Velarion Records

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Skilled nursing facility · CMS certification number 155855

MCGIVNEY HEALTH CARE CENTER

CARMEL, Indiana · Medicare and Medicaid

Certified beds, as filed in Care Compare: 37

Finances, as filed

From this facility’s Medicare cost reports on form CMS-2540, each figure with the worksheet, line and column it was read from.

Cost report for 1 January 2024 to 31 December 2024 — a reporting period of 365 days, on form CMS-2540-10, settled, processed by CMS on 29 August 2025.

Revenue and expenses, fiscal year 2024
FigureAs filedWhere it comes from
Total patient revenue$3,897,819CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts−$242,609CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$4,140,428CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$4,140,667CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$239CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$239CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2024
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Bed days available, all components13,542CMS-2540-10 worksheet S300001 line 800 column 200
Medicare (Title XVIII) patient days117CMS-2540-10 worksheet S300001 line 800 column 400
Other-payer patient days11,977CMS-2540-10 worksheet S300001 line 800 column 600
Total patient days, all components12,094CMS-2540-10 worksheet S300001 line 800 column 700
Medicare discharges2CMS-2540-10 worksheet S300001 line 800 column 900
Other-payer discharges5CMS-2540-10 worksheet S300001 line 800 column 1100
Total discharges, all components7CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, Medicare, in days58.5CMS-2540-10 worksheet S300001 line 800 column 1400
Average length of stay, all patients, in days1,727.71CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1436735, read from the public cost report file SNF10FY2024.zip.

Fiscal year 2023, ended 31 December 2023

Cost report for 1 January 2023 to 31 December 2023 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on 23 September 2024.

Revenue and expenses, fiscal year 2023
FigureAs filedWhere it comes from
Total patient revenue$3,253,455CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts−$334,558CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$3,588,013CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$3,588,183CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$170CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$170CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2023
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Total patient days, all components12,504CMS-2540-10 worksheet S300001 line 800 column 700
Total discharges, all components5CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, Medicare, in days73CMS-2540-10 worksheet S300001 line 800 column 1400
Average length of stay, all patients, in days2,500.8CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1395510, read from the public cost report file SNF10FY2023.zip.

Fiscal year 2022, ended 31 December 2022

Cost report for 1 January 2022 to 31 December 2022 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on 31 July 2024.

Revenue and expenses, fiscal year 2022
FigureAs filedWhere it comes from
Total patient revenue$3,300,365CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts−$96,205CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$3,396,570CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$3,526,141CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$129,571CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$129,571CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2022
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Total patient days, all components12,294CMS-2540-10 worksheet S300001 line 800 column 700
Total discharges, all components17CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, Medicare, in days79.67CMS-2540-10 worksheet S300001 line 800 column 1400
Average length of stay, all patients, in days723.18CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1390673, read from the public cost report file SNF10FY2022.zip.

Fiscal year 2021, ended 31 December 2021

Cost report for 1 January 2021 to 31 December 2021 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on 20 December 2022.

Revenue and expenses, fiscal year 2021
FigureAs filedWhere it comes from
Total patient revenue$3,749,721CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts$239,391CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$3,510,330CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$3,510,481CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$151CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$151CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2021
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Total patient days, all components12,268CMS-2540-10 worksheet S300001 line 800 column 700
Total discharges, all components5CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, all patients, in days2,453.6CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1338632, read from the public cost report file SNF10FY2021.zip.

Fiscal year 2020, ended 31 December 2020

Cost report for 1 January 2020 to 31 December 2020 — a reporting period of 365 days, on form CMS-2540-10, settled, processed by CMS on 25 November 2021.

Revenue and expenses, fiscal year 2020
FigureAs filedWhere it comes from
Total patient revenue$3,085,822CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts−$137,683CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$3,223,505CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$3,494,844CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$271,339CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$271,339CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2020
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Total patient days, all components11,929CMS-2540-10 worksheet S300001 line 800 column 700
Total discharges, all components19CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, Medicare, in days317CMS-2540-10 worksheet S300001 line 800 column 1400
Average length of stay, all patients, in days627.84CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1305512, read from the public cost report file SNF10FY2020.zip.

