Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mckinney Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents had medications and topical treatments, such as wound cleansers, barrier creams, and ointments, left unsecured in their rooms without proper assessments for self-administration. Some of these residents had cognitive impairments or no physician orders for the medications present. Staff confirmed that these items should not have been accessible and should have been stored securely.
A wound care cart containing drugs and biologicals was left unlocked and unattended in a hallway, with the keys placed on top of the cart, making its contents easily accessible to residents, staff, and visitors. The drawers, which included ointments, creams, and wound cleansers, could be opened without restriction, and the cart was not under direct observation by authorized staff. Facility staff confirmed that this was not in accordance with policy, and the nurse responsible acknowledged forgetting to secure the cart and keys after use.
A facility failed to maintain an effective Infection Prevention and Control Program when a CNA did not perform hand hygiene between glove changes during incontinence care for a resident with a urinary tract infection. Despite training and available hand sanitizer, the CNA admitted to skipping hand hygiene due to nervousness and uncertainty about glove usage. The DON confirmed the lapse, noting the CNA's nervousness and overuse of gloves.
The facility failed to develop and update comprehensive care plans for residents, leading to deficiencies in care. A resident with contractures did not have interventions in her care plan, and another resident's care plan lacked updates for a scoop mattress and discontinued BiPAP use. Staff interviews revealed communication breakdowns and oversight in care plan management.
The facility failed to re-order medications timely for five residents, risking medication shortages. A resident with congestive heart failure and another with acute kidney failure faced Lasix shortages due to a medication aide's oversight. Another resident with heart failure had insufficient Entresto. A resident with hypertension had only one Metoprolol tablet left, and a resident with GERD required emergency kit Famotidine due to re-order delays. The DON and Administrator stressed timely re-ordering per policy to prevent missed doses.
A long-term care facility failed to maintain an effective Infection Prevention and Control Program, leading to several deficiencies. A resident's PICC line was left uncapped by an LVN, increasing the risk of infection. Additionally, multiple staff members did not adhere to proper glove use and hand hygiene protocols during incontinence care, risking cross-contamination. These lapses were acknowledged by the staff and confirmed by the DON and Administrator, indicating a gap between policy and practice.
A resident with cognitive impairments was at risk due to the facility's failure to investigate alleged misappropriation of property by her friend, who had Power of Attorney. Despite staff suspicions and a report to Adult Protective Services, the facility did not conduct a thorough investigation, contrary to its policy.
A facility failed to provide timely incontinence care to a resident who required extensive assistance, leaving her soaked in urine and with a bowel movement from morning until afternoon. Despite the facility's policy to check and change incontinent residents every two hours, staff interviews revealed a lack of adherence, resulting in discomfort and redness for the resident. The DON acknowledged the risk of skin breakdown and infections due to this failure.
A resident with severe cognitive impairment and incontinence issues did not receive proper perineal care from a nursing assistant, who failed to clean the genital area adequately and did not follow hand hygiene protocols. This oversight could lead to urinary tract infections and skin breakdown.
A facility failed to update the labeling on a resident's Sertraline blister pack, resulting in a discrepancy between the blister pack and the eMAR. The blister pack indicated a 50 mg dosage, while the eMAR showed a new dosage of 100 mg. Staff interviews revealed that the facility's procedure required a change of instruction sticker on the blister pack when orders changed, which was not done, potentially leading to medication errors.
A resident with a seizure disorder did not have physician orders for Dilantin level lab draws transcribed into their clinical record, and the facility failed to promptly notify the physician of elevated lab results. The resident's care plan required lab monitoring and reporting, but records lacked documentation of orders and notifications. Staff interviews revealed misunderstandings about order transcription and notification documentation, leading to delays in physician notification and follow-up.
