McGivney Health Care Center
2907 East Smoky Row, Carmel, IN 46033 · Hamilton County · 37 certified beds · avg 34 residents/day · certified since Aug 16, 2017
3/5
Health inspection rating (on-site)
1
Serious findings on record
$8,189
Fines, last 3 years
2.98
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 22, 2023 · F-0760
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 27, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (43)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Sep 22, 2023 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 22, 2023 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Sep 22, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 25 | 1 | G ▲ |
| 2024 | 5 | 0 | D |
| 2025 | 13 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,189, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Sep 22, 2023 | Fine | $8,189 |
| Sep 22, 2023 | Payment Denial | 8 days from Oct 20, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Indiana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.98 | 3.42 | 3.95 | bottom 27% in Indiana; bottom 13% in the U.S. |
| Registered Nurse hours | 0.13 | 0.62 | 0.69 | bottom 1% in Indiana; bottom 1% in the U.S. |
| Weekend total nurse staffing | 2.99 | 3.01 | 3.50 | top 41% in Indiana; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.47 | 0.48 | bottom 37% in Indiana; bottom 44% in the U.S. |
| Total nursing staff turnover (%) | 20.0 | 45.9 | 45.8 | top 1% in Indiana; top 3% in the U.S. |
| RN turnover (%) | 0.0 | 40.4 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.91, RN 0.13, weekend 2.91. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Witham Memorial Hospital | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2015 |
| Banks, Joe | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/27/2024 |
| Banks, Joe | Individual | ADP of the SNF | NOT APPLICABLE | 12/08/2025 |
| Bayston, Brett | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Brand, John | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| Braverman, Kelly | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2021 |
| Castetter, Andrea | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Compton, John | Individual | Corporate Director | NOT APPLICABLE | 07/01/2015 |
| Emminger, Deborah | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2024 |
| Funk, James | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Gibault Care, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2015 |
| Hawkins, Claude | Individual | Corporate Director | NOT APPLICABLE | 09/01/2013 |
| Hornbecker, Michael | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Patrick, Lori | Individual | Corporate Director | NOT APPLICABLE | 07/01/2022 |
| Reagan, Julie | Individual | Corporate Director | NOT APPLICABLE | 02/21/2025 |
| Schmits, Fred | Individual | Corporate Director | NOT APPLICABLE | 07/01/2015 |
| Sellers, Daniel | Individual | Corporate Officer | NOT APPLICABLE | 06/24/2024 |
| Shera, Randall | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/02/2018 |
| Shera, Randall | Individual | ADP of the SNF | NOT APPLICABLE | 12/08/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Restoracy of Carmel | 2.4 mi | Carmel, IN | ★★★★☆ | 3/5 | |
| Bridgewater Healthcare Center | 2.4 mi | Carmel, IN | ★★★★★ | 4/5 | |
| Carmel Health & Living Community | 2.7 mi | Carmel, IN | ★★☆☆☆ | 2/5 | |
| Allisonville Meadows | 3.0 mi | Fishers, IN | ★★★☆☆ | 2/5 | |
| Barrington of Carmel, the | 3.4 mi | Carmel, IN | ★★★★★ | 5/5 | |
| Majestic Care of Carmel | 4.0 mi | Carmel, IN | ★★☆☆☆ | 3/5 | |
| Wellbrooke of Carmel | 4.0 mi | Carmel, IN | ★★★☆☆ | 2/5 | |
| Prairie Lakes Health Campus | 4.7 mi | Noblesville, IN | ★★★★★ | 4/5 | |
| Hamilton Trace of Fishers | 4.7 mi | Fishers, IN | ★★★☆☆ | 2/5 | |
| Waters of Castleton Skilled Nursing Facility, the | 4.9 mi | Indianapolis, IN | ★★☆☆☆ | 1/5 | |
| Clearvista Lake Health Campus | 4.9 mi | Indianapolis, IN | ★★★★☆ | 3/5 | |
| Allison Pointe Healthcare Center | 4.9 mi | Indianapolis, IN | ★★☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 155855.