McGivney Health Care Center
2907 East Smoky Row, Carmel, IN 46033
McGivney Health Care Center is a nursing home in Carmel, Indiana. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionAugust 26, 2025 (1 year ago)
- Health citations since September 22, 202344 (Indiana average 23)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of October 8, 2026
Ownership
CMS lists this home under a new chain.
Health inspection on August 21, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0628. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 8, 2026.
CMS has cited this home for F0628 2 times since 2025.
CMS update of April 29, 2026
Staffing
Total nurse staffing reported to CMS went from 3.1 to 2.4 hours per resident per day.
CMS update of March 25, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Staffing
Total nurse staffing reported to CMS went from 3.7 to 3.1 hours per resident per day.
Health inspection on August 26, 2025
13 citationsCMS lists this as a standard inspection.
Show the 13 citations
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 15, 2025.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on September 19, 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 15, 2025.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on September 15, 2025.
CMS has cited this home for F0644 2 times since 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 15, 2025.
CMS has cited this home for F0656 3 times since 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 15, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 16, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on September 16, 2025.
CMS has cited this home for F0690 2 times since 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 16, 2025.
Citation F0727. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 15, 2025.
CMS has cited this home for F0727 2 times since 2023.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 15, 2025.
CMS has cited this home for F0812 3 times since 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 16, 2025.
CMS has cited this home for F0880 2 times since 2023.
Citation F0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
CMS lists it as corrected on September 15, 2025.
CMS has cited this home for F0912 3 times since 2023.
Fire safety inspection on August 26, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 21, 2025.
CMS has cited this home for K0918 2 times since 2024.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on November 21, 2025.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on November 21, 2025.
CMS has cited this home for K0363 2 times since 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 21, 2025.
CMS has cited this home for K0321 2 times since 2023.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of March 26, 2025
Fine
CMS changed the fine from September 22, 2023 from $8,018 to $8,189.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on October 2, 2024
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 24, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on October 24, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 24, 2024.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 24, 2024.
Citation F0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
CMS lists it as corrected on October 24, 2024.
Fire safety inspection on October 2, 2024
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 21, 2024.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on November 21, 2024.
CMS has cited this home for K0351 2 times since 2023.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on November 21, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 6, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on November 21, 2024.
Citation E0041. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on November 21, 2024.
Citation K0918. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 21, 2024.
CMS update of September 26, 2024
Fine
CMS changed the fine from September 22, 2023 from $12,335 to $8,018.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.2 to 2.9 hours per resident per day.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on September 22, 2023
25 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
29 of 507 Indiana homes (6%) got a citation at the actual harm level in 2023.
Show the 25 citations
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on October 27, 2023.
Citation F0809. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on October 27, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 27, 2023.
Citation F0835. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on October 27, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 27, 2023.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on October 27, 2023.
Citation F0882. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on October 27, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 27, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 27, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 27, 2023.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on October 27, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 27, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 27, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on October 27, 2023.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 27, 2023.
Citation F0727. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 27, 2023.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on October 27, 2023.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on October 27, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 27, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on October 27, 2023.
Citation F0867. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on October 27, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on October 27, 2023.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 27, 2023.
Citation F0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on October 27, 2023.
Fire safety inspection on September 22, 2023
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 6, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on November 6, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 6, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 6, 2023.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on November 6, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 6, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (317) 846-0265
- Last standard health inspection
- August 26, 2025 (1 year ago)
- Certified beds
- 37
- Residents per day, on average
- 33.2
- Ownership type
- Non profit - Corporation
- Legal business name
- Witham Memorial Hospital
- Chain
- Witham Memorial Hospital
- Takes part in
- Medicare and Medicaid
More health citations than the Indiana average (44 vs 23).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- WITHAM MEMORIAL HOSPITAL5% or greater direct ownership interest · 100% · since 04/01/2015
- GIBAULT CARE, INC.Operational/managerial control · not applicable · since 04/01/2015
- BANKS, JOEOperational/managerial control · not applicable · since 06/27/2024
- SHERA, RANDALLOperational/managerial control · not applicable · since 04/02/2018
Questions
When was McGivney Health Care Center last inspected?
CMS lists August 26, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does McGivney Health Care Center have?
CMS lists 44 health citations since September 22, 2023. CMS also calls these deficiencies.
Has McGivney Health Care Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of McGivney Health Care Center?
Its CMS overall star rating is 1 of 5.
Is McGivney Health Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.