A resident with dementia and anxiety expressed dissatisfaction with the facility's food, stating it was unappetizing and that she was unaware of alternative meal options. Observations confirmed that while meal times and menus were posted, there was no information about alternative options or snacks. The Dietary Manager acknowledged that the Spring menu lacked alternative options, unlike previous menus, and the facility's dietary policy did not address this issue.
The facility failed to ensure no more than 14 hours between the evening meal and breakfast unless a snack was provided, affecting all residents. Meal times were posted, but no information on snack availability was given. Residents were not routinely offered snacks, and staff did not inform them of available options. The spring menu lacked alternative meal options, unlike previous menus.
The facility failed to dispose of an expired graham cracker crust found in the kitchen freezer, violating food service safety standards. The Dietary Manager confirmed the oversight and acknowledged the risk of food-borne illness from serving expired food.
Failure to Secure Medications and Topical Treatments in Resident Rooms
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with state and federal regulations, resulting in multiple instances where medications and topical treatments were left unsecured in resident rooms. Surveyors observed wound cleansers, antiseptic skin cleansers, barrier creams, nystatin powder, and povidone-iodine sachets left in plain sight in the room of a cognitively intact female resident with multiple sclerosis and a surgical wound. There was no assessment for self-administration of medications, nor any documentation indicating the resident was competent to manage her own medications. The resident confirmed that the nurse performed her wound care and that no one had discussed the risks of having these items in her room. In another case, a female resident with dementia and moderate cognitive impairment was found to have a basket containing a squeeze eye drop bottle, hemorrhoid ointment, hydrocortisone ointment, and triple antibiotic ointment in her room. There were no physician orders for these medications, no assessment for self-administration, and no evidence the resident was competent to manage her own medications. The resident did not respond when asked about the medications, and staff later confirmed these items should not have been accessible. Additional observations included a cognitively intact female resident with no current wounds who had two containers of wound cleanser in her room, and another cognitively intact female resident with urinary and bowel incontinence who had sachets of skin barrier ointment left on her side table, including an open sachet with ointment residue. Staff interviews confirmed that medications and topical treatments should not be left in resident rooms unless a proper assessment for self-administration had been completed, and that these items should be stored securely to prevent misuse or accidental ingestion by residents.
Unlocked Wound Care Cart with Unsecured Keys Left Unattended
Penalty
Summary
A wound care cart was observed parked in the hallway in front of the nurses' station, left unlocked with keys placed on top of the cart. The drawers of the cart, which contained various wound care supplies including ointments, creams, wound cleansers, and other medical items, were easily accessible to anyone passing by, including residents, staff, and visitors. Multiple staff and residents were seen passing in front of the cart, and the drawers could be opened without restriction. The cart was not under the direct observation of authorized staff at the time of the observation. Interviews with the ADON, DON, and the Administrator confirmed that facility policy requires all carts containing drugs and biologicals to be locked when unattended and that keys should not be left unsecured. The DON identified that the night nurse had left the cart unlocked and the keys on top of it. LVN A admitted to forgetting to lock the cart and secure the keys after providing wound care earlier that morning, citing being busy as a factor but acknowledging that this was not an acceptable excuse.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA B during incontinence care for Resident #5. Resident #5, a female with a history of urinary tract infection and incontinence, was observed receiving care from CNA B, who did not perform hand hygiene between glove changes. This lapse in protocol occurred despite the presence of hand sanitizer in the room and the facility's policy requiring handwashing after direct resident contact. CNA B, who had been trained on hand hygiene, admitted to not using hand sanitizer or washing her hands each time she changed gloves, citing nervousness during observation and uncertainty about glove usage when only urine was present. The Director of Nursing confirmed that CNA B should have adhered to hand hygiene protocols and noted that CNA B was likely overusing gloves due to nervousness, leading to a shortage before completing the care task. The facility's policy on perineal care did not specify glove use, which may have contributed to the oversight.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and updated for several residents, leading to deficiencies in care. Resident #6, a severely cognitively impaired female with contractures in her right hand, did not have her contractures addressed in her care plan. Despite receiving occupational therapy services, there were no recent orders for therapy, and observations revealed that hand splints were not consistently used. Interviews with staff indicated a lack of clarity on who was responsible for splint placement, and the Director of Rehabilitation acknowledged the oversight in therapy orders and care plan updates. Resident #16, also severely cognitively impaired, had contractures in her hands and elbows that were not addressed in her care plan. Although there were physician orders for the use of bilateral c-splints, observations showed that the splints were not in use during the survey. Interviews with nursing staff and the MDS Coordinator revealed that the care plan should have included interventions for contracture management, and the failure to update the care plan was acknowledged as a risk for further decline in the resident's condition. Resident #49's care plan did not include the use of a scoop mattress, despite a hospice order for it due to the resident's history of falls. Interviews with staff, including the DON, revealed a lack of awareness about the hospice order and the presence of the scoop mattress, indicating a communication breakdown between hospice and facility staff. Similarly, Resident #287's care plan was not updated to reflect the discontinuation of BiPAP use, leading to potential confusion in care. Interviews with the DON and other staff confirmed that the care plan should have been revised to reflect the resident's current needs, highlighting an oversight in care plan management.
