Country Village Care

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Village Care

721 W Mulberry Angleton, TX 77515

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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 .

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