Federal inspectors responding to a complaint on November 25 found the violations during their review of the facility's medication storage practices.
Resident #1, who was bed-bound, had wound care supplies stored inside her room instead of secured with nursing staff. The Assistant Director of Nursing, who also served as the wound care nurse, told inspectors she didn't know why the supplies were there.
"She would get the things needed for her wound care from her treatment cart," inspectors noted after interviewing the ADON.
But the nursing supervisor acknowledged the problem extended beyond one resident's inability to reach the supplies.
"Other residents might be able to use them aside from what they were intended to," she told inspectors.
Resident #4 presented an even more puzzling case. She had no wounds but kept wound cleansers in her room anyway. The ADON admitted she didn't know why.
The Director of Nursing explained the risks to inspectors in stark terms. Residents could use topical medications "without any assessment" and "might be using it more than as ordered and nobody would know."
She said skin barrier creams posed the same dangers when left accessible to residents.
The medication storage violations weren't isolated incidents. Multiple residents had access to supplies they shouldn't have been able to reach.
The DON told inspectors she worried about residents with psychological disorders who might enter rooms and misuse medications. The Administrator-in-Training echoed these safety concerns during his interview.
"Medications inside the rooms of the residents could be harmful for the residents," he told inspectors.
Both administrators acknowledged staff should scan resident rooms during their rounds specifically to prevent these violations. The expectation was clear, but the execution had failed.
The facility's own policy, last revised in July 2019, required all drugs and biological materials to be "stored in locked compartments." The medication supply should be "accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications."
Reality didn't match policy.
The DON had already begun damage control by the time inspectors arrived, starting an in-service about proper medication storage. The ADON suggested a basic fix: securing supplies "by putting them inside a plastic bag and put them inside the drawer."
But the violations revealed a broader breakdown in medication security protocols. Staff had left supplies accessible to residents who could misuse them, ignored facility policy requiring locked storage, and failed to notice the problems during routine room checks.
The Administrator-in-Training said staff should scan rooms during rounds "because medications inside the rooms of the residents could be harmful for the residents." Yet somehow multiple violations had persisted long enough to trigger a federal complaint investigation.
The DON and ADON promised to collaborate on addressing the medication storage issues. They acknowledged that residents might "eat, drink, or use them improperly" if given access to medications meant for controlled administration.
For Resident #1, bed-bound and unable to reach her wound care supplies, the violation meant treatment materials sat uselessly in her room instead of being properly secured with nursing staff who could monitor their use.
For Resident #4, the presence of wound cleansers she didn't need created unnecessary risk of misuse or confusion about her actual treatment needs.
The facility's medication access policy was seven years old and clearly stated. But on November 25, inspectors found a nursing home where basic medication security had broken down in multiple resident rooms, creating exactly the risks administrators said they were trying to prevent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mckinney Healthcare and Rehabilitation Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
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