Health inspection·November 26, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 (Resident #1) of 3 resident reviewed for medication administration. The facility failed to ensure MA G did not administer Resident # 1's morning medication late. This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication.Record review of Resident #1's face sheet dated 10/23/25 revealed she was a [AGE] year-old female admitted to the facility initial on 07/02/24 and readmitted on [DATE]. Resident #1 had diagnoses which included: hypertension(force of the blood pushing against the artery walls is consistently too high), epilepsy(brain disorder that causes repeated unprovoked seizures)heart failure (heart muscle cannot pulp enough blood and oxygen to meet the body's needs), and cerebral infarction (stroke where a part of the brain is damaged) Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS of 12 out of 15 indicating moderately impaired cognition. Further review revealed Resident #1needed maximal assistance with ADLs which required at least one staff assistance. Record review of Resident #1's care plan initiated on 08/19/25 revealed the following care areas: *Resident #1 had a seizure disorder. An intervention was to : administer anticonvulsant medication routinely as ordered by physician. *Resident #1 had anxiety. An intervention was to administer medication buspirone as ordered by physician. *Resident #1 had dementia and impaired thought processes. An intervention was to administer medication memantine as ordered. *Resident #1 had depression. An intervention was to administer antidepressant medications, Lexapro and trazodone as ordered by physician. Record review of Resident #1's order summary report for October 2025 read in part::*Acidophilus Probiotic Oral Tablet (Lactobacillus) 1 tablet by mouth one time a day for Supplement 500 start date 08/19/2025,* Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 table by mouth one time a day for Anemiastart date 08/27/2025, *Gabapentin Capsule 100 MG Give 1 capsule by mouth three times a day start date 01/27/2025, Levetiracetam Oral Tablet (Levetiracetam) Give 500 mg by mouth every 12 hours for Seizures start date 07/03/2024,Lexapro Oral Tablet 10 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for Anxiety start date 07/03/2024,Memantine HCI Oral Tablet 10 MG (Memantine HCI) Give 1 tablet by mouth two times a day for dementia start date 08/21/2025,Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) Give 0.5 tablet by mouth every 12 hours for depression and insomnia r/t depression start 10/12/2025,Triamterene-HCTZ Tablet 37.5-25 MG Give 1 tablet by mouth one lime a day for HF Hold for SBP less than 100 OR DBP < 60 Start date 04/29/2025,Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth one time a day for supplement start date 10/16/2024, and Buspirone HCI Oral Tablet 10 MG (buspirone HCI) Give 1 tablet by mouth one time a day for Anxiety start 02/13/2025Record review of Resident #1's MAR for October 2025 read as follows:*Acidophilus Probiotic 500 million CFU was scheduled for 8:00a.m once a Page 1 of 4 675696 675696 11/26/2025 Country Village Care 721 W Mulberry Angleton, TX 77515

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few day*Ferrous Sulfate Tablet 325 (65 Fe) mg was scheduled for 8:00a.m. once a day*Lexapro Oral Tablet 10 mg (Escitalopram Oxalate) was scheduled for 8:00a.m. once a day*Zinc Oral Tablet 50 MG(Zinc) was scheduled for 8:00 a.m. once a day*Trazodone HCI Oral Tablet50 MG (Trazodone HCI) Give 0.5 tablet every 12 hours was scheduled for 8:00 a.m. and 8:00 p.m.*Memantine HCI Oral Tablet 10MG (Memantine HCI) Give 1 tablet by mouth two times a day was scheduled for 8:00 a.m., and 7:00 p.m.*Gabapentin Capsule 100MG was scheduled for 8:00a.m.,1:00 p.m., and 6:00p.m., three times at *Triamterene-HCTZ Tablet 37.5-25 MG scheduled for 7:00a.m for once a day*Levetiracetam Oral Tablet (Levetiracetam) Give 500 mg by mouth every 12 hours for Seizures scheduled for 7:00 a.m. and 7:00p.m.*Buspirone HCL 10mg was scheduled for 9:00a.m., for once a day.During observation and interview on 10:23/25 at 10:49 a.m., it was revealed that MA G's computer screen showed that all morning medication for Resident #1 was marked red. MA G said the computer screen was red because she did not administer the medication as scheduled. The surveyor observed MA G administered the following medications at 10:49 a.m.: *Acidophilus Probiotic Oral Tablet (Lactobacillus), *Ferrous Sulfate Tablet 325 (65 Fe), *Gabapentin 100 mg, *Levetiracetam 500 mg, *Lexapro 10 mg, Memantine HCI 10 mg, *Trazodone HCI 50 mg, *Triamterene-HCTZ Tablet 37.5-25 mg, *Zinc 50 mg, and Buspirone HCI 10 mg. During an interview on 10/23/25 at 3:10 p.m., MA G said she did not give Resident #1's morning medication on time today, because she was late passing medication. MA G said she did not follow the physician's order because she did not administer all of Resident #1's morning medication on time. MA G said she did not give Resident #1's seizure medication on time, and it could have caused the resident to have a seizure. MAG said Resident#1's blood pressure would start to go high because she did not get her blood pressure medication on time, and she could have a change in behavior because she did not get her anxiety medication. MA G said she did not tell the nurse today that she gave Resident #1 her medication late. MA G said she was supposed to report to the nurse if medication was not given on time, as residents could experience side effects. During an interview on 10/23/25 at 3:01 p.m., LVN J said MA G did not tell her she gave Resident #1's morning medication late. She said if MA G gave Resident #1 medication late, it could affect the resident negatively, because medication such as Keppra should be given as prescribed to prevent Resident #1 from getting seizures or blood pressure medication to avoid the resident's blood pressure from going high, which could cause a stroke. She said MA G should have told her, and she would have notified the physician, who would have given further instructions, and she would have followed the physician's instructions.During an interview on 10/23/25 at 3:45 p.m., the DON said she was not made aware that MA G did not give Resident #1's morning medication on time. The DON said MA G should have administered the medications per the doctor's order. She said MA G should have told LVN J she had administered Resident #1's medication late, so the nurse would assess the resident and notify the physician. The DON said the Physician would give an order to change the medication times when one medicine was given multiple times a day. She said if the resident was not given her seizure medication on time, the resident could have a seizure, and if it is given too close to the previous dose, it could cause sedation for the resident. The DON said that if MA G did not give Resident #1's blood pressure medicine on time, it could cause the resident's blood pressure to go up. The DON said that if Resident #1 did not get her depression or anxiety medication, it could affect the resident's behavior.During a telephone interview on 10/27/25 at 2:35 p.m., NP B stated she would not be the person facility staff would report to if there were concerns about Resident #1's medication. She said she was not sure whether the facility staff had notified the physician. She said, as a general rule, the medication should be administered as scheduled, with the dose given 1 hour before or 1 hour after. NP B stated that after one hour, it would be considered late medication administration. She said she 675696 Page 2 of 4 675696 11/26/2025 Country Village Care 721 W Mulberry Angleton, TX 77515

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 675696 Page 3 of 4 675696 11/26/2025 Country Village Care 721 W Mulberry Angleton, TX 77515

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 . 675696 Page 4 of 4