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

Compare this facility

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

Certified beds

Average residents

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

Changed ownership

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

0.23

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.55

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.09

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

0.77

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.35

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.24

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.22

CMS adjusted RN staffing hours

Adjusted total hours

3.03

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

44%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,003

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

9.08

Composite VBP score used to determine payment impact.

Payment multiplier

0.9808

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Performance 84.85% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.82

Baseline 2.74 hours · Performance 3.44 hours · Measure score 1.82 · Achievement 1.29 · Improvement 1.82

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 28
Staff flu vaccination coverage	28.57%	42% 13.4 pts worse	Numerator 8 · Denominator 28
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.

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 · Q1 100.0% · Q2 97.0% · Q3 90.9% · Q4 88.2% · 4Q avg 93.9%
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 · 4Q avg 97.0%
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 · Q1 3.1% · Q2 6.1% · Q3 3.0% · Q4 5.9% · 4Q avg 4.5% · Used in QM five-star
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 · Q1 18.8% · Q2 6.7% · Q3 9.7% · Q4 8.8% · 4Q avg 11.0%
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 · Q1 0.0% · Q2 9.1% · Q3 6.1% · Q4 5.9% · 4Q avg 5.3%
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 · Q1 12.5% · Q2 12.1% · Q3 9.1% · Q4 11.8% · 4Q avg 11.4%
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 · Q1 43.5% · Q2 40.0% · Q3 28.6% · Q4 31.8% · 4Q avg 36.0% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 7.3% · Used in QM five-star
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 · Q1 38.7% · Q2 29.0% · Q3 25.8% · Q4 14.7% · 4Q avg 26.8% · Used in QM five-star
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 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
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 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
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 · Q1 20.1% · Q2 23.5% · Q3 28.2% · Q4 30.0% · 4Q avg 25.5%
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 · Q1 0.0% · Q2 9.7% · Q3 6.6% · Q4 3.1% · 4Q avg 4.9% · Used in QM five-star

Survey summary

Recent inspection cycles

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)

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