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McGivney Health Care Center

2907 East Smoky Row, Carmel, IN 46033 · Hamilton County · (317) 846-0265

37 certified beds, about 34 residents a day · Non profit - Corporation · Medicare and Medicaid since 2017

Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
3 of 5
Staffing
1 of 5
CMS note: This facility reported a high number of days without a registered nurse onsite.
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 155855 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on August 26, 2025, inspectors cited 13 health deficiencies (the Indiana average is 7.2, the national average 9.2).

Of 43 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $8,189 in the last three years; the largest was $8,189, and the latest is dated September 22, 2023.

Nurses and nurse aides worked 2.91 hours per resident per day, against 3.69 across Indiana and 3.86 nationally. Registered nurses accounted for 0.13 of those hours.

20.0% of nursing staff left within the year CMS measured (Indiana average 45.9%).

CMS links it to Witham Memorial Hospital, an affiliated group of 5 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
36D
4E
2F
Potential for minimal harm
0A
0B
0C
August 26, 2025Standard inspection · 13 citations
  1. 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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for advanced directive was accurate for 1 of 1 resident reviewed for advanced directives. (Resident 30)
  2. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications which were ordered as needed (prn) had a 14 day stop date and baseline Abnormal Involuntary Movement Scale (AIMS) assessments were completed for 2 of 5 residents reviewed for unnecessary medications. (Resident 6 and 30)
  3. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure a resident and the resident's representative was provided the written transfer and bed hold notices for 1 of 1 resident reviewed for hospitalization. (Resident 5)
  4. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was updated when new diagnoses and antipsychotic medications were added for 2 of 2 residents reviewed for PASARR. (Resident 30 and 3)
  5. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were developed to address the resident's medical needs for 2 of 14 residents reviewed for comprehensive care plans. (Resident 12 and 22)
  6. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were reviewed and updated after Minimum Data Set (MDS) assessments were completed for 2 of 14 residents reviewed for care planning. (Resident 4 and 6)
  7. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 16, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure daily weights were obtained according to the physician's order and to assess and treat a resident for constipation for 2 of 2 residents reviewed for quality of care. (Resident 31 and 22)
  8. 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.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 16, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were aware of who was responsible to complete catheter care and to document catheter care was provided for 1 of 2 residents reviewed for urinary catheters. (Resident 12)
  9. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 16, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were obtained for changing and dating oxygen tubing and to ensure humidified water was changed and dated for 2 of 2 residents reviewed for respiratory therapy. (Resident 1 and 12)
  10. 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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight (8) consecutive hours, seven (7) days a week for 1 of 14 days reviewed for RN coverage. (8/22/25)
  11. D
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 15, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure spoiled food was discarded in 1 of 2 dry food storage areas reviewed for food storage. (the basement food storage area)
  12. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 16, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and followed for 2 of 2 residents reviewed for enhanced barrier precautions. (Resident 12 and 31)
  13. D
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    F912 · Environmental · No actual harm, potential for more than minimal harm, isolated · deficient, provider has September 15, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in 1 of 18 rooms. (room [ROOM NUMBER])
October 2, 2024Standard inspection · 5 citations
  1. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 24, 2024
    Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan which addressed constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed for Based on interview and record review, the facility failed to develop a comprehensive care plan which addressed constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed for comprehensive care plans. (Resident 11 and 26)
  2. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 24, 2024
    Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory results for the monitoring and effectiveness of a cholesterol medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 26)
  3. 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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 24, 2024
    Inspectors wroteBased on interview and record review, the facility failed to monitor and document a resident's delusions related to the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 28)
  4. D
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 24, 2024
    Inspectors wroteBased on observation and interview, the facility failed to ensure food was properly stored in a kitchen refrigerator for 1 of 1 kitchen reviewed for food service safety. (the refrigerator)
  5. D
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    F912 · Environmental · No actual harm, potential for more than minimal harm, isolated · Waiver October 24, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in 1 of 18 rooms reviewed for living space. (room [ROOM NUMBER])
September 22, 2023Standard inspection · 25 citations
  1. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received the correct medication for 1 of 1 resident reviewed for a significant medication error. (Resident 20) Resident 20 required an intensive care stay in the hospital for 5 days.
  2. 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.
    F809 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered bedtime snacks each evening. There was a 15-hour time lapse between the supper meal and breakfast. This deficient practice had the potential to affect 35 of 35 residents who resided in the facility.
  3. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on observation, interview and record review, the facility failed to thaw out meat safely and have the sanitizing solution (used to disinfect tables and counters) bucket levels at the recommended range to kill bacteria. This deficient practice had the potential to affect 35 of 35 residents who received food from the kitchen.
  4. E
