MCGIVNEY HEALTH CARE CENTER
Open-data reference.
MCGIVNEY HEALTH CARE CENTER is a non profit - corporation facility in CARMEL, IN with 37 certified beds and a 2-star overall CMS rating. The facility has 42 deficiency records on file. Total penalties: $8K.
2907 EAST SMOKY ROW, CARMEL, IN 46033
Phone: 3178460265
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 155855
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 37
- Residents
- 34
- In Hospital
- No
- County
- Hamilton
- Last Inspection
- Aug 26, 2025
Staffing Data
- RN Hours
- 0.23 (nat'l avg: 0.68)
- LPN Hours
- 0.55
- CNA Hours
- 2.32
- Total Nursing Hours
- 3.09 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 44.4%
What the CMS Record Reveals About MCGIVNEY HEALTH CARE CENTER
MCGIVNEY HEALTH CARE CENTER operates 37 certified beds in CARMEL, IN with approximately 34 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (1★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 42 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $8K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.09 total nursing hours per resident day (national average 3.89), with RN coverage at 0.23 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, MCGIVNEY HEALTH CARE CENTER falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 44.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (42 most recent)
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category: Environmental Deficiencies
Corrected: Oct 24, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 24, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 24, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Oct 24, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 24, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Oct 27, 2023
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category: Environmental Deficiencies
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.
Category: Infection Control Deficiencies
Corrected: Oct 27, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Oct 27, 2023
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category: Infection Control Deficiencies
Corrected: Oct 27, 2023
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Oct 27, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 27, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Oct 27, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 27, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Oct 27, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 27, 2023
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 27, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 27, 2023
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Oct 27, 2023
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 27, 2023
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 27, 2023
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 27, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 27, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 27, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 27, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 27, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 27, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 27, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 27, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Oct 27, 2023
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Category: Environmental Deficiencies
Corrected: Oct 31, 2022
Perform COVID19 testing on residents and staff.
Category: Infection Control Deficiencies
Corrected: Oct 31, 2022
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Oct 31, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 31, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Oct 31, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 31, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 31, 2022
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 31, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 31, 2022
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Oct 31, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Oct 31, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Oct 31, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 26.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 11.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.5% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 93.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | N/A | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | N/A | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 11.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 97.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 25.5% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 36.0% | Yes |
Penalty History 1 penalties totaling $8K
| Date | Type | Amount |
|---|---|---|
| Sep 22, 2023 | Fine | $8K |
| Sep 22, 2023 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for MCGIVNEY HEALTH CARE CENTER?
What are the staffing levels at MCGIVNEY HEALTH CARE CENTER?
How many beds does MCGIVNEY HEALTH CARE CENTER have?
Does MCGIVNEY HEALTH CARE CENTER have any deficiencies on record?
Has MCGIVNEY HEALTH CARE CENTER received any fines or penalties?
Who owns MCGIVNEY HEALTH CARE CENTER?
When was MCGIVNEY HEALTH CARE CENTER last inspected?
What quality measures are tracked for MCGIVNEY HEALTH CARE CENTER?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.