Cycle 1
Health 2025-03-10 · Fire 2025-03-10
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Monticello, IN
White Oak Health Campus
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
814 S 6th St, Monticello, IN
(574) 583-0324
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
61
Certified beds
Average residents
52
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2010-09-08
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
1.17
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,154
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0146
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.65% · Performance 15.66% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.40
Baseline 9.66% · Performance 6.91% · Measure score 5.40 · Achievement 3.09 · Improvement 5.40
Total nurse turnover
7.81
Baseline 40.00% · Performance 31.75% · Measure score 7.81 · Achievement 7.81 · Improvement 4.95
Adjusted total nurse staffing
0.55
Baseline 2.94 hours · Performance 3.23 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 197 · Observed rate 12.18% · Lower 95% interval 8.38% |
| Discharge to community | 59.42% |
50.57%
8.9 pts better
|
Better than the National Rate · Eligible stays 186 · Observed rate 54.3% · Lower 95% interval 51.67% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 145 · Denominator 145 |
| Falls with major injury | 1.38% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 145 |
| Discharge self-care score | 81.15% |
53.69%
27.5 pts better
|
Numerator 99 · Denominator 122 |
| Discharge mobility score | 81.97% |
50.94%
31 pts better
|
Numerator 100 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 0.69% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 145 · Adjusted rate 0.54% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 6.85% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 67.11% |
42%
25.1 pts better
|
Numerator 100 · Denominator 149 |
| Discharge function score | 85.25% |
56.45%
28.8 pts better
|
Numerator 104 · Denominator 122 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 94 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 32.84% |
25.2%
7.6 pts better
|
Numerator 22 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
93.6%
3.5 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 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 | 2.9% |
3.8%
0.9 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.8% · Q3 2.9% · Q4 3.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.0% |
24.6%
6.6 pts better
|
11.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 12.5% · Q4 19.4% · 4Q avg 18.0% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.6%
2.1 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
23.5%
5.1 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.7% · Q3 13.8% · Q4 14.3% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
14.8%
6.6 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.0% · Q3 7.7% · Q4 8.7% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 13.9% |
13.3%
0.6 pts worse
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
11.7%
0.5 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.8% · Q3 14.3% · Q4 18.5% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 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% |
1.2%
1.2 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 | 28.0% |
24.2%
3.8 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 31.0% · Q3 19.6% · Q4 24.1% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.1%
2.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
81.6%
14 pts better
|
81.7%
13.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 94.0% · Q3 97.5% · Q4 95.9% · 4Q avg 95.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
10.5%
1.5 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 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 | 93.3% |
79.0%
14.3 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
22.4%
0.6 pts worse
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 19.5% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-12 · Fire 2024-02-12
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-01-30 · Fire 2023-01-30
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-10
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-03
C · Minimal harm
2025-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-03
E · Potential for more than minimal harm
2024-02-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-04
E · Potential for more than minimal harm
2024-02-12
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-04-04
F · Potential for more than minimal harm
2023-01-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-10
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 2025-03-27
D · Potential for more than minimal harm
2025-03-10
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 2025-03-27
D · Potential for more than minimal harm
2025-03-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-10
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 2025-03-27
D · Potential for more than minimal harm
2024-02-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-17
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
W-2 Managing Employee · Individual
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hawkins, Claude
Corporate Director · Individual
Pogas, George
Corporate Officer · Individual
Trilogy Healthcare Of Monticello LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Monticello Healthcare
Monticello, IN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
St Elizabeth Healthcare Center
Delphi, IN
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Parkview Haven
Francesville, IN
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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