Medication Re-ordering Deficiency
Penalty
Summary
The facility failed to ensure timely re-ordering of medications for five residents, leading to a risk of medication shortages. Resident #289, a female with congestive heart failure, was prescribed Lasix, a diuretic, to manage fluid overload. However, the medication aide, MA L, did not re-order the medication in time, leaving only one tablet remaining. Similarly, Resident #290, a male with acute kidney failure, also faced a shortage of Lasix due to the same oversight by MA L. Resident #61, a male with biventricular heart failure, was prescribed Entresto, but the medication was not re-ordered timely, resulting in only three tablets left. MA L acknowledged the failure to re-order these medications and noted that skipping doses could exacerbate the residents' conditions. Resident #79, a female with hypertension, was prescribed Metoprolol, an anti-hypertensive medication. The medication aide, MA J, failed to re-order the medication in a timely manner, leaving only one tablet available. MA J confirmed the oversight and recognized the potential for worsening medical conditions if the medication was not administered as prescribed. Additionally, Resident #16, a female with gastro-esophageal reflux disease, was prescribed Famotidine. LVN B had to use the last tablet from the emergency kit due to a delay in re-ordering, which was attributed to weather-related delivery issues. LVN B acknowledged that medications should be re-ordered before reaching the refill point to avoid such situations. The Director of Nursing (DON) and the Administrator both emphasized the importance of timely medication re-ordering to prevent residents from running out of their prescribed medications. The facility's policy required medications to be re-ordered seven days in advance to ensure an adequate supply. The failure to adhere to this policy resulted in the potential for residents to miss critical doses, which could worsen their medical conditions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in several deficiencies related to infection control practices. One significant issue involved a resident with a PICC line, which was not capped by an LVN after disconnection from an IV bag. This oversight occurred despite the resident's ongoing treatment for osteomyelitis, a serious bone infection, and the facility's policy requiring a closed system for PICC lines to prevent contamination and infection. Additionally, multiple instances of improper glove use and hand hygiene were observed during incontinence care for several residents. In one case, a CNA failed to change gloves and perform hand hygiene after cleaning a resident's buttocks, subsequently contaminating a clean brief. Similar lapses were noted with other CNAs and an LVN, who did not change gloves or wash hands between handling soiled and clean items, increasing the risk of cross-contamination and infection among residents. The facility's policies on hand hygiene and glove use were not adhered to, as evidenced by staff failing to change gloves and perform hand hygiene at critical points during resident care. These actions, or lack thereof, were acknowledged by the staff involved, who recognized the importance of proper infection control practices to prevent the spread of germs and infections. The DON and Administrator also confirmed the expectations for staff to follow these protocols, highlighting a gap between policy and practice.
