McKinney Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services.1. The facility failed to ensure items were dated in the freezer and dry storage. 2. The facility failed to ensure staff properly wore beard restraints.3. The facility failed to ensure staff sanitized the thermometer before taking food temperatures for the lunch meal on 07/15/2026. These failures could place residents at risk of cross contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to ensure the kitchen was free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 (Resident #92) reviewed for transfer/discharge. The facility failed to notify Resident #92 and/or her representative in writing when the resident was transferred to the hospital on [DATE]. The facility also failed to send a notice to the Ombudsman. This failure could place residents at risk of not knowing their rights at the time of the transfer/discharge.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals; and establishes a system of records of receipt and disposition all controlled drugs in sufficient detail to enable an accurate reconciliation) to meet the needs of each resident for 1 of 3 medication carts (200 Hallway cart) reviewed for pharmacy services. The facility failed to ensure the 200 Hallway medication aide cart had accurate narcotic counts for Residents #63 and #72. This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 8.11%, based on 3 errors out of 37 opportunities, which involved 1 of 5 residents (Resident #5) and 1 of 4 staff (RN D) observed during medication administration reviewed for medication error. RN D failed to administer all the crushed medications in medication cups leading to 3 cups being left with residual medication. This failure could place residents at risk of not receiving proper medication doses leading to an altered therapeutic response.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for four of fifteen residents (Resident #1, #2, #3, and #4) reviewed for medication storage. 1. The facility failed to ensure a wound cleanser, an antiseptic (substance that stops the growth of microorganisms) skin cleanser, tubes of barrier creams (used to prevent skin irritation), a bottle of nystatin powder (antifungal medication), and sachets of povidone-iodine (solution used to prevent wound infection) were not left within reach inside Resident #1's room on 11/25/2025. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #13) of 15 residents on 100 hall reviewed for resident rights. 1. The Housekeeping Supervisor did not knock on Resident #13's room door and bathroom door before entering. 2. The Housekeeping Supervisor did not inform Resident #13 that he was in her room or of the service he was to provide. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #32) of five residents reviewed for personal property. The Activity Director utilized residents' personal inventories of crayons/markers for the purpose of group activities. This failure could place residents at risk of not being able to retain and use personal property.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #61) observed for infection control. A COTA failed to perform hand hygiene while providing incontinence care to Resident #61. The failures could place the residents at risk for infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in a locked cart or under the direct observation of authorized staff in an area where residents could access it for one (Wound Care Cart) of five carts reviewed for pharmacy services The facility failed to ensure that LVN A locked the wound care cart after providing wound care on 05/01/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six (Resident #5) residents reviewed for infection control. 1. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 03/06/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four of 18 (Residents #6, #16, #49 and #287) reviewed for comprehensive care plans. 1. The facility failed to include in the care plan on 01/16/24 Resident #6's contractures to her right hand with interventions required to prevent further decline. 2. The facility failed to include in the care plan dated 03/28/24 Resident #16's contractures to her hands with interventions required to prevent further decline. 3. The facility failed to create a care plan on 03/26/24 for Resident #49's scoop mattress. 4. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure that five (Resident #289, Resident #290, Resident #61, Resident # 79, and Resident #16) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. 1. The facility failed to ensure MA L re-ordered medications in a timely manner for Residents #289 (Lasix ), Resident #290 (Lasix), and Resident #61 (Entresto). 2. The facility failed to ensure MA J re-ordered medications in a timely manner for Residents #79 (Metoprolol). 3. The facility failed to ensure LVN B re-ordered medications in a timely manner for Resident #16 (Famotidine). This failure placed the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five of sixteen residents (Resident #50, Resident #77, Resident #6, Resident #8, and Resident #47) observed for infection control. 1. The facility failed to ensure that LVN K capped Resident #50's PICC (peripherally inserted central catheters) line while not in use on 04/09/24. 2. The facility failed to ensure that CNA I changed her gloves and perform hand hygiene while providing incontinence care to Resident #77 on 04/09/24 3. The facility failed to ensure that CNA E changed her gloves and perform hand hygiene while providing incontinence care to Resident #6 on 04/11/24 4. [...]

Inspectors wroteBased on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one (Resident # 138) of six residents reviewed for misappropriation of property. The Administrator failed to start thoroughly investigating a misappropriation of property on 01/11/2024, after the facility filed a report to the state regarding Resident # 138's [NAME] Of Attorney misappropriating her property. Failure to timely investigate misappropriation of property placed residents at risk for unidentified misappropriation of property.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who was unable to carry out activities of daily living for one of six residents (Resident #8) reviewed for ADL care. The facility failed to provide Resident #8, who required extensive assistance, with timely incontinence care on 04/09/24 from 9:30 a.m. to 3:00 p.m. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of six residents (Resident #47) reviewed for incontinence care. The facility failed to ensure NA C provided appropriate perineal care for Resident # 47 after an incontinent episode when he failed to clean the resident's scrotum, and penis on 04/09/24. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #81) of two residents reviewed for labelling of drugs and biologicals. The facility failed to ensure MA L placed a change of instruction label for Resident #81's Sertraline blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) after the order was changed. This failure could place residents at risk for wrong medication administration, mismanagement of care, adverse effects, and physical harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were obtained for lab services and failed to promptly notify the physician of laboratory results that fall outside of clinical reference ranges in accordance with facility policy and procedures for notification of a practitioner or per the ordering physician orders for one of two (Resident #6) reviewed for labs. 1. The Facility failed to transcribe the physician orders for a lab draw to obtain a Dilantin (medication used for seizure control) level on 02/13/24 and 03/28/24 into Resident #6's clinical record. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide each resident with a nourishable, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for 1 (Resident # 31) of 24 residents reviewed for needs and preferences. The facility failed to ensure Resident # 31 was offered alternative meal options. This failure placed residents at risk of not having their needs and preferences honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 1 of 3 residents (Resident #1) reviewed for timely meals, in that: The facility failed to ensure residents were offered snacks at bedtimes as required due to meal times being more than 14 hours apart. This failure could affect all 70 residents who received meals served from the facility's only kitchen by placing residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. There was an expired, large, sealable, plastic bag of graham cracker crust. Which expired on 03/31/2024. Dietary staff failed to dispose of expired food items in freezer. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.