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the Executive Director (ED) failed to ensure the Director of Nursing (DON) was completing the infection surveillance and antibiotic stewardship for the infection control program, to ensure the facility had policies for infection surveillance and antibiotic stewardship, to ensure policies were reviewed annually, to ensure QAPI (quality assurance and performance improvement) meetings had documentation of items reviewed during the meetings, to ensure the facility was staffed according to the needs listed in the facility assessment and to ensure the facility environment was clean and in good repair.
  5. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to document an annual review of the infection control policies, to ensure multiple use glucometers were clean and to ensure soiled clothing was not thrown on the floor for 1 of 1 residents reviewed for incontinence care (Resident 6).
  6. E
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to establish policies and a program for antibiotic stewardship, to monitor the use of antibiotics including the use of standardized tools for the appropriateness of antibiotics prescribed and to have a system of surveillance for residents with repeated urinary tract infections (UTIs) for 2 of 2 residents reviewed for UTIs. (Resident 186 and 32)
  7. E
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    F882 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) was knowledgeable, had completed the facility infection surveillance and antibiotic stewardship documentation, and was not also the acting Director of Nursing (DON) for 1 of 1 Infection Preventionist reviewed. (The DON)
  8. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a weekly weight gain and a blood sugar outside the call parameters for 2 of 2 residents reviewed for notification of change. (Resident 1 and 12)
  9. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure a significant medication error which resulted in a resident requiring an intensive care stay of 5 days in the hospital was reported to the State Agency for 1 of 1 resident reviewed for reporting. (Resident 20)
  10. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure a new diagnosis of systolic heart failure was included in the MDS (Minimum Data Set) under medical diagnoses for 1 of 1 resident reviewed for assessments. (Resident 32)
  11. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure another PASARR (Preadmission Screening and Resident Review) level I was completed when the resident was prescribed an antipsychotic medication for 1 of 2 residents reviewed for PASARR. (Resident 29)
  12. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a new seizure diagnosis had a care plan for 1 of 1 resident reviewed for care plans. (Resident 22)
  13. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to document and investigate a fall with a major injury for 1 of 4 residents reviewed for falls. (Resident 186)
  14. 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.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident being treated for a urinary tract infection was provided timely incontenent care and was free from wearing two incontinent briefs, failed to obtain a culture and sensitivity after a urinalysis, and failed to prevent a recurrent urinary tract infection for 2 of 3 residents reviewed for urinary tract infections. (Resident 6 and 32)
  15. D
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on observation, record review and interview, the facility failed to ensure there was 24 hours of CNA (Certified Nursing Assistant) coverage during the day and evening shift according to the facility assessment, failed to ensure staff were able to complete documentation on the Medication Administration Record (MAR), and failed to ensure a resident was provided timely incontinent care for 8 shifts and 2 of 2 residents reviewed for sufficient staffing. (5/28/23 day shift, 5/27/23 evening shift, 5/21/23 evening shift, 5/7/23 evening shift, 5/6/23 day and evening shift, and 4/30/23 day and evening shift, and Residents 28 and 6)
  16. 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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was in the facility for 8 hours each day during a 24-hour period for 27 days of the third quarter reviewed for sufficient staffing. (April 1, 2, 7, 8, 9, 15, 16, 22, 29, and 30, May 6, 7, 13, 14, 20, 21, 27, 28, and 29, June 3, 4, 10, 11, 17, 18, 24 and 25, 2023).
  17. D
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on record review and interview, the facility failed to ensure performance reviews were completed for nurse aides at least every 12 months for 5 of 5 CNAs (Certified Nursing Assistants) reviewed for employee records. (CNA 14, CNA 15, CNA 16, CNA 17, and CNA 10)
  18. D
    Post nurse staffing information every day.
    F732 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on observation, interview and record review, the facility failed to post nurse staffing information in an area which could be clearly seen for 35 of 35 residents and visitors reviewed for nurse staffing.
  19. 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure by mouth (PO) medications, injectable medications and eye drops were stored separately, medications and food were not stored together, medications were labeled when opened and glucometers were stored in a separate bag for 2 of 2 medication carts reviewed and 1 of 1 medication rooms reviewed. (long hall cart, short hall cart and the medication room)
  20. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Administration Records (MARs) were documented completely to identify if the residents did or did not receive the prescribed medication for 2 of 2 residents reviewed for medication administration documentation. (Residents 6 and 28)
  21. D
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Review (QAPI) committee had documentation of quarterly meetings, documentation of problem areas identified, documentation of staff feedback regarding identified problems and documentation if the problems had improved or worsened.
  22. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received the influenza vaccination after consenting to be vaccinated for 1 of 5 residents reviewed for infection control. (Resident 26)
  23. 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.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on record review and interview, the facility failed to ensure a facility employee had documentation of receiving the Covid-19 vaccination or had obtained an exemption for the vaccine for 1 of 3 employees reviewed for Covid-19 vaccinations. (Activity Director)
  24. D
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    F912 · Environmental · No actual harm, potential for more than minimal harm, isolated · Waiver
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in 1 of 18 rooms. (room [ROOM NUMBER])
  25. D
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 27, 2023
    Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms and the dining room were clean, painted, and free of debris and dirt for 4 of 36 rooms and 1 of 1 dining room reviewed for environment. (room [ROOM NUMBER], 1, 11, 13, and dining room)