Failure to Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to thoroughly investigate an alleged misappropriation of property involving a resident's friend who had obtained a Power of Attorney. The incident was reported to the state on 01/11/2024, but the administrator did not initiate a comprehensive investigation. This oversight placed residents at risk for unidentified misappropriation of property. Resident #138, a female with dementia, schizophrenia, cognitive communication deficit, and end-stage renal disease, was the subject of the investigation. She had a BIMS score indicating moderately impaired cognition and required moderate assistance with daily activities. Concerns arose when her friend, who was appointed as her Power of Attorney, began showing a sudden interest in her finances, prompting the facility's Social Services staff to file a report with Adult Protective Services. Interviews with facility staff, including the Business Office Manager and the Director of Nursing, revealed that the friend's actions raised suspicions of financial exploitation. Despite these concerns, the facility did not follow through with a thorough investigation to ensure the resident's finances were protected. The facility's policy mandates immediate reporting and investigation of such allegations, but this was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary incontinence care to a resident who required extensive assistance with activities of daily living. On the specified date, the resident, who was cognitively intact and had a history of atrial fibrillation, depression, and bipolar disorder, was not changed from 9:30 a.m. to 3:00 p.m. despite being incontinent of both bladder and bowel. The resident expressed that she was not changed throughout the day and was left in a wet state until after her last smoke break in the evening. This lack of timely care was confirmed during an observation when the resident was found soaked in urine and had a bowel movement, causing discomfort and redness on her buttocks. Interviews with staff revealed a lack of adherence to the facility's policy of checking and changing incontinent residents every two hours. The LVN and CNAs involved were unsure if the resident had been changed earlier in the shift, and it was noted that the resident was not checked for incontinence until after her last smoke break. The Director of Nursing acknowledged that failing to provide timely incontinence care could lead to skin breakdown and urinary tract infections. The facility's policy emphasized the importance of removing urine or feces from the skin and providing dry, odor-free perineal care every two hours.
Inadequate Incontinence Care for Male Resident
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a potential risk of urinary tract infections and skin breakdown. The resident, a male with severe cognitive impairment and a history of diabetes, stroke, and dementia, required extensive assistance with personal hygiene and was frequently incontinent of urine and always incontinent of bowel. During an observation, a nursing assistant (NA) did not properly clean the resident's genital area after an incontinent episode. The NA failed to clean the resident's scrotum and penis, did not pull back the foreskin to clean the tip of the penis, and did not change gloves or perform hand hygiene after handling soiled materials. The NA admitted to being unsure about the proper steps for male perineal care and acknowledged missing critical steps that could lead to infections and skin breakdown. Despite having been assessed as competent in providing male perineal care, the NA did not follow the facility's procedure, which includes using a different section of the wipe for each stroke and performing hand hygiene after removing gloves. The Director of Nursing (DON) confirmed that the failure to provide accurate incontinent care placed residents at risk for infections and poor hygiene.
Medication Labeling Discrepancy for Antidepressant
Penalty
Summary
The facility failed to ensure that medication was labeled in accordance with currently accepted professional principles for a resident, leading to a discrepancy between the medication blister pack and the electronic medication administration record (eMAR). Specifically, the blister pack for Sertraline, an antidepressant medication, was labeled with an outdated dosage instruction of 50 mg, while the eMAR indicated a new dosage of 100 mg. This discrepancy was identified during an observation and interview with a medication aide (MA L), who acknowledged the inconsistency and the absence of a change of instruction label on the blister pack. Interviews with staff, including another medication aide (MA J) and the Director of Nursing (DON), revealed that the facility's procedure required staff to place a change of instruction sticker on the blister pack when there was a change in medication order. The failure to update the blister pack label could lead to medication errors, such as overmedication or undermedication, posing potential risks to the resident's health. The facility's policy on medication orders emphasized the importance of transcribing new orders and discontinuing previous entries to prevent such errors.
