Inspection Reports for Country Village Care
721 W MULBERRY ST., ANGLETON, TX, 77515
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 26, 2025
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to provide pharmaceutical services meeting the needs of residents, specifically medication administration timeliness and medication storage safety.
Complaint Details
The complaint investigation found that medication aide MA G administered Resident #1's morning medications late, did not report the late administration to nursing staff, and left a medication aide cart unlocked, risking resident safety. Interviews with staff and the Director of Nursing confirmed these findings and the potential risks involved.
Findings
The facility failed to ensure timely administration of morning medications for Resident #1, which could place residents at risk for adverse effects. Additionally, the facility failed to ensure that medication carts were properly locked, posing a risk of unauthorized access and potential medication errors.
Deficiencies (2)
Failure to provide pharmaceutical services to meet the needs of each resident, including timely administration of medications.
Failure to ensure drugs and biologicals were stored in locked compartments; medication aide cart was left unlocked, risking resident access and medication errors.
Report Facts
Residents reviewed for medication administration: 3
Residents affected: 1
Medication administration times: 10
Medication aide cart residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA G | Medication Aide | Named in findings for late medication administration and leaving medication cart unlocked |
| LVN J | Licensed Vocational Nurse | Interviewed regarding late medication administration and medication cart safety |
| DON | Director of Nursing | Interviewed regarding medication administration and medication cart security policies |
| NP B | Nurse Practitioner | Interviewed regarding medication administration timing and reporting |
| NP A | Nurse Practitioner | Interviewed regarding medication order adjustments after late administration |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in a resident with a Stage 4 sacral pressure ulcer.
Complaint Details
The complaint investigation found that the facility staff failed to provide treatment and care in accordance with professional standards for 1 of 5 residents reviewed for pressure ulcers. The resident's Stage 4 sacral pressure ulcer worsened significantly, antibiotics were not administered as ordered, and the resident developed infection and suspected sepsis. Immediate Jeopardy was identified on 2025-09-17 and removed on 2025-09-19, but the facility remained out of compliance.
Findings
The facility failed to ensure that a resident with a Stage 4 sacral pressure ulcer received proper treatment and care, including failure to administer prescribed antibiotics, resulting in wound deterioration, infection, and suspected sepsis. An Immediate Jeopardy was identified but later removed, with the facility remaining out of compliance at a severity level of no actual harm with potential for more than minimal harm.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Wound measurements: 2.2
Wound measurements: 1.1
Wound measurements: 0.1
Wound area: 2.42
Wound measurements: 5.4
Wound measurements: 6
Wound measurements: 2.3
Wound area: 32.4
Heart rate: 113
Antibiotic dosage: 300
Antibiotic duration: 10
Pain medication dosage: 50
Pressure ulcer onset date: 2024
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, nutrition, and care quality at Country Village Care nursing home.
Findings
The facility was found deficient in maintaining resident dignity by failing to provide privacy covers for urinary catheter bags for two residents, and in ensuring timely implementation of therapeutic diet orders for a resident with nutritional problems. These deficiencies posed risks of emotional distress, privacy violations, and potential health complications such as fluid overload.
Deficiencies (2)
Failed to provide privacy covers for urinary catheter bags for 2 residents, risking emotional distress and privacy violations.
Failed to ensure timely ordering and implementation of therapeutic diet and fluid restrictions for 1 resident, risking electrolyte imbalances and fluid overload.
Report Facts
Residents affected: 2
Residents affected: 1
Fluid restriction order: 1500
BIMS score: 14
BIMS score: 4
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding catheter privacy cover practices and issues | |
| CNA A | Interviewed regarding catheter privacy cover practices and issues | |
| DON | Director of Nursing | Interviewed regarding dignity issues and policy absence on catheter privacy covers |
| LVN B | Documented progress note for Resident #3 regarding fluid restriction orders | |
| MD A | Medical Doctor | Interviewed regarding diet orders, fluid restrictions, and resident compliance |
| Consultant Dietician | Interviewed regarding facility diet protocols |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide pharmaceutical services that meet the needs of residents, specifically concerning medication administration errors involving opioids.
