Cycle 1
Health 2025-08-18 · Fire 2025-08-18
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Munster, IN
Rehabilitation Center At Hartsfield Village
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
503 Otis R Bowen Dr, Munster, IN
(219) 934-0590
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-03-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.88
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
5.07
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.60
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,675
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.83
Baseline 22.85% · Performance 22.07% · Measure score 0.83 · Achievement 0 · Improvement 0.83
Healthcare-associated infections
0
Baseline 5.84% · Performance 8.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.14
Baseline 46.15% · Performance 38.58% · Measure score 6.14 · Achievement 6.14 · Improvement 3.05
Adjusted total nurse staffing
3.44
Baseline 4.06 hours · Performance 4.06 hours · Measure score 3.44 · Achievement 3.44 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.78% |
10.72%
2.1 pts worse
|
Worse than the National Rate · Eligible stays 1123 · Observed rate 13.98% · Lower 95% interval 11.43% |
| Discharge to community | 63.3% |
50.57%
12.7 pts better
|
Better than the National Rate · Eligible stays 1210 · Observed rate 54.55% · Lower 95% interval 59.06% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.99% |
95.27%
2.7 pts better
|
Numerator 634 · Denominator 647 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 5 · Denominator 647 |
| Discharge self-care score | 59.13% |
53.69%
5.4 pts better
|
Numerator 246 · Denominator 416 |
| Discharge mobility score | 53.13% |
50.94%
2.2 pts better
|
Numerator 221 · Denominator 416 |
| Pressure ulcers or injuries, new or worsened | 1.08% |
2.29%
1.2 pts better
|
Numerator 7 · Denominator 647 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 8.43% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 740 · Observed rate 9.05% · Lower 95% interval 6.66% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 200 |
| Staff flu vaccination coverage | 77.9% |
42%
35.9 pts better
|
Numerator 282 · Denominator 362 |
| Discharge function score | 58.65% |
56.45%
2.2 pts better
|
Numerator 244 · Denominator 416 |
| Transfer of health information to provider | 99.26% |
95.95%
3.3 pts better
|
Numerator 536 · Denominator 540 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 82 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 18.63% |
25.2%
6.6 pts worse
|
Numerator 60 · Denominator 322 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 100.0% |
| 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 | 3.0% |
3.8%
0.8 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.6%
3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
23.5%
3 pts better
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.8%
14.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 44.4% |
11.7%
32.7 pts worse
|
14.9%
29.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 44.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.4%
0.7 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.2%
2.1 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
24.2%
2.1 pts better
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.1%
0.2 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
81.6%
17.1 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.4% · Q3 98.0% · Q4 98.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
10.5%
0.8 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 1.2% · Q4 0.6% · 4Q avg 1.1% · 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 | 28.4% |
22.4%
6 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 27.8% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-03 · Fire 2024-06-03
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-13 · Fire 2023-03-13
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-16
F · Potential for more than minimal harm
2024-06-03
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 2024-07-12
D · Potential for more than minimal harm
2024-06-03
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-24
F · Potential for more than minimal harm
2023-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-18
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 2025-09-17
E · Potential for more than minimal harm
2025-08-18
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 2025-09-17
D · Potential for more than minimal harm
2025-08-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-18
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 2025-09-17
D · Potential for more than minimal harm
2025-08-18
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 2025-09-17
D · Potential for more than minimal harm
2025-08-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-17
D · Potential for more than minimal harm
2024-09-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-09-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-06-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-03
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 2024-06-21
D · Potential for more than minimal harm
2024-06-03
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 2024-06-21
D · Potential for more than minimal harm
2024-06-03
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 2024-06-21
D · Potential for more than minimal harm
2024-06-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-03
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 2024-06-21
D · Potential for more than minimal harm
2024-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-03-20
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 2024-04-11
D · Potential for more than minimal harm
2024-03-20
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-04-11
E · Potential for more than minimal harm
2023-03-13
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 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
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 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
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 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-13
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 2023-03-31
D · Potential for more than minimal harm
2023-03-13
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 2023-03-31
D · Potential for more than minimal harm
2023-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
Community Foundation Of Northwest Indiana, Inc
5% Or Greater Direct Ownership Interest · Organization
Darrow, Leslie
Corporate Director · Individual
Darrow, Leslie
W-2 Managing Employee · Individual
Dunn, John
Corporate Director · Individual
Fesko, Donald
Corporate Officer · Individual
Fesko, Frankie
Corporate Director · Individual
Schumacher, Richard
Corporate Director · Individual
Schumacher, Richard
Corporate Officer · Individual
Torrenga, Donald
Corporate Director · Individual
Torrenga, Donald
Corporate Officer · Individual
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1-star overall rating with 1-star inspections with $23,257 in total fines with 25 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Tri-State Village Nrsg & Rhb
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1-star overall rating with 2-star inspections with $208,847 in total fines with 18 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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