Fiscal year 2019, ended 31 December 2019

Cost report for 1 January 2019 to 31 December 2019 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on 17 December 2020.

Revenue and expenses, fiscal year 2019
FigureAs filedWhere it comes from
Total patient revenue$3,237,506CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts$119,756CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$3,117,750CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$3,117,834CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$84CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$84CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2019
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Total patient days, all components12,459CMS-2540-10 worksheet S300001 line 800 column 700
Total discharges, all components17CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, Medicare, in days186CMS-2540-10 worksheet S300001 line 800 column 1400
Average length of stay, all patients, in days732.88CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1276544, read from the public cost report file SNF10FY2019.zip.

Fiscal year 2018, ended 31 December 2018

Cost report for 1 January 2018 to 31 December 2018 — a reporting period of 364 days, on form CMS-2540-10, settled, processed by CMS on 1 August 2019.

Revenue and expenses, fiscal year 2018
FigureAs filedWhere it comes from
Total patient revenue$3,450,975CMS-2540-10 worksheet G300000 line 100 column 100
Contractual allowances and discounts$208,129CMS-2540-10 worksheet G300000 line 200 column 100
Net patient revenue$3,242,846CMS-2540-10 worksheet G300000 line 300 column 100
Total operating expenses$3,242,998CMS-2540-10 worksheet G300000 line 400 column 100
Net income from service to patients−$152CMS-2540-10 worksheet G300000 line 500 column 100
Total other income$152CMS-2540-10 worksheet G300000 line 2500 column 100
Beds, days and discharges, fiscal year 2018
FigureAs filedWhere it comes from
Total facility beds, all components37CMS-2540-10 worksheet S300001 line 800 column 100
Total patient days, all components10,379CMS-2540-10 worksheet S300001 line 800 column 700
Total discharges, all components21CMS-2540-10 worksheet S300001 line 800 column 1200
Average length of stay, Medicare, in days122CMS-2540-10 worksheet S300001 line 800 column 1400
Average length of stay, all patients, in days494.24CMS-2540-10 worksheet S300001 line 800 column 1600

CMS report record 1239082, read from the public cost report file SNF10FY2018.zip.

Fiscal year 2017, ended 31 December 2017

Cost report for 16 August 2017 to 31 December 2017 — a reporting period of 137 days, not a full year, on form CMS-2540-10, settled, processed by CMS on 12 June 2018.

None of these figures is carried on this report.

CMS report record 1192610, read from the public cost report file SNF10FY2017.zip.

Nurse staffing

Nurse staffing hours from the Payroll-Based Journal, quarter by quarter, are on this facility’s staffing page, each quarter with the file it came from.

The staffing record →

Ownership, as filed with CMS

Care Compare

As filed in the CMS file dated 1 August 2026 (Care Compare ownership).