Fire safety inspections

17 fire safety citations on file: 4 on August 26, 2025, 7 on October 2, 2024, 6 on September 22, 2023.

Every fire safety citation17 citations
  1. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · August 26, 2025 · Corrected (the home has a date of correction)
  2. F
    Ensure that testing and maintenance of electrical equipment is performed.
    K 921 · August 26, 2025 · Corrected (the home has a date of correction)
  3. E
    Install corridor and hallway doors that block smoke.
    K 363 · August 26, 2025 · Corrected (the home has a date of correction)
  4. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · August 26, 2025 · Corrected (the home has a date of correction)
  5. F
    Have simulated fire drills held at unexpected times.
    K 712 · October 2, 2024 · Corrected (the home has a date of correction)
  6. E
    Install an approved automatic sprinkler system.
    K 351 · October 2, 2024 · Corrected (the home has a date of correction)
  7. E
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · October 2, 2024 · Corrected (the home has a date of correction)
  8. E
    Install corridor and hallway doors that block smoke.
    K 363 · October 2, 2024 · Corrected (the home has a date of correction)
  9. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · October 2, 2024 · Corrected (the home has a date of correction)
  10. C
    Implement emergency and standby power systems.
    E 41 · October 2, 2024 · Corrected (the home has a date of correction)
  11. C
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · October 2, 2024 · Corrected (the home has a date of correction)
  12. 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.
    K 222 · September 22, 2023 · Corrected (the home has a date of correction)
  13. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · September 22, 2023 · Corrected (the home has a date of correction)
  14. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · September 22, 2023 · Corrected (the home has a date of correction)
  15. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · September 22, 2023 · Corrected (the home has a date of correction)
  16. E
    Install an approved automatic sprinkler system.
    K 351 · September 22, 2023 · Corrected (the home has a date of correction)
  17. E
    Ensure proper usage of power strips and extension cords.
    K 920 · September 22, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
September 22, 2023Fine $8,189
September 22, 2023Payment Denial 8 days from October 20, 2023

