Cycle 1
Health 2025-03-21 · Fire 2025-03-21
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Chesterton, IN
Addison Pointe Health & Rehabilitation Center
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
780 Dickinson Road, Chesterton, IN
(219) 921-2200
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
100
Certified beds
Average residents
94
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
2012-12-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 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
0.70
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.54
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
3.01
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.40
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
24%
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
4,716
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9919
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.27% · Performance 24.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.04
Baseline 7.97% · Performance 5.43% · Measure score 8.04 · Achievement 8.04 · Improvement 8.03
Total nurse turnover
7.51
Baseline 46.74% · Performance 32.99% · Measure score 7.51 · Achievement 7.51 · Improvement 5.78
Adjusted total nurse staffing
0
Baseline 2.99 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 332 · Observed rate 11.14% · Lower 95% interval 8.77% |
| Discharge to community | 68.36% |
50.57%
17.8 pts better
|
Better than the National Rate · Eligible stays 342 · Observed rate 63.16% · Lower 95% interval 63.28% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.58% |
95.27%
4.3 pts better
|
Numerator 239 · Denominator 240 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 240 |
| Discharge self-care score | 63.43% |
53.69%
9.7 pts better
|
Numerator 85 · Denominator 134 |
| Discharge mobility score | 65.67% |
50.94%
14.7 pts better
|
Numerator 88 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 0.83% |
2.29%
1.5 pts better
|
Numerator 2 · Denominator 240 · Adjusted rate 0.81% |
| Healthcare-associated infections requiring hospitalization | 5.43% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 221 · Observed rate 3.62% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 8.72% |
8.2%
0.5 pts better
|
Numerator 13 · Denominator 149 |
| Staff flu vaccination coverage | 13.51% |
42%
28.5 pts worse
|
Numerator 25 · Denominator 185 |
| Discharge function score | 72.39% |
56.45%
15.9 pts better
|
Numerator 97 · Denominator 134 |
| Transfer of health information to provider | 96.03% |
95.95%
0.1 pts better
|
Numerator 121 · Denominator 126 |
| Transfer of health information to patient | 89.36% |
96.28%
6.9 pts worse
|
Numerator 84 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 4.24% |
25.2%
21 pts worse
|
Numerator 5 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.6
1.1 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
93.6%
4.2 pts worse
|
93.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 94.5% · Q3 90.7% · Q4 79.5% · 4Q avg 89.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.4%
3.3 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.8%
0.8 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.1% · Q3 6.7% · Q4 3.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.8% |
24.6%
6.8 pts better
|
11.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 18.5% · Q3 20.6% · Q4 19.7% · 4Q avg 17.8% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.6%
1.7 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.9% · Q3 2.8% · Q4 5.6% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
23.5%
6.4 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 17.6% · Q3 14.1% · Q4 18.1% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
14.8%
6.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.0% · Q3 6.1% · Q4 8.8% · 4Q avg 8.1% · 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 | 4.9% |
13.3%
8.4 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.0% · Q3 3.7% · Q4 3.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
11.7%
8.6 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.6% · Q3 1.5% · Q4 4.5% · 4Q avg 3.1% · 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 | 1.0% |
1.2%
0.2 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
24.2%
11 pts better
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 8.3% · Q3 15.3% · Q4 25.7% · 4Q avg 13.2% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.1%
0.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.5% · Q3 4.8% · Q4 3.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.2% |
81.6%
64.4 pts worse
|
81.7%
64.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 21.5% · Q3 16.4% · Q4 10.0% · 4Q avg 17.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
10.5%
3.3 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 13.5% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 2.7% · Q4 1.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 19.1% |
79.0%
59.9 pts worse
|
79.7%
60.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 19.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
22.4%
5.5 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 26.5% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-01-13 · Fire 2023-01-13
13 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-03-21
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-15
E · Potential for more than minimal harm
2024-02-23
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-03-30
E · Potential for more than minimal harm
2024-02-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-30
E · Potential for more than minimal harm
2024-02-23
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-03-30
E · Potential for more than minimal harm
2024-02-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-30
E · Potential for more than minimal harm
2023-01-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-08
C · Minimal harm
2023-01-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-08
C · Minimal harm
2023-01-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-08
Inspection history
Recent health citations
G · Actual harm
2025-03-21
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 2024-10-16
E · Potential for more than minimal harm
2025-03-21
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 2025-04-11
D · Potential for more than minimal harm
2025-03-21
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 2025-04-11
D · Potential for more than minimal harm
2025-03-21
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 2025-04-11
D · Potential for more than minimal harm
2025-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2024-07-31
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-02-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-23
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-23
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 2024-03-16
D · Potential for more than minimal harm
2023-09-18
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 2023-10-09
E · Potential for more than minimal harm
2023-08-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-01-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
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 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-06
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Dobben, Steven
W-2 Managing Employee · Individual
Friend, Jayna
Operational/Managerial Control · Individual
Friend, Jayna
Corporate Officer · Individual
Friend, Jayna
W-2 Managing Employee · Individual
Grindstaff, Aaron
W-2 Managing Employee · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Warren, Seth
Corporate Officer · Individual
Warren, Seth
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Chesterton Manor
Chesterton, IN
1-star overall rating with 2-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Ignite Medical Resort Chesterton
Chesterton, IN
1-star overall rating with 1-star inspections with 37 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Valparaiso
Valparaiso, IN
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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