Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcdowell Healthcare Center during CMS and state inspections, most recent first.
Failure to provide hand hygiene before lunch in the dining room. Residents entered the dining room in wheelchairs and no hand hygiene was observed during lunch service. An LPN confirmed that activities gave hand hygiene before lunch, but residents who arrived after activities left were not provided hand hygiene, including multiple residents in the dining room.
A resident had physician orders and a care plan requiring fingerstick blood glucose checks and provider notification for readings above 400 mg/dl. Record review showed multiple BG readings over 400 mg/dl, but there was no documentation that the provider was notified, and the DON confirmed the lack of documentation during interview.
A resident who preferred to be clean-shaven did not receive needed assistance with shaving after his electric razor broke. He told staff and the surveyor that he wanted help, but he remained unshaven over several days and stated no one had asked to assist him. The DON confirmed the resident had not been shaved in at least three days.
Menus were not updated when food item changes were made. During dining room observations, a slice of white bread was served instead of the listed buttered dinner roll on two separate meal occasions, and the issue was verified with an employee and the DON.
The facility failed to update PASRRs for five residents with new qualifying diagnoses. A resident's PASRR from 2016 did not reflect new diagnoses of dementia and psychosis. Another resident's PASRR from 2023 missed a diagnosis of schizoaffective disorder. A third resident was diagnosed with major depressive disorder in 2020, but no new PASRR was completed. A fourth resident's PASRR from 2022 did not include multiple mental health diagnoses. The DSS and social worker acknowledged the backlog of updates needed.
The facility failed to update PASRR forms for several residents, missing critical diagnoses such as major depressive disorder, bipolar disorder, and psychosis. Staff acknowledged a backlog and the need for updates, but these were not completed, leading to deficiencies in the admission process.
A facility failed to change wound dressings as ordered for two residents, with discrepancies in documentation. Another resident experienced a delay in receiving a necessary x-ray after a fall, and a resident with diabetes did not receive a scheduled accu-check. These deficiencies were identified and substantiated by investigating staff.
A resident reported that an employee was disrespectful when responding to their call bell. The facility's grievance report lacked a statement from the employee, contrary to the policy requiring a thorough investigation involving staff interviews.
The facility failed to update care plans for three residents with new diagnoses. A resident with Major Depression Disorder was only monitored for anti-depressant use, another with schizoaffective disorder, bipolar type, was only monitored for anti-psychotic medication, and a third resident's hallucinations were not care-planned. The CM RN confirmed these omissions during interviews.
A resident using smokeless tobacco did not have a smoking assessment completed upon admission, as required by the facility's policy. The deficiency was identified during a survey when the resident was observed using smokeless tobacco in their room. The Interim Director of Nursing confirmed the oversight, acknowledging that the assessment was only completed after surveyor intervention.
The facility failed to monitor side effects of psychotropic medications for three residents, as identified during a survey. A resident was not monitored for side effects of antidepressant, antianxiety, and antipsychotic medications on multiple occasions. Another resident experienced a lack of side effect monitoring for various medications, including antianxiety, antidepressant, antipsychotic, and mood stabilizers. Similarly, a third resident was not monitored for side effects of antianxiety, antidepressant, and antipsychotic medications as ordered.
The facility failed to accurately document POST forms for two residents, missing required MPOA signatures and relying on insufficient witness signatures and email communication, contrary to professional standards.
The facility failed to ensure required attendance and signatures for QAPI meetings, with the DON not signing in for several meetings. The Medical Director did not attend, and the Administrator suggested the DON might have forgotten to sign or was absent. This issue was identified during a survey, potentially affecting more than a limited number of residents.
Failure to Provide Hand Hygiene Before Lunch
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not provide a sanitary environment to help prevent the development and prevention of communicable disease and infection by not providing hand hygiene to multiple residents in the first floor dining room before lunch. During a dining observation on 02/26/26 beginning at 11:15 AM, residents were observed entering the first floor dining room in wheelchairs until lunch was served, and no hand hygiene was observed during lunch service. In an interview at 11:41 AM, Nurse #18 confirmed that activities distributed hand hygiene before lunch, but residents who arrived after activities left were not provided hand hygiene. Residents #24, #81, #41, #82, and #12 arrived after activities left and were not provided hand hygiene in the dining room, and Nurse #18 confirmed this.
Failure to Notify Provider of Elevated Blood Glucose Readings
Penalty
Summary
Resident #7 had physician orders and a care plan directing staff to perform fingerstick blood glucose testing and to notify the provider if the blood glucose was less than 60 mg/dl or greater than 400 mg/dl. Review of the blood glucose monitoring records showed elevated readings of 416 mg/dl on 01/24/26, 477 mg/dl on 01/29/26, 448 mg/dl on 02/11/26, and 440 mg/dl on 02/18/26. The medical record contained no documentation that the provider was notified for any of these readings. During interview on 02/26/26 at 12:50 PM, the DON reviewed the record and confirmed there was no documentation showing the provider had been notified of the elevated blood glucose readings as required by the resident's care plan.