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIndianaUnited States
All nursing staff (RN, LPN and aides)2.913.693.86
Registered nurses0.130.670.69
All nursing staff on weekends2.913.253.42
Nurse aides2.06
Licensed practical nurses0.72
Nursing staff turnover (share who left in a year)20.0%45.9%45.8%
Registered nurse turnovernot reported40.3%42.9%
Administrators who leftnot reported

CMS expects 3.74 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 2.90 on weekdays and 2.91 on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 16.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.72 in April to June 2025 to 2.91 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20262.910.132.902.91 16.8%51 of 9034
Oct to Dec 20252.390.082.382.41 20.4%66 of 9235
Jul to Sep 20253.090.233.382.35 3.7%4 of 9234
Apr to Jun 20253.720.243.933.20 12.4%2 of 9133
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Indiana, Jan to Mar 20263.630.623.803.193.4%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Indiana

JobMedianMiddle halfEmployed
Indiana, all employers
CNAs (nursing assistants)$18.43$17.80 to $21.3633,640
LPNs and LVNs$31.60$29.35 to $35.3014,480
Registered nurses$40.14$37.86 to $48.2868,980
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For McGivney Health Care Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIndianaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
27.511.013.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.71.11.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
6.63.93.2
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
11.511.914.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.13.64.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
33.313.615.4

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for McGivney Health Care Center's Medicare short-stay residents. How to read these, and what Medicare pays for.

CMS reports none of these results for this home: The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: WITHAM MEMORIAL HOSPITAL. CMS links this home to Witham Memorial Hospital, a group of 5 nursing homes averaging 1.6 stars overall.

NameRoleTypeShareSince
Witham Memorial Hospital5% or greater direct ownership interestOrganization100%04/01/2015
Bayston, BrettCorporate directorIndividual01/01/2023
Brand, JohnCorporate directorIndividual01/01/2015
Castetter, AndreaCorporate directorIndividual01/01/2023
Compton, JohnCorporate directorIndividual07/01/2015
Funk, JamesCorporate directorIndividual07/01/2011
Hawkins, ClaudeCorporate directorIndividual09/01/2013
Hornbecker, MichaelCorporate directorIndividual01/01/2024
Patrick, LoriCorporate directorIndividual07/01/2022
Reagan, JulieCorporate directorIndividual02/21/2025
Schmits, FredCorporate directorIndividual07/01/2015
Braverman, KellyCorporate officerIndividual12/01/2021
Emminger, DeborahCorporate officerIndividual07/01/2024
Sellers, DanielCorporate officerIndividual06/24/2024
Gibault Care, Inc.Operational/managerial controlOrganization04/01/2015
Banks, JoeOperational/managerial controlIndividual06/27/2024
Shera, RandallOperational/managerial controlIndividual04/02/2018
Banks, JoeAdp of the SNFIndividual12/08/2025
Shera, RandallAdp of the SNFIndividual12/08/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. When is the care plan meeting, and can family attend it?Inspectors cited 8 problems in this area, most recently on August 26, 2025: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed."
  2. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 6 problems in this area, most recently on August 26, 2025: "Provide and implement an infection prevention and control program."
  3. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 5 problems in this area, most recently on August 26, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  4. How many nurses and aides work each shift, nights and weekends included?Inspectors cited 5 problems in this area, most recently on August 26, 2025: "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."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.91 hours per resident per day, below the Indiana average of 3.25.

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Common questions

What is McGivney Health Care Center's Medicare star rating?
CMS rates McGivney Health Care Center 2 out of 5 stars overall, with 3 for health inspections, 1 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did McGivney Health Care Center get at its last inspection?
13 health deficiencies at the standard inspection on August 26, 2025. The Indiana average is 7.2.
Has McGivney Health Care Center been fined?
Yes. CMS lists 1 fine totaling $8,189 in the last three years.
Does McGivney Health Care Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns McGivney Health Care Center?
CMS lists 19 owners and managers, and links the home to Witham Memorial Hospital. Legal business name: WITHAM MEMORIAL HOSPITAL.

Sources

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