Complaint Details
The complaint investigation focused on medication errors involving resident #1, who was administered morphine and Norco too closely together on 01/01/25, resulting in an opioid overdose. The resident was hospitalized, treated with Narcan, admitted to hospice, and died on 01/09/25. Family members reported concerns of overmedication prior to the incident.
Findings
The facility failed to ensure that resident #1's morphine and Norco medications were not administered too close together, resulting in an accidental opioid overdose on 01/01/25. An Immediate Jeopardy was identified but later removed after the facility implemented corrective actions including audits, staff education, and monitoring. The resident was hospitalized and later died from acute toxic encephalopathy related to the overdose.
Deficiencies (3)
Failure to provide pharmaceutical services to meet the needs of each resident, including accurate acquiring, receiving, dispensing, and administering of drugs.
Failure to ensure resident #1's morphine and Norco medications were not administered too close together to prevent accidental overdose.
Failure to ensure residents were free from significant medication errors.
Report Facts
Residents reviewed for pharmacy services: 5
Residents affected: 1
Residents with narcotic orders: 38
Residents with narcotic medication(s) discontinued: 12
Staff in-serviced: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Noted resident's lethargy and change in condition on 01/01/25, called doctor and 911 |
| DON | Director of Nursing | Provided information about resident's condition and medication management |
| MA B | Medication Aide | Interviewed about medication administration and familiarity with resident #1 |
| Doctor/Medical Director/Physician | Physician | Provided orders for morphine and Norco, explained medication use and overdose treatment |
| CNA C | Certified Nursing Assistant | Notified Nurse A of resident's condition change on 01/01/25 |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, quality of care, medication administration, infection control, food safety, and medication storage at Country Village Care nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, inadequate skin assessments and wound care, medication errors related to Midodrine administration, improper labeling of oxygen tubing, unsecured medication carts, improper food storage with dented cans, and lapses in infection prevention and control practices.
Deficiencies (7)
Failed to ensure the resident's right to formulate advance directives; Resident #165 did not have an active physician's order for code status.
Failed to provide appropriate treatment and care according to orders and resident preferences; Resident #59 had impaired skin integrity with untreated fungal infection and cellulitis.
Failed to provide safe and appropriate respiratory care; Resident #93's oxygen tubing was not labeled and dated as required.
Failed to ensure residents were free from significant medication errors; Midodrine was administered outside physician parameters to Resident #100.
Failed to ensure drugs and biologicals were stored and labeled properly; 200-hall treatment cart was left unlocked and unattended.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; seven dented cans were found in dry storage.
Failed to provide and implement an infection prevention and control program; improper hand hygiene and infection control practices observed during wound and incontinent care for Resident #31.
Report Facts
Residents reviewed for advance directives: 40
Residents reviewed for quality of care: 40
Residents reviewed for medication errors: 23
Medication administration errors: 2
Dented cans found: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in relation to leaving the 200-hall treatment cart unlocked. |
| LVN A | Licensed Vocational Nurse | Named in relation to improper infection control and hand hygiene during wound care for Resident #31. |
| CNA A | Certified Nursing Assistant | Named in relation to improper infection control and hand hygiene during incontinent care for Resident #31. |
| MA A | Medication Aide | Named in relation to medication administration error for Midodrine. |
| MA B | Medication Aide | Named in relation to medication administration error for Midodrine. |
| DON | Director of Nursing | Named in relation to oversight of medication administration and treatment cart security. |
| ADON | Assistant Director of Nursing | Named in relation to infection control oversight and expectations. |
| Dietary Supervisor | Dietary Supervisor | Named in relation to food storage and dented cans. |
Inspection Report
Routine
Deficiencies: 5
Date: Oct 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, quality of care, respiratory care, infection control, and food safety at Country Village Care nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, inadequate skin assessments and wound care for residents, failure to label and date oxygen tubing, improper food storage with dented cans, and lapses in infection prevention and control practices such as hand hygiene during wound and incontinent care.
