Cycle 1
Health 2025-06-03 · Fire 2025-06-03
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Logansport, IN
Woodbridge Health Campus
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
602 Woodbridge Ave, Logansport, IN
(574) 753-3223
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
69
Certified beds
Average residents
61
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2003-07-03
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
862
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.83
Composite VBP score used to determine payment impact.
Payment multiplier
1.0177
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.37% · Performance 16.89% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.99
Baseline 6.79% · Performance 6.05% · Measure score 5.99 · Achievement 5.99 · Improvement 3.66
Total nurse turnover
7.58
Baseline 53.57% · Performance 32.69% · Measure score 7.58 · Achievement 7.58 · Improvement 6.77
Adjusted total nurse staffing
1.57
Baseline 2.58 hours · Performance 3.24 hours · Measure score 1.57 · Achievement 0.58 · Improvement 1.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.9% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 6.7% · Lower 95% interval 5.99% |
| Discharge to community | 62.45% |
50.57%
11.9 pts better
|
Better than the National Rate · Eligible stays 166 · Observed rate 60.84% · Lower 95% interval 54.57% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 98 |
| Discharge self-care score | 66.29% |
53.69%
12.6 pts better
|
Numerator 59 · Denominator 89 |
| Discharge mobility score | 66.29% |
50.94%
15.4 pts better
|
Numerator 59 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 98 · Adjusted rate 1.96% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 4.07% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 28.33% |
42%
13.7 pts worse
|
Numerator 34 · Denominator 120 |
| Discharge function score | 68.54% |
56.45%
12.1 pts better
|
Numerator 61 · Denominator 89 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 61 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 5 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
93.6%
2.9 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 100.0% · Q3 97.5% · Q4 100.0% · 4Q avg 96.5% |
| 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 | 8.1% |
3.8%
4.3 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 9.3% · Q3 7.5% · Q4 11.1% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
24.6%
19.8 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 2.5% · Q4 7.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
5.6%
3.4 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 12.1% · Q3 5.9% · Q4 10.3% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
23.5%
6.3 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 18.2% · Q3 14.7% · Q4 17.5% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
14.8%
3.1 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 20.8% · Q3 20.0% · Q4 17.6% · 4Q avg 17.9% · 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 | 8.4% |
13.3%
4.9 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 12.4% · Q3 3.9% · Q4 5.3% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
11.7%
1.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 6.1% · Q3 5.9% · Q4 12.5% · 4Q avg 10.3% · 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 | 28.1% |
24.2%
3.9 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 30.1% · Q3 16.2% · Q4 32.6% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.1%
3.6 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · 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 | 97.8% |
81.6%
16.2 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 100.0% · Q3 96.3% · Q4 97.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
10.5%
2.7 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.1% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
79.0%
13.9 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
22.4%
6.9 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 13.1% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-26 · Fire 2024-04-26
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
7 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-04-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-07
F · Potential for more than minimal harm
2024-04-26
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 2024-06-07
F · Potential for more than minimal harm
2024-04-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-04-26
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-06-07
C · Minimal harm
2024-04-26
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-04
C · Minimal harm
2024-04-26
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-06-04
C · Minimal harm
2024-04-26
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-04
C · Minimal harm
2024-04-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-04
E · Potential for more than minimal harm
2023-01-26
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-02-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-03
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 2025-06-20
D · Potential for more than minimal harm
2025-06-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-20
E · Potential for more than minimal harm
2024-04-26
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 2024-05-09
D · Potential for more than minimal harm
2024-01-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-01
G · Actual harm
2023-05-15
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 2023-06-05
D · Potential for more than minimal harm
2023-01-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-26
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 2023-02-09
D · Potential for more than minimal harm
2023-01-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-26
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 2023-02-09
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
Hornbecker, Michael
Corporate Director · Individual
Pogas, George
Corporate Officer · Individual
Trilogy Healthcare Of Logansport LLC
Operational/Managerial Control · Organization
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#2
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Miller's Merry Manor
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5-star overall rating with 4-star inspections with 2 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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