Owner or managerRoleTypeOwnership percentageAssociation
WITHAM MEMORIAL HOSPITAL5% OR GREATER DIRECT OWNERSHIP INTERESTOrganization100%since 04/01/2015
BANKS, JOEADP OF THE SNFIndividualNOT APPLICABLEsince 12/08/2025
SHERA, RANDALLADP OF THE SNFIndividualNOT APPLICABLEsince 12/08/2025
BAYSTON, BRETTCORPORATE DIRECTORIndividualNOT APPLICABLEsince 01/01/2023
BRAND, JOHNCORPORATE DIRECTORIndividualNOT APPLICABLEsince 01/01/2015
CASTETTER, ANDREACORPORATE DIRECTORIndividualNOT APPLICABLEsince 01/01/2023
COMPTON, JOHNCORPORATE DIRECTORIndividualNOT APPLICABLEsince 07/01/2015
FUNK, JAMESCORPORATE DIRECTORIndividualNOT APPLICABLEsince 07/01/2011
HAWKINS, CLAUDECORPORATE DIRECTORIndividualNOT APPLICABLEsince 09/01/2013
HORNBECKER, MICHAELCORPORATE DIRECTORIndividualNOT APPLICABLEsince 01/01/2024
PATRICK, LORICORPORATE DIRECTORIndividualNOT APPLICABLEsince 07/01/2022
REAGAN, JULIECORPORATE DIRECTORIndividualNOT APPLICABLEsince 02/21/2025
SCHMITS, FREDCORPORATE DIRECTORIndividualNOT APPLICABLEsince 07/01/2015
BRAVERMAN, KELLYCORPORATE OFFICERIndividualNOT APPLICABLEsince 12/01/2021
EMMINGER, DEBORAHCORPORATE OFFICERIndividualNOT APPLICABLEsince 07/01/2024
SELLERS, DANIELCORPORATE OFFICERIndividualNOT APPLICABLEsince 06/24/2024
BANKS, JOEOPERATIONAL/MANAGERIAL CONTROLIndividualNOT APPLICABLEsince 06/27/2024
GIBAULT CARE, INC.OPERATIONAL/MANAGERIAL CONTROLOrganizationNOT APPLICABLEsince 04/01/2015
SHERA, RANDALLOPERATIONAL/MANAGERIAL CONTROLIndividualNOT APPLICABLEsince 04/02/2018

Medicare enrollment

As filed in the CMS file dated 1 August 2026 (Medicare enrollment ownership), under the enrollment of WITHAM MEMORIAL HOSPITAL (enrollment ID O20170315001837).

OwnerIndividual or organizationRoleOwnership percentageAssociation dateDescribed in the filing as
WITHAM MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST1004/1/2015
Private equity company: No
Real estate investment trust: No
Holding company: No
JOE BANKSIndividualADP OF THE SNFCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.12/8/2025
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
RANDALL SHERAIndividualADP OF THE SNFCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.12/8/2025
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
ANDREA CASTETTERIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.1/1/2023
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
BRETT BAYSTONIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.1/1/2023
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
CLAUDE A HAWKINSIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.9/1/2013
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
FRED SCHMITSIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.7/1/2015
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
JAMES W FUNKIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.7/1/2011
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
JOHN COMPTONIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.7/1/2015
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
JOHN W BRANDIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.1/1/2015
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
JULIE REAGANIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.2/21/2025
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
LORI PATRICKIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.7/1/2022
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
MICHAEL JASON HORNBECKERIndividualCORPORATE DIRECTORCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.1/1/2024
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
DANIEL E SELLERSIndividualCORPORATE OFFICERCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.6/24/2024
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
DEBORAH EMMINGERIndividualCORPORATE OFFICERCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.7/1/2024
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
KELLY BRAVERMANIndividualCORPORATE OFFICER10012/1/2021
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
GIBAULT CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL1004/1/2015
Private equity company: No
Real estate investment trust: No
Holding company: No
JOE BANKSIndividualOPERATIONAL/MANAGERIAL CONTROLCMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.6/27/2024
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
RANDALL SHERAIndividualOPERATIONAL/MANAGERIAL CONTROL04/2/2018
Private equity company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Real estate investment trust: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.
Holding company: CMS paused the expanded ownership disclosure on Form CMS-855A in guidance dated December 11, 2025; this field has not been filed under the current cycle.

Changes in ownership

Recent changes on this record

Inspections

Inspection cycleHealth inspectionFire safety inspectionHealth deficienciesFire safety deficiencies
126 August 202526 August 2025134
22 October 20242 October 202457
322 September 202322 September 2023256

From the Care Compare inspection summary file NH_SurveySummary_Aug2026.csv, processed on 1 August 2026.