Deficiencies (5)
Failed to ensure resident's right to formulate advance directives; missing active physician's order for code status for Resident #165.
Failed to provide appropriate treatment and care according to orders and resident preferences; inadequate skin assessments and wound care for Resident #59 resulting in redness, brown exudate, and pungent odor.
Failed to provide safe and appropriate respiratory care; Resident #93's oxygen tubing was not labeled and dated as required.
Failed to procure food from approved sources and store food safely; seven dented cans found in dry storage room.
Failed to implement infection prevention and control program; improper hand hygiene and infection control practices observed during wound care and incontinent care for Resident #31.
Report Facts
Residents reviewed for advance directives: 40
Residents reviewed for quality of care: 40
Residents reviewed for respiratory care: 40
Residents reviewed for infection control: 8
Dented cans found: 7
Skin assessment BIMS score: 10
Skin assessment BIMS score: 14
Skin assessment BIMS score: 7
Wound size: 11.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in infection control deficiency for improper hand hygiene during wound care for Resident #31 | |
| CNA A | Named in infection control deficiency for improper hand hygiene before incontinent care for Resident #31 | |
| MDS Nurse/LVN | Interviewed regarding advance directives and skin assessments | |
| DON | Director of Nursing | Interviewed regarding advance directives, skin assessments, wound care, and infection control |
| ADON | Assistant Director of Nursing | Interviewed regarding skin assessments, wound care, and infection control |
| Dietary Supervisor | Interviewed regarding dented cans found in dry storage | |
| CNA B | Interviewed regarding oxygen tubing and skin assessments | |
| RN D | Interviewed regarding skin assessments and oxygen tubing | |
| Admissions Nurse/LVN | Interviewed regarding oxygen tubing labeling and resident setup | |
| NP | Nurse Practitioner | Interviewed regarding wound care and resident refusals |
| MD | Physician | Interviewed regarding wound care and resident refusals |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 8, 2023
Visit Reason
The inspection was conducted based on complaints regarding pharmaceutical services, medication error rates, medication labeling and storage, and resident privacy concerns at the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about expired medications, medication errors, improper medication labeling and storage, and lack of resident privacy. The medication error rate was substantiated at 12%, exceeding the acceptable 5% threshold.
Findings
The facility failed to provide pharmaceutical services meeting residents' needs, including expired insulin vials in medication carts, a medication error rate of 12% exceeding the 5% threshold, improper medication administration via gastrostomy tube, and unlabeled insulin pens. Additionally, the facility did not ensure full visual privacy for residents in 7 rooms due to the use of free-standing privacy screens instead of ceiling-to-floor curtains.
Deficiencies (4)
Failed to provide pharmaceutical services including accurate acquiring, receiving, dispensing, and administering of drugs; expired insulin vials found in Courtyard station nursing cart.
Medication error rate of 12%, exceeding the 5% threshold; errors included improper administration of medications via gastrostomy tube and incorrect dosage given.
Drugs and biologicals not labeled in accordance with professional principles; undated opened insulin pens found in Parkside and Courtyard station nursing carts.
Failed to provide full visual privacy in 7 resident rooms; used free-standing privacy screens instead of ceiling-to-floor curtains.
Report Facts
Medication error rate: 12
Medication carts reviewed: 3
Residents affected by medication error: 2
Staff involved in medication errors: 2
Resident rooms lacking full privacy curtains: 7
Cubicle Curtain Track Packages ordered: 112
Bezel Privacy Curtains ordered: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Named in medication error finding for improper gastrostomy tube medication administration | |
| MA G | Named in medication error finding for administering incorrect dosage of Sodium Bicarbonate | |
| LVN S | Mentioned in relation to expired insulin vials and insulin pen labeling | |
| LVN G | Mentioned in relation to insulin pen labeling deficiencies | |
| DON | Director of Nursing | Provided interviews regarding medication administration, insulin labeling, and privacy issues |
| Administrator | Provided interviews regarding medication storage protocols and privacy curtain orders | |
| MA N | Provided interview regarding privacy screen effectiveness |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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