Federal inspection record · CMS data as of October 1, 2026
Mcgivney Health Care Center
2907 East Smoky Row, Carmel, IN · (317) 846-0265
- Certified beds
- 37
- Residents per day
- 33
- Ownership
- Non-Profit
- Chain
- Witham Memorial Hospital
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- August 16, 2017
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Indiana.
-
Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Indiana homes
Mcgivney Health Care Center carries 55 inspection points. That is fewer than 28% of Indiana's 504 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Indiana: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–24 pts
- 3★ 24–42 pts
- 2★ 42–72 pts
- 1★ over 72 pts
Bars show every rated home in Indiana by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
44 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Ensure that residents are free from significant medication errors.
Everything else, by area of care
Resident Assessment and Care Planning8D
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control6E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Implement a program that monitors antibiotic use.
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
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.
Quality of Life and Care5D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Nursing and Physician Services5D
- D
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.
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
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.
- D
Observe each nurse aide's job performance and give regular training.
- D
Post nurse staffing information every day.
Resident Rights4F
- F
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
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.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Nutrition and Dietary4F
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental4D
- D
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- D
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- D
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Pharmacy Service3D
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
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.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration2E
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspection history
2025-08-26
14 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2024-10-02
5 health deficiencies · 7 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2023-09-22
25 health deficiencies · 6 fire-safety deficiencies
Top issue: Infection Control (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 53 min of nursing staff time a day, 6 min of it from a registered nurse.
This home
2 h 53 min
Indiana average
3 h 44 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 23% of nursing staff and 0% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine4.7 pts worse | 89.0% | 93.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2 pts better | 97.1% | 95.1% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury3.6 pts worse | 7.4% | 3.8% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms15.6 pts better | 9.9% | 25.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.6 pts worse | 5.9% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication11 pts better | 12.5% | 23.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication22.8 pts worse | 36.5% | 13.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.3 pts worse | 12.4% | 11.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased16.9 pts worse | 27.7% | 10.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.4 pts worse | 1.5% | 1.1% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1 pts worse | 23.4% | 22.4% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.1 pts better | 2.4% | 3.5% | 4.5% |
·
Who owns and runs it
19 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Witham Memorial Hospital | 5% Or Greater Direct Ownership Interest · Organization | 100% | 29 facilities |
| Banks, Joe | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Banks, Joe | Adp Of The SNF · Individual | 0% | 1 facilities |
| Bayston, Brett | Corporate Director · Individual | 0% | 29 facilities |
| Brand, John | Corporate Director · Individual | 0% | 29 facilities |
| Braverman, Kelly | Corporate Officer · Individual | 0% | 29 facilities |
| Castetter, Andrea | Corporate Director · Individual | 0% | 29 facilities |
| Compton, John | Corporate Director · Individual | 0% | 1 facilities |
| Emminger, Deborah | Corporate Officer · Individual | 0% | 1 facilities |
| Funk, James | Corporate Director · Individual | 0% | 1 facilities |
| Gibault Care, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Hawkins, Claude | Corporate Director · Individual | 0% | 29 facilities |
| Hornbecker, Michael | Corporate Director · Individual | 0% | 29 facilities |
| Patrick, Lori | Corporate Director · Individual | 0% | 1 facilities |
| Reagan, Julie | Corporate Director · Individual | 0% | 28 facilities |
| Schmits, Fred | Corporate Director · Individual | 0% | 1 facilities |
| Sellers, Daniel | Corporate Officer · Individual | 0% | 29 facilities |
| Shera, Randall | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Shera, Randall | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
17 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke8E
- E
Install corridor and hallway doors that block smoke.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install an approved automatic sprinkler system.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install an approved automatic sprinkler system.
Gas, Vacuum, and Electrical Systems4F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure that testing and maintenance of electrical equipment is performed.
- C
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
Miscellaneous2F
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Egress2F
- F
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.
- F
Install emergency lighting that can last at least 1 1/2 hours.
Emergency Preparedness1C
- C
Implement emergency and standby power systems.
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Other homes nearby
-
Restoracy Of Carmel
Carmel, IN
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 24 min
- Fines
- $0
-
Bridgewater Healthcare Center
Carmel, IN · Communicare Health
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 28 min
- Fines
- $0
-
Carmel Health & Living Community
Carmel, IN · Cardon & Associates
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 43 min
- Fines
- $9,110