D69

MCGIVNEY HEALTH CARE CENTER

Grade D 69/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
1/5
Health Insp.
2/5
Quality
3/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

37

Ownership

Non profit - Corporation

Total Fines

$8,189

Last Survey

N/A

2907 EAST SMOKY ROW, CARMEL, IN 46033
3178460265

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.22h
LPN
0.54h
CNA
2.28h
Total
3.03h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

WITHAM MEMORIAL HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2015

100%

GIBAULT CARE, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2015

BANKS, JOE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jun 2024

SHERA, RANDALL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2018

BAYSTON, BRETT

IndividualCORPORATE DIRECTORSince Jan 2023

BRAND, JOHN

IndividualCORPORATE DIRECTORSince Jan 2015

CASTETTER, ANDREA

IndividualCORPORATE DIRECTORSince Jan 2023

COMPTON, JOHN

IndividualCORPORATE DIRECTORSince Jul 2015

FUNK, JAMES

IndividualCORPORATE DIRECTORSince Jul 2011

HAWKINS, CLAUDE

IndividualCORPORATE DIRECTORSince Sep 2013

HORNBECKER, MICHAEL

IndividualCORPORATE DIRECTORSince Jan 2024

PATRICK, LORI

IndividualCORPORATE DIRECTORSince Jul 2022

REAGAN, JULIE

IndividualCORPORATE DIRECTORSince Feb 2025

SCHMITS, FRED

IndividualCORPORATE DIRECTORSince Jul 2015

BRAVERMAN, KELLY

IndividualCORPORATE OFFICERSince Dec 2021

EMMINGER, DEBORAH

IndividualCORPORATE OFFICERSince Jul 2024

SELLERS, DANIEL

IndividualCORPORATE OFFICERSince Jun 2024

Penalties & Fines (2)

$8,189total fines
DateTypeDescriptionAmount
Sep 22, 2023Fine$8,189
Sep 22, 2023Payment Denial

Health Inspection Deficiencies (42)

October 2, 2024Health5 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 24, 2024
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Oct 24, 2024
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Oct 24, 2024
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 24, 2024
0912DMinimal harm, Isolated

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Environmental Deficiencies

Corrected Oct 24, 2024
September 22, 2023Health25 deficiencies1 severe
0881EMinimal harm, Pattern

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Oct 27, 2023
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Oct 27, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 27, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 27, 2023
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 27, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 27, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Oct 27, 2023
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Oct 27, 2023
0725DMinimal harm, Isolated

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Oct 27, 2023
0727DMinimal harm, Isolated

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.

Nursing and Physician Services Deficiencies

Corrected Oct 27, 2023
0730DMinimal harm, Isolated

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Oct 27, 2023
0732DMinimal harm, Isolated

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Oct 27, 2023
0760GActual harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Oct 27, 2023
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Oct 27, 2023
0809FMinimal harm, Widespread

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.

Nutrition and Dietary Deficiencies

Corrected Oct 27, 2023
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 27, 2023
0835EMinimal harm, Pattern

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Oct 27, 2023
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 27, 2023
0867DMinimal harm, Isolated

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Oct 27, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 27, 2023
0882EMinimal harm, Pattern

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies

Corrected Oct 27, 2023
0883DMinimal harm, Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Oct 27, 2023
0887DMinimal harm, Isolated

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.

Infection Control Deficiencies

Corrected Oct 27, 2023
0912DMinimal harm, Isolated

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Environmental Deficiencies

0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Oct 27, 2023
July 26, 2022Health12 deficiencies
0578DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Oct 31, 2022
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Oct 31, 2022
0582DMinimal harm, Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Corrected Oct 31, 2022
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 31, 2022
0661DMinimal harm, Isolated

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 31, 2022
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Oct 31, 2022
0700DMinimal harm, Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Corrected Oct 31, 2022
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Oct 31, 2022
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 31, 2022
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Oct 31, 2022
0886FMinimal harm, Widespread

Perform COVID19 testing on residents and staff.

Infection Control Deficiencies

Corrected Oct 31, 2022
0912DMinimal harm, Isolated

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Environmental Deficiencies

Corrected Oct 31, 2022

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Frequently Asked Questions

What is the CareGrader rating for MCGIVNEY HEALTH CARE CENTER?

MCGIVNEY HEALTH CARE CENTER in CARMEL, Indiana has a CareGrader grade of D (Below Average), with a composite score of 68.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for MCGIVNEY HEALTH CARE CENTER?

MCGIVNEY HEALTH CARE CENTER has an overall CMS star rating of 1 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does MCGIVNEY HEALTH CARE CENTER have?

MCGIVNEY HEALTH CARE CENTER has 42 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has MCGIVNEY HEALTH CARE CENTER been fined?

Yes. MCGIVNEY HEALTH CARE CENTER has $8,189 in total fines from CMS enforcement actions across 2 penalties.

How many beds does MCGIVNEY HEALTH CARE CENTER have?

MCGIVNEY HEALTH CARE CENTER has 37 certified beds with approximately 33 current residents (89% occupancy). The facility is located at 2907 EAST SMOKY ROW, CARMEL, Indiana 46033. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.