Failure to Assist with Personal Grooming
Penalty
Summary
The facility failed to ensure one resident received the assistance needed with activities of daily living, specifically personal grooming. Resident #88 stated his electric razor had broken and he had not been shaved since then, and he preferred to be clean-shaven. He had several days of beard growth noted. During a later interview, he again stated he would like someone to shave him, and the surveyor informed Nurse #103 of the request, who said she would let the aides know. On a subsequent interview and observation, Resident #88 remained unshaven and stated no one had asked to help him shave. He said he would allow the aides to shave him with a regular razor since his electric razor was broken. The DON stated that nurse aides should go in and ask the resident if he needed assistance with shaving, and confirmed Resident #88 had not been shaved in at least three days.
Menu Changes Not Reflected in Meal Service
Penalty
Summary
Menus were not updated when food item changes were made. On 02/24/26, the lunch menu listed meat sauce with spaghetti noodles, garlic green beans, a buttered dinner roll with margarine, and a cinnamon brown sugar blondie for dessert, but a slice of white bread was offered instead of the roll. On 02/26/26, a menu review showed the meal would include crispy baked chicken, brussels sprouts, macaroni and cheese, and a buttered dinner roll with chocolate pudding for dessert, but a slice of white bread was again offered instead of a dinner roll. This was verified by observation in the dining room on 02/24/26 at 12:15 PM and 02/26/26 at 12:20 PM, and the surveyor interviewed Employee #111 and the DON on 02/26/26 at 1:03 PM.
Failure to Update PASRRs with New Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASRR) for five residents with new qualifying diagnoses during the long-term survey process. Resident #17 had a PASRR dated 08/19/16 with no level two required, but new diagnoses of unspecified dementia with psychotic disturbances and unspecified psychosis were not updated. The Director of Social Services (DSS) acknowledged the need for updates but had not completed them, and the issue was not addressed in the Quality Assurance meeting. Resident #26's PASRR dated 06/12/23 did not reflect a new diagnosis of schizoaffective disorder. Although the DSS completed the update on 08/06/24, it was not discussed in the Quality Assurance meeting. Resident #49 was diagnosed with major depressive disorder on 01/08/20, but a new PASRR was not completed. The Social Worker stated there was a backlog of PASRRs to be updated. Resident #14's PASRR dated 01/28/22 did not reflect multiple mental health diagnoses, and the social worker was aware of the need for updates but was still working on them for the entire building.
Deficiencies in PASRR Updates for Residents
Penalty
Summary
The facility failed to ensure accurate diagnoses on the Pre-Admission Screening and Resident Review (PASRR) forms for five residents, leading to deficiencies in the admission process. Resident #53 was admitted with a diagnosis of major depressive disorder, which was not reflected in the PASRR, and the facility did not submit a new PASRR upon this diagnosis. The Social Worker acknowledged a backlog of PASRRs needing resubmission, including Resident #53. Similarly, Resident #33's PASRR did not reflect multiple diagnoses present at admission, including Bipolar Disorder and Major Depressive Disorder, and the facility failed to update the PASRR accordingly. Resident #7's PASRR was also outdated, missing diagnoses of Major Depressive Disorder and Psychosis present at admission. The Administrator and Social Worker confirmed the oversight. Resident #17's PASRR lacked a diagnosis of major depressive disorder, and the Director of Social Services admitted awareness of the need for updates but had not completed them. Lastly, Resident #29's PASRR was missing diagnoses of hallucinations and psychotic disorder with delusions, which were not included upon submission. The Director of Social Services acknowledged the missing information and the need for resubmission.
Deficiencies in Wound Care and Diagnostic Follow-Up
Penalty
Summary
The facility experienced a deficiency related to the failure to change wound dressings according to physician orders for two residents. Resident #45 had an order to change the dressing on the coccyx daily, but the dressing was not changed for three days, as evidenced by the old dressing being dated 07/18/24 and the documentation inaccurately reflecting a change on 07/20/24. Similarly, Resident #77 had an order to change the dressing on the right heel daily, but the dressing was also not changed for three days, with the same discrepancy in documentation. These incidents were substantiated by the investigating staff. Additionally, Resident #84 reported a fall and was supposed to receive an x-ray for the left stump of her amputated leg, but the x-ray was delayed due to issues with the x-ray service provider. The resident expressed concern about the delay affecting her prosthetic leg process. Furthermore, Resident #29 had an order for accu-checks twice a day due to Type 2 Diabetes Mellitus, but the morning accu-check on 07/22/24 was not completed, as confirmed by the Director of Nursing.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to properly investigate and resolve a grievance from a resident, identified as Resident #19, during the Long Term Care Survey Process. The resident reported that an employee, identified as Employee #86, was disrespectful when responding to the resident's call bell, using dismissive language. The surveyor informed the facility Administrator, who indicated that the Social Worker would address the issue with the resident. However, upon review, it was found that the facility's Grievance/Complaint Report did not include a statement from Employee #86, which was a requirement according to the facility's Resident Grievance policy. The policy mandates a timely investigation involving interviews with staff and others involved in resident care, which was not fully adhered to in this case.
