01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-26 | 13 | 2025-08-26 | 4 |
| Cycle 2 | 2024-10-02 | 5 | 2024-10-02 | 7 |
| Cycle 3 | 2023-09-22 | 25 | 2023-09-22 | 6 |
CMS CCN 1558552026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Mcgivney Health Care Center
2907 East Smoky Row · Carmel, IN 46033 · Hamilton County
Certified beds37CMS provider file
Recent citation rows60current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
60 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-08-26 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0605Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2025-09-192025-08-26 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-09-162025-08-26 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-09-162025-08-26 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-09-162025-08-26 · HEALTHF0727Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-09-152025-08-26 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-09-162025-08-26 · HEALTHF0912Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Correction field: Deficient, Provider has plan of correction · 2025-09-152025-08-26 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-11-212025-08-26 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-11-212025-08-26 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-11-212025-08-26 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-11-212024-10-02 · FIREE0041Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2024-11-212024-10-02 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-10-242024-10-02 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-10-242024-10-02 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-10-242024-10-02 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-10-242024-10-02 · HEALTHF0912Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Correction field: Waiver has been granted · 2024-10-242024-10-02 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-11-2103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-09-22 | Fine | $8,189 | 0 |
| 2023-09-22 | Payment Denial | $0 | 8 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- WITHAM MEMORIAL HOSPITALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2015
- BAYSTON, BRETTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- BRAND, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- CASTETTER, ANDREAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- COMPTON, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2015
- FUNK, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2011
- HAWKINS, CLAUDEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2013
- HORNBECKER, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- PATRICK, LORIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2022
- REAGAN, JULIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/21/2025
- SCHMITS, FREDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2015
- BRAVERMAN, KELLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2021
- EMMINGER, DEBORAHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2024
- SELLERS, DANIELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/24/2024
- GIBAULT CARE, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2015
- BANKS, JOEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/27/2024
- SHERA, RANDALLIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/02/2018
- BANKS, JOEIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/08/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.91per resident day
RN hours0.13per resident day
Weekend nurse hours2.91per resident day
Staff turnover20.0%CMS reported field
06 / LOCAL RECORDS
Open the Carmel ledger →Other published facilities nearby
Barrington Of Carmel, The8 beds · CMS overall 5/55 citation rowsBridgewater Healthcare Center120 beds · CMS overall 5/530 citation rowsCarmel Health & Living Community188 beds · CMS overall 2/547 citation rowsMajestic Care Of Carmel94 beds · CMS overall 2/538 citation rowsRestoracy Of Carmel72 beds · CMS overall 4/541 citation rowsRetreat At The Stratford, The18 beds · CMS overall 4/539 citation rowsWellbrooke Of Carmel74 beds · CMS overall 3/534 citation rows