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Complaint Investigation

Country Village Care

November 26, 2025 · Angleton, TX · 721 W Mulberry
Citations 2
CMS Rating 1/5
Beds 136
Provider ID 675696
Healthcare Facility
Country Village Care
Angleton, TX  ·  View full profile →
Inspection Summary

Country Village Care in Angleton, TX — inspection on November 26, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0755
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

did not think that 2 to 3 hours would have any adverse effect on Resident #1.

She said it is crucial to give medication on time. NP B said that because Resident #1 did not have a seizure when MA G did not administer Resident #1's medication on time, it did not mean she could not have had a seizure.During a telephone interview on 10/27/25 at 3:31 p.m., NP A said she was only notified that MA G had given Resident #1's seizure medication late, and she gave the order to move the second dose to 10:00 p.m. and resume the regular medication administration time tomorrow.

She said Resident #1 would not get any acute change because MA G gave the seizure medication late one time, but she was not saying MA G should not administer medication as ordered. NP A said she would say no because she adjusted the seizure medication time. NP A said she was not notified about Resident #1's other morning medications, and she did not make any time changes for those medications.

She stated that medicines administered more than once or twice a day should have at least 8 hours between doses. NP said medication should be administered as ordered.

During an interview on 1/27/25 at 3:44 p.m., the Surveyor requested a timestamp for Resident #1's morning medication administration from 10/20/25 through 10/23/25, and the DON said she did not know how to pull the timestamp.

Record review of the facility undated medication administration, general read in part .4.

Medications are considered to be administered timely, in general, if given 1 hour before or 1 hour after the designated time. 5.

Remember the six (6) Rs of correct medication administration. e.

Right Time Verify against the MAR.

Record review of the facility undated pharmacy services read in part . procedure: the facility must: 2.

Provide pharmaceutical services (including procedures that assure .dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Village Care

721 W Mulberry Angleton, TX 77515

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, record review, and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1(station A) of 3 medication aide cart, reviewed for medications storage.-

The facility failed to ensure MA G did not leave Station A's MA medication cart unattended.

This failure could affect residents, placing them at risk for taking medication which could affect the resident's health, requiring medical intervention and drug diversion.

The findings include: During an observation on 10/23/25 at 9:52 a.m., surveyor observed MA G parked the unlocked station A medication aide's cart close to the TV room and the dining area.

There were six residents in the TV area, and several residents were propelling themselves around the area.During an observation and interview on 10/23/25 at 9:54 a.m., LVN J said she could see MA G had left station A medication aide's cart unlocked. LVN J said MA G should always lock station A medication aide cart for safety.

She said MA G should have locked the medication to prevent residents from accessing the medication cart and taking any medication. LVN J said when station A medication aide's cart was left unlocked, it would cause medication errors because anybody could get into the cart and take any medication.

She said if the resident had taken any medication from the cart and administered the medication to himself, it could be harmful for the resident because the resident took the medication he was not supposed to take.

During an interview on 10/23/25 at 3:29 p.m., MA G said she should have locked the station A medication aide cart when not in use or out of sight.

She said she forgot to lock the cart when she went to the restroom, because she was moving very fast. MA G said it was a safety hazard issue because a resident could get into the cart and take medicine, which could harm the resident.

During an interview on 10/23/25 at 3:41 p.m., the DON stated nurses and medication aides are supposed to lock their carts when not in use.

The DON said the medication aides' carts are supposed to be locked to prevent residents from getting into them, and they have many residents with dementia.

She said there could be a thief if staff or anyone else took medication from the unlocked cart.

The DON said if a resident takes medication from Station A medication aide's cart and administers the medication to himself, the resident could overdose or be exposed to other side effects.

She said Station A medication aide cart contained all the residents' medication in 200 hall.

Record review of the facility undated storage of medication storage policy read in part . ensure that all medications are stored in a safe, secure. procedure #6 . compartments containing medications are locked when not in use .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Angleton, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Country Village Care or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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