| Mcgivney Health Care Center | |
| 2907 East Smoky Row, Carmel, Indiana 46033 | |
| (317) 846-0265 | |
| Name | Mcgivney Health Care Center |
|---|---|
| Location | 2907 East Smoky Row, Carmel, Indiana |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 37 |
| Occupancy Rate | 92.16% |
| Medicare ID (CCN) | 155855 |
| Legal Business Name | Witham Memorial Hospital |
| Ownership Type | Non Profit - Corporation |
| NPI Number | 1629066790 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Witham Memorial Hospital |
| Doing Business As | Mcgivney Health Care Center |
| Address | 2907 E 136th St, Carmel, IN 46033 |
| Phone Number | 317-846-0265 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 2.91 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.13 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.72 | 0.86 |
| Nurse aide hours per resident per day | 2.06 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 2.91 | 3.42 |
| RN hours per resident per day on the weekend | 0.36 | 0.48 |
| Physical therapist hours per resident per day | 0.05 | 0.07 |
| Total nursing staff turnover | 20% | 45.8% |
| Registered nurse turnover | Not available: the staffing data did not meet CMS's criteria for this measure | 42.9% |
| Number of administrators who have left the nursing home | Not available: no valid staffing data was submitted | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 1 |
| Total Amount of Fines in Dollars | $8,189 |
| Number of Payment Denials | 1 |
| Total Number of Penalties | 2 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Aug 26, 2025 | 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, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | 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, Standard inspection | Potential for harm, isolated | Corrected by Sep 19, 2025 |
| Aug 26, 2025 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. F0628, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. F0644, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | 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, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | 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, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Sep 16, 2025 |
| Aug 26, 2025 | 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, Standard inspection | Potential for harm, isolated | Corrected by Sep 16, 2025 |
| Aug 26, 2025 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Sep 16, 2025 |
| Aug 26, 2025 | 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, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Sep 15, 2025 |
| Aug 26, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Sep 16, 2025 |
| Aug 26, 2025 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. F0912, Environmental, Standard inspection | Potential for harm, isolated | Plan of correction |
| Oct 2, 2024 | 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, Standard inspection | Potential for harm, isolated | Corrected by Oct 24, 2024 |
| Oct 2, 2024 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Oct 24, 2024 |
| Oct 2, 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Oct 24, 2024 |
| Oct 2, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Oct 24, 2024 |
| Oct 2, 2024 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. F0912, Environmental, Standard inspection | Potential for harm, isolated | Waiver has been granted |
| Sep 22, 2023 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Standard inspection | Actual harm, isolated | Corrected by Oct 27, 2023 |
| Sep 22, 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. F0809, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. F0835, Administration, Standard inspection | Potential for harm, pattern | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Implement a program that monitors antibiotic use. F0881, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. F0882, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | 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, Standard inspection | Potential for harm, isolated | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Ensure each resident receives an accurate assessment. F0641, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. F0644, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Oct 27, 2023 |
| Sep 22, 2023 | 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, Standard inspection | Potential for harm, isolated | Corrected by Oct 27, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.48 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 5.19 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0.74 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 9.92 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.62 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.71 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Not Available | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | Not Available | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.47 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.97 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Not Available | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 3.12 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.48 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 33.33 | 15.38 |
Carmel Health & Living Community Location: 118 Medical Dr, Carmel, Indiana 46032 Phone: (317) 844-4211 |
Majestic Care of Carmel Location: 12999 N Pennsylvania St, Carmel, Indiana 46032 Phone: (317) 848-2448 |