Cycle 1
Health 2025-08-26 · Fire 2025-08-26
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Carmel, IN
Mcgivney Health Care Center
2-star overall rating with 3-star inspections with $8,189 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2907 East Smoky Row, Carmel, IN
(317) 846-0265
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-08-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.23
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
2.32
Nurse aide staffing
Weekend hours
2.35
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
93.6%
0.3 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
95.4%
1.6 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.8%
0.7 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
24.6%
13.6 pts better
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.6%
0.3 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
23.5%
12.1 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 36.0% |
14.8%
21.2 pts worse
|
16.7%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.3% |
13.3%
6 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
11.7%
15.1 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
24.2%
1.3 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.1%
0.8 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-02 · Fire 2024-10-02
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-09-22 · Fire 2023-09-22
25 health deficiencies
Top issue: Infection Control (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-21
F · Potential for more than minimal harm
2025-08-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-11-21
F · Potential for more than minimal harm
2024-10-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-21
C · Minimal harm
2024-10-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-21
C · Minimal harm
2024-10-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-21
F · Potential for more than minimal harm
2023-09-22
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 2023-11-06
F · Potential for more than minimal harm
2023-09-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-06
F · Potential for more than minimal harm
2023-09-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-26
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 2025-09-15
D · Potential for more than minimal harm
2025-08-26
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-26
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-26
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 2025-09-15
D · Potential for more than minimal harm
2025-08-26
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 2025-09-15
D · Potential for more than minimal harm
2025-08-26
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 2025-09-15
D · Potential for more than minimal harm
2025-08-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-26
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 2025-09-16
D · Potential for more than minimal harm
2025-08-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-26
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-26
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 2025-09-15
D · Potential for more than minimal harm
2025-08-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-26
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-09-15
D · Potential for more than minimal harm
2024-10-02
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 2024-10-24
D · Potential for more than minimal harm
2024-10-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-02
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 2024-10-24
D · Potential for more than minimal harm
2024-10-02
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 2024-10-24
D · Potential for more than minimal harm
2024-10-02
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-10-24
G · Actual harm
2023-09-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-22
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-22
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 2023-10-27
E · Potential for more than minimal harm
2023-09-22
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-22
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
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 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-22
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Not marked corrected
D · Potential for more than minimal harm
2023-09-22
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-27
Penalties and ownership
What sits behind the stars
$8,189
2023-09-22
Fine
Fine · fine $8,189
Fine
$0
2023-09-22
Payment Denial
Payment Denial · denial start 2023-10-20 · 8 days
8 day denial
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Banks, Joe
Operational/Managerial Control · Individual
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Compton, John
Corporate Director · Individual
Emminger, Deborah
Corporate Officer · Individual
Funk, James
Corporate Director · Individual
Gibault Care, Inc.
Operational/Managerial Control · Organization
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Patrick, Lori
Corporate Director · Individual
Reagan, Julie
Corporate Director · Individual
Schmits, Fred
Corporate Director · Individual
Sellers, Daniel
Corporate Officer · Individual
Shera, Randall
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Restoracy Of Carmel
Carmel, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Bridgewater Healthcare Center
Carmel, IN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Carmel Health & Living Community
Carmel, IN
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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