Deficiencies cited

43 deficiencies on file, newest inspection first
Inspection dateInspection typeTagCategoryWhat was citedScope and severityComplaintCorrectedCorrection date
26 August 2025HealthF 0578Resident Rights DeficienciesHonor 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.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0605Freedom from Abuse, Neglect, and Exploitation DeficienciesPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.DNoDeficient, Provider has date of correction19 September 2025
26 August 2025HealthF 0628Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0644Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0656Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0657Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0684Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.DNoDeficient, Provider has date of correction16 September 2025
26 August 2025HealthF 0690Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DNoDeficient, Provider has date of correction16 September 2025
26 August 2025HealthF 0695Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.DNoDeficient, Provider has date of correction16 September 2025
26 August 2025HealthF 0727Nursing and Physician Services DeficienciesHave 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.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0812Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.DNoDeficient, Provider has date of correction15 September 2025
26 August 2025HealthF 0880Infection Control DeficienciesProvide and implement an infection prevention and control program.DNoDeficient, Provider has date of correction16 September 2025
26 August 2025HealthF 0912Environmental DeficienciesProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.DNoDeficient, Provider has plan of correction15 September 2025
2 October 2024HealthF 0656Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DNoDeficient, Provider has date of correction24 October 2024
2 October 2024HealthF 0757Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.DNoDeficient, Provider has date of correction24 October 2024
2 October 2024HealthF 0758Pharmacy Service DeficienciesImplement 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.DNoDeficient, Provider has date of correction24 October 2024
2 October 2024HealthF 0812Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.DNoDeficient, Provider has date of correction24 October 2024
2 October 2024HealthF 0912Environmental DeficienciesProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.DNoWaiver has been granted24 October 2024
22 September 2023HealthF 0580Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0609Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0641Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0644Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0656Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0689Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0690Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0725Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0727Nursing and Physician Services DeficienciesHave 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.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0730Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0732Nursing and Physician Services DeficienciesPost nurse staffing information every day.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0760Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.GNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0761Pharmacy Service DeficienciesEnsure 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.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0809Nutrition and Dietary DeficienciesEnsure 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.FNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0812Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0835Administration DeficienciesAdminister the facility in a manner that enables it to use its resources effectively and efficiently.ENoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0842Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0867Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0880Infection Control DeficienciesProvide and implement an infection prevention and control program.ENoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0881Infection Control DeficienciesImplement a program that monitors antibiotic use.ENoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0882Infection Control DeficienciesDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.ENoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0883Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0887Infection Control DeficienciesEducate 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.DNoDeficient, Provider has date of correction27 October 2023
22 September 2023HealthF 0912Environmental DeficienciesProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.DNoWaiver has been granted
22 September 2023HealthF 0921Environmental DeficienciesMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.DNoDeficient, Provider has date of correction27 October 2023

From the Care Compare health citations file NH_HealthCitations_Aug2026.csv, processed on 1 August 2026.

Penalties

Penalty dateTypeFine amountPayment denial beganPayment denial, daysFine ID
22 September 2023Fine$8,18951076
22 September 2023Payment Denial20 October 20238

From the Care Compare penalties file NH_Penalties_Aug2026.csv, processed on 1 August 2026.

Care Compare provider information

FieldAs filed
Provider TypeMedicare and Medicaid
Ownership TypeNon profit - Corporation
Legal Business NameWITHAM MEMORIAL HOSPITAL
Date First Approved to Provide Medicare and Medicaid Services2017-08-16
Provider Resides in HospitalN
Continuing Care Retirement CommunityN
UrbanY
County/ParishHamilton
Telephone Number3178460265
Provider Changed Ownership in Last 12 MonthsN
With a Resident and Family CouncilResident
Automatic Sprinkler Systems in All Required AreasYes
Number of Certified Beds37
Average Number of Residents per Day34.1
Overall Rating2
Health Inspection Rating3
QM Rating3
Long-Stay QM Rating3
Processing Date2026-08-01

From the Care Compare Provider Information file NH_ProviderInfo_Aug2026.csv, processed on 1 August 2026.

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