Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Village At Gleannloch Farms during CMS and state inspections, most recent first.
Expired and undated medications were found in Medication Cart B and the medication storage room. Surveyors observed two albuterol inhalers and a fluticasone-salmeterol inhaler for a resident without proper open-date control, along with expired Juven packets and glucose test strips without an open date. In the storage room, an expired Align probiotic was also found. RN and the DON stated staff were responsible for checking expiration dates and dating opened items.
Medication error rate exceeded the allowed threshold after an RN missed three ordered meds for a resident during a med pass. The resident had normal cognition and orders for Fluticasone nasal spray, Biotin, and Magnesium Oxide, but the RN forgot the Fluticasone and stated she likely checked off the Biotin and Magnesium without pulling them. The DON said staff were expected to check off meds while pulling them and not save the MAR until after the resident took the meds.
The facility failed to accurately document MDS assessments for three residents, leading to deficiencies in care documentation. A resident with a history of falls had incidents not recorded in her MDS, while two other residents on oxygen therapy had their treatments omitted from their MDS assessments. The MDS Coordinator acknowledged these oversights, citing human error and the absence of a formal policy for MDS completion.
A resident with heart failure and atrial fibrillation was receiving 4L of oxygen instead of the physician-ordered 2L. Despite awareness of the discrepancy, the LVN did not update the order, and the DON acknowledged the oversight, emphasizing the importance of matching physician orders with actual care provided.
The facility failed to assess and obtain necessary consents and orders for bed rail use for two residents. One resident, with a history of spinal surgery, was observed with bed rails before any formal assessment or order. Another resident, with vascular dementia, also had bed rails without required documentation. Staff interviews confirmed the facility did not follow its policy for bed rail use, potentially risking resident safety.
The facility failed to ensure sanitary conditions in the kitchen by not enforcing the use of hair restraints. An individual was observed preparing food without a hair net, which was acknowledged as a mistake by another staff member. The facility's policy requires hair coverings to prevent contamination, and the Administrator confirmed the importance of this practice.
A resident with a PICC line for IV antibiotic therapy was not properly cared for under Enhanced Barrier Precautions (EBP) by CNA B, who failed to wear PPE and change gloves during incontinence care. Despite clear signage, CNA B was unaware of the required PPE, leading to potential cross-contamination. Interviews revealed a lack of understanding of EBP protocols among staff, although facility policies mandated training and PPE use during high-contact activities.
Expired and Undated Medications Found in Cart and Storage Room
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles for 1 of 2 medication carts and 1 of 1 medication storage rooms reviewed. In Medication Cart B, surveyors found 2 albuterol inhalers for Resident #24 without an open date, a Fluticasone-Salmeterol inhaler for Resident #24 with an open date of 8/3/25 that was past the 30-day limit, a box of Juven nutrition powder with 19 packets that had expired 9/1/25, and a bottle of glucose test strips without an open date and only good for 30 days after opening. Resident #24 was a female with diagnoses including COPD, Afib, dysphagia, dementia, major depression, HTN, anemia, and polyneuropathy. Her record showed she had COPD/asthma and shortness of breath when lying flat. Her care plan directed staff to give aerosols or bronchodilators as ordered and monitor for breathing difficulty. Her physician orders included Albuterol Sulfate inhalation aerosol, ordered 8/1/25 and discontinued 8/4/25, and Advair Diskus (fluticasone-salmeterol) ordered 8/4/25. In the medication storage room, surveyors found a box of Align probiotic with 7 capsules left that had expired 8/31/25. RN L stated there was no one assigned to monitor medications for expiration and said all nurses were responsible for checking dates when giving medications. The DON stated staff were expected to check expiration dates before administering medications, that someone checked the medication storage closet for expired medications, and that inhalers and glucose strips should be dated when opened because they were only good for 30 days.
Medication error rate exceeded threshold due to missed doses during med pass
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors found a 10% medication error rate, based on 3 errors out of 28 opportunities, involving 1 of 4 residents reviewed for medication administration. The errors involved Resident #13, a female with diagnoses including acute sinusitis, afib, major depression, osteoarthritis, GERD, HTN, polyneuropathy, a cardiac pacemaker, and arthrodesis. Her MDS showed a BIMS score of 15 out of 15, indicating normal cognition, and her care plan included medication management with a goal that she would be informed of her medication regimen. Record review showed orders for Fluticasone Propionate nasal spray 50 mcg/actuation, Biotin 5000 mcg, and Magnesium Oxide 400 mg. During an observation of the medication pass, RN A held some blood pressure medications because the resident's diastolic blood pressure was below 60 and did not give other medications that the resident refused, but 8 pills remained in the medication cup. In interview, RN A stated she forgot about the Fluticasone and said she must have checked off the Biotin and Magnesium but forgot to pull them, and she was not sure what happened because she did not check off the medications before pulling them. The DON stated staff were expected to check off medications in the system while pulling them and not save the screen until after the resident took the medication.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to conduct comprehensive and accurate assessments for three residents, leading to deficiencies in their care documentation. Resident #20, a female with severely impaired cognition and a history of falls, had two falls that were not documented in her Minimum Data Set (MDS) assessments. Despite having a care plan that identified her risk for falls and interventions in place, the MDS assessments did not reflect these incidents, which were recorded in her chart and care plan. Resident #8, who has normal cognition and is diagnosed with heart and lung conditions, was on continuous oxygen therapy as per her care plan and physician orders. However, her MDS assessment did not indicate the use of oxygen therapy, despite consistent documentation in her medical records and observations confirming her use of oxygen at 2 liters per minute via nasal cannula. Resident #2, with moderately impaired cognition and a history of respiratory issues, had physician orders for oxygen therapy as needed. Her MDS assessment failed to document this treatment, even though her medical records showed multiple instances of oxygen use. The MDS Coordinator acknowledged the oversight in the MDS documentation, attributing it to human error and a lack of a formal policy and procedure for completing the MDS, as the facility followed the RAI Manual.
Failure to Adhere to Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in maintaining the correct oxygen therapy as ordered by the physician. The resident, a male with a history of acute on chronic combined systolic and diastolic heart failure, atrial fibrillation, and hypertension, was observed to be receiving 4 liters of oxygen per nasal cannula instead of the 2 liters ordered by the physician. This discrepancy was noted over several days, with the resident consistently receiving the incorrect oxygen level. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) was aware of the discrepancy but did not update the order, citing the need for physician verification. The Director of Nursing (DON) acknowledged the oversight, stating that the physician's batch order was for 2 liters, but the resident had been on 4 liters. The DON emphasized that nurses are responsible for ensuring that physician orders match what the resident receives, and that failure to do so could lead to respiratory issues. The facility's policy on administering medications requires that they be administered as prescribed, highlighting the importance of adherence to physician orders.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain necessary consents and orders for the use of bed rails for two residents. For Resident #11, the facility did not initially assess the resident for the risk of entrapment or obtain a physician's order and informed consent before the use of bed rails. The resident, who had a history of spinal surgery and normal cognition, was observed with bed rails in use before any formal assessment or order was documented. The necessary documentation and orders were only completed after the facility became aware of the oversight. Similarly, for Resident #3, the facility did not secure a physician's order or informed consent for the use of bed rails. The resident, who had a history of vascular dementia and other significant health issues, was observed with bed rails in use without the required assessment and documentation. Despite the care plan indicating the need for an assessment and consent, these steps were not completed prior to the use of bed rails. Interviews with facility staff, including the DON and an LVN, confirmed that the proper procedures for bed rail use were not followed. The facility's policy required an interdisciplinary assessment, physician consultation, and informed consent before the use of bed rails, which were not adhered