Failure to Transcribe Lab Orders and Notify Physician of Abnormal Results
Penalty
Summary
The facility failed to ensure that physician orders were obtained for lab services and did not promptly notify the physician of laboratory results that were outside of clinical reference ranges for a resident. Specifically, the facility did not transcribe physician orders for a Dilantin level lab draw into the resident's clinical record on two occasions. Additionally, the facility did not provide timely notification to the physician or nurse practitioner of the lab results that indicated elevated Dilantin levels, which were outside the reference range. The resident involved was a severely cognitively impaired female with a history of aphasia, stroke, dementia, and seizure disorder. Her care plan included obtaining and monitoring lab work as ordered and reporting results to the medical team. However, the facility's records did not reflect any orders for the Dilantin level lab requests, nor did they document the notification of the physician regarding the lab results received. Interviews with facility staff revealed that there was a misunderstanding regarding the transcription of lab orders into the electronic record and the documentation of physician notifications. The staff assumed that placing the order request into the lab portal created the physician's order and did not realize the need to update the resident's clinical record. This oversight led to delays in notifying the physician of lab results and any necessary follow-up actions.
Failure to Provide Alternative Meal Options
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of a resident, specifically Resident #31. This resident, an elderly female with diagnoses including unspecified dementia and anxiety, expressed dissatisfaction with the food, stating it was not appetizing and that she was unaware of available meal options. During a group meeting, residents indicated that if a food item was not on the menu, it was not considered an option, and they were unaware of alternative food choices. Observations revealed that while meal times and menus were posted near the dining room, there was no information about alternative meal options or snacks available between meals. The Dietary Manager confirmed that the Spring menu, which had recently started, did not include alternative meal options, unlike the Fall/Winter menu cycle. A review of the facility's dietary policy from June 2017 showed it did not address alternative meal options for residents, contributing to the deficiency in meeting residents' dietary needs and preferences.
Failure to Provide Timely Snacks Between Meals
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the substantial evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime. This deficiency was observed for one resident, but it potentially affected all 70 residents who received meals from the facility's only kitchen. The posted meal service times indicated that breakfast was served from 7:30 to 9:30 AM, lunch from 11:45 AM to 1:45 PM, and the evening meal from 5:00 to 7:00 PM. However, there was no posting to inform residents about the availability of snacks after these specified times. Interviews with residents and staff revealed that residents were not made aware of snack options, and staff did not routinely offer snacks to residents. During a confidential Resident Council meeting, all six residents present confirmed that they were not offered any bedtime snacks. The facility's policies and procedures, dated June 2017, stated that meals should be served at the specified times, but there was no specific policy for snacks. The Dietary Manager (DM) indicated that staff could request snacks for residents, but options were not provided to them. The DM also mentioned that the spring menu did not include options for alternative meals, unlike the fall and winter menus. This lack of communication and failure to offer snacks as required contributed to the deficiency.
Expired Food Item Found in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not properly storing and disposing of expired food items in the kitchen. During an observation, a large plastic bag of graham cracker crust was found in the freezer, which had expired. The dietary staff did not dispose of this expired food item, which is a violation of the facility's food storage policy. The Dietary Manager (DM) confirmed the surveyor's observations during an interview and acknowledged the oversight in food storage. The DM admitted responsibility for ensuring proper storage of food products and recognized the potential risk of food-borne illness from serving expired food. The facility's policy on food receiving and storage mandates that food must be labeled and dated according to applicable regulations, which was not followed in this instance.
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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.
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Nursing homes near Mckinney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Of Mckinney | 3.5 mi | — | 0 | 0 |
| North Park Health And Rehabilitation Center | 3.9 mi | — | 0 | 0 |
| Belterra Health & Rehab | 4.4 mi | — | 0 | 0 |
| The Belmont At Twin Creeks | 4.6 mi | — | 3 | 0 |
| Victoria Gardens Of Allen | 4.8 mi | — | 13 | 0 |
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