discharge self-care score | 41.89% |
53.69%
11.8 pts worse
|
Numerator 31 · Denominator 74 |
| Discharge mobility score | 58.11% |
50.94%
7.2 pts better
|
Numerator 43 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 0.88% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 114 · Adjusted rate 0.82% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 5.04% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 41.84% |
42%
0.2 pts worse
|
Numerator 59 · Denominator 141 |
| Discharge function score | 66.22% |
56.45%
9.8 pts better
|
Numerator 49 · Denominator 74 |
| Transfer of health information to provider | 98.67% |
95.95%
2.7 pts better
|
Numerator 74 · Denominator 75 |
| Transfer of health information to patient | 92.31% |
96.28%
4 pts worse
|
Numerator 24 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 3.45% |
25.2%
21.8 pts worse
|
Numerator 2 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
92.4%
5.8 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
94.5%
2.4 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 56.9% |
26.1%
30.8 pts worse
|
11.4%
45.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.0% · Q2 72.4% · Q3 64.0% · Q4 26.1% · 4Q avg 56.9% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.2%
1 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.4% · Q3 8.7% · Q4 0.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.6% |
25.4%
3.8 pts better
|
19.6%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.2% · Q3 26.1% · Q4 18.2% · 4Q avg 21.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
11.5%
1.4 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 14.3% · Q3 5.0% · 4Q avg 10.1% · 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 | 12.2% |
7.7%
4.5 pts worse
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.2% |
6.2%
3 pts better
|
14.9%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 4.5% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 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 | 0.9% |
0.5%
0.4 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
21.7%
3.8 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 24.2% · Q3 11.2% · Q4 19.4% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
3.7%
2.4 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.3% · Q3 8.5% · Q4 2.7% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
78.1%
18.6 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 99.2% · Q3 100.0% · Q4 94.2% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
12.5%
1.9 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 14.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.4% |
75.6%
1.2 pts worse
|
79.7%
5.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
25.1%
0.8 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 26.4% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-19 · Fire 2021-08-19
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-03-07 · Fire 2019-03-07
14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-06-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-13
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 2024-07-05
E · Potential for more than minimal harm
2024-06-13
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-05
F · Potential for more than minimal harm
2021-08-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-09-01
E · Potential for more than minimal harm
2021-08-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-09-01
E · Potential for more than minimal harm
2021-08-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-01
F · Potential for more than minimal harm
2019-03-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-04-17
E · Potential for more than minimal harm
2019-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-17
E · Potential for more than minimal harm
2019-03-07
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2019-04-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-23
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 2025-09-26
D · Potential for more than minimal harm
2025-06-04
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 2025-07-09
D · Potential for more than minimal harm
2024-08-15
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 2024-08-22
D · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-06-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-05
F · Potential for more than minimal harm
2021-08-19
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 2021-09-01
F · Potential for more than minimal harm
2019-03-07
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 2019-04-17
E · Potential for more than minimal harm
2019-03-07
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 2019-04-17
E · Potential for more than minimal harm
2019-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
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 2019-04-17
D · Potential for more than minimal harm
2019-03-07
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 2019-04-17
D · Potential for more than minimal harm
2019-03-07
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 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2019-04-17
D · Potential for more than minimal harm
2019-03-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-04-17
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
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
Ward, Stacie
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
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