McGivney Health Care Center

CMS star ratings

Overall★★★★★ 2/5

State avg 3.1

Health inspections★★★★★ 3/5

State avg 2.8

Staffing★★★★★ 1/5

State avg 2.5

Quality measures★★★★★ 3/5

State avg 4.1

Long-stay quality★★★★★ 3/5

Short-stay qualityNot rated

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing: 2.91 (state 3.68 · U.S. 3.86)
Registered nurses (RN): 0.13 (state 0.67 · U.S. 0.69)
Licensed practical nurses: 0.72 (state 0.78 · U.S. 0.86)
Nurse aides: 2.06 (state 2.23 · U.S. 2.32)
Weekend total: 2.91 (state 3.24 · U.S. 3.42)
Nursing staff turnover: 20.0 (state 45.9 · U.S. 45.8)%
RN turnover: —

Inspections

Last standard inspection: August 26, 2025
Health deficiencies (last cycle): 13.0 (state 7.2 · U.S. 9.3)
From complaints: 0
Citations on record (3 years): 43 health · 17 fire safety · includes actual harm

Date	Citation	Severity	Status
2025-08-26	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. F0578 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. F0605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-19
2025-08-26	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. F0628 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. F0644 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-16
2025-08-26	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-16
2025-08-26	Provide safe and appropriate respiratory care for a resident when needed. F0695 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-16
2025-08-26	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. F0727 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2025-08-26	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-16
2025-08-26	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. F0912 · Environmental Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-09-15
2024-10-02	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-10-24
2024-10-02	Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-10-24
2024-10-02	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. F0758 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-10-24
2024-10-02	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-10-24
2024-10-02	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. F0912 · Environmental Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-10-24
2023-09-22	Ensure that residents are free from significant medication errors. F0760 · Pharmacy Service Deficiencies	G Actual harm	Corrected 2023-10-27
2023-09-22	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. F0809 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Administer the facility in a manner that enables it to use its resources effectively and efficiently. F0835 · Administration Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Implement a program that monitors antibiotic use. F0881 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. F0882 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Ensure each resident receives an accurate assessment. F0641 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. F0644 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. F0725 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	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. F0727 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Observe each nurse aide's job performance and give regular training. F0730 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Post nurse staffing information every day. F0732 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867 · Administration Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	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. F0887 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27
2023-09-22	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. F0912 · Environmental Deficiencies	D No actual harm, potential for more than minimal harm	Waiver has been granted
2023-09-22	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. F0921 · Environmental Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-10-27

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

2 penalties in the last three years, including $8,189 in fines.

Date	Type	Amount
2023-09-22	Payment Denial	8 days payment denial
2023-09-22	Fine	$8,189

Ownership & management

Name	Role	Since
Witham Memorial Hospital (organization)	5%+ Direct Ownership Interest · 100%
Banks, Joe (individual)	Administrator · NOT APPLICABLE
Shera, Randall (individual)	Administrator · NOT APPLICABLE
Bayston, Brett (individual)	Corporate Director · NOT APPLICABLE
Brand, John (individual)	Corporate Director · NOT APPLICABLE
Castetter, Andrea (individual)	Corporate Director · NOT APPLICABLE
Compton, John (individual)	Corporate Director · NOT APPLICABLE
Funk, James (individual)	Corporate Director · NOT APPLICABLE
Hawkins, Claude (individual)	Corporate Director · NOT APPLICABLE
Hornbecker, Michael (individual)	Corporate Director · NOT APPLICABLE
Patrick, Lori (individual)	Corporate Director · NOT APPLICABLE
Reagan, Julie (individual)	Corporate Director · NOT APPLICABLE
Schmits, Fred (individual)	Corporate Director · NOT APPLICABLE
Braverman, Kelly (individual)	Corporate Officer · NOT APPLICABLE
Emminger, Deborah (individual)	Corporate Officer · NOT APPLICABLE
Sellers, Daniel (individual)	Corporate Officer · NOT APPLICABLE
Banks, Joe (individual)	Operational/managerial Control · NOT APPLICABLE
Gibault Care, INC. (organization)	Operational/managerial Control · NOT APPLICABLE
Shera, Randall (individual)	Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of McGivney Health Care Center?

McGivney Health Care Center has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.1-star average in Indiana.

How many beds does McGivney Health Care Center have?

It has 37 certified beds and cares for about 34 residents per day.

Has McGivney Health Care Center been fined?

Yes. CMS lists 2 penalties totaling $8,189 in the last three years.

What is the phone number of McGivney Health Care Center?

(317) 846-0265. The facility is located at 2907 East Smoky Row, Carmel, IN 46033.

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Contact & location

Facility details