Failure to Update Care Plans for New Diagnoses
Penalty
Summary
The facility failed to update the care plans for three residents with new diagnoses, as identified during a medical record review and staff interview. Resident #17 was diagnosed with Major Depression Disorder, but the care plan only included monitoring for the use of an anti-depressant, not the diagnosed condition itself. Similarly, Resident #26 had a diagnosis of schizoaffective disorder, bipolar type, but the care plan only addressed monitoring for anti-psychotic medication use, omitting the specific condition. Additionally, Resident #29 was diagnosed with hallucinations, but the care plan did not reflect this diagnosis. The Clinical Manager Registered Nurse (CM RN) #51 confirmed during interviews that the care plans for these residents did not include the necessary updates for their respective conditions. This oversight affected three out of thirty residents reviewed, indicating a lapse in the facility's care planning process.
Failure to Conduct Smoking Assessment for Smokeless Tobacco Use
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards by not completing a smoking assessment for a resident using smokeless tobacco upon admission. This deficiency was identified during a survey process where it was observed that a resident was using smokeless tobacco in their room. Upon reviewing the resident's records, it was found that no smoking assessment had been completed since the resident's admission. The Interim Director of Nursing (IDON) confirmed that the facility's policy required smokeless tobacco assessments to be completed on admission, quarterly, and upon significant changes in condition. However, the assessment for the resident in question was only completed after surveyor intervention, indicating a lapse in following the facility's policy. This oversight was acknowledged by the IDON, who confirmed that the assessment was not conducted as required upon the resident's admission.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor side effects of psychotropic medications for three residents, as identified during a survey process. Resident #30 was not monitored for side effects of antidepressant, antianxiety, and antipsychotic medications on multiple occasions, as documented in the Medication Administration Record (MAR). The Interim Director of Nursing (IDON) confirmed the lack of documentation for side effect monitoring on specific dates and was unable to provide additional evidence that monitoring had occurred. Resident #29 also experienced a lack of side effect monitoring for various medications, including antianxiety, antidepressant, antipsychotic, and mood stabilizers. The behavior monitoring documentation revealed numerous instances where monitoring was not completed as ordered. The Director of Nursing (DON) acknowledged the discrepancies in the monitoring orders during an interview, confirming that the required monitoring was not conducted. Similarly, Resident #82 was not monitored for side effects of antianxiety, antidepressant, and antipsychotic medications as ordered. The behavior monitoring documentation showed missing entries for several dates, indicating that the monitoring was not performed. The DON agreed that the monitoring was not completed as required, highlighting a consistent issue with medication side effect monitoring for these residents.
Deficiency in Accurate Documentation of POST Forms
Penalty
Summary
The facility failed to ensure that medical records for residents were accurately documented, specifically regarding the Physician Orders for Scope of Treatment (POST) forms. For one resident, a verbal consent was obtained, but the POST form was only signed by one witness and lacked the required signature from the Medical Power of Attorney (MPOA). This was contrary to the guidance which requires two witness signatures if the MPOA is unavailable, until the original signature can be obtained. The facility acknowledged this oversight during an interview with the administrator and social worker. For another resident, the POST form was missing the necessary signature from the patient or their MPOA representative. Instead, there was a handwritten note indicating communication via email with a case worker, which is not an acceptable form of signature according to the guidance. The Director of Social Services confirmed the deficiency and acknowledged that the email did not meet the signature requirements. The facility was in the process of addressing these documentation issues.
Deficiency in QAPI Meeting Attendance and Documentation
Penalty
Summary
The facility failed to ensure that all required members attended and signed the Quality Assurance Performance Improvement (QAPI) meetings, as discovered during a long-term care survey. The Director of Nursing (DON), who was also the Person In Charge (PIC), did not sign in attendance for several QAPI meetings. The meetings in question occurred on specific dates, and the absence of the DON's signature was noted during a record review. The QAPI information was reportedly reviewed with the Medical Director verbally, but the Medical Director did not attend the meetings. The Administrator suggested that the DON might have forgotten to sign or was not present, and the Medical Director and his Family Nurse Practitioner signed the form later. The report highlights multiple instances where the required signatures and attendance were not documented, potentially affecting more than a limited number of residents. The Administrator acknowledged the discrepancies, noting that the DON might have forgotten to sign or was absent due to other commitments. In one instance, the DON was an interim and might have left for the week. Despite verbal reviews with the Medical Director, the lack of proper documentation and attendance at these meetings was a significant issue identified during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyoming Healthcare Center | 14.8 mi | ★★★★★ | 6 | 0 |
| Heritage Hall Tazewell | 16.5 mi | ★★★★★ | 0 | 0 |
| Westwood Center | 17.9 mi | ★★★★★ | 0 | 0 |
| Mercer Healthcare Center | 18.4 mi | ★★★★★ | 0 | 0 |
| Bluestone Health And Rehabilitation | 18.6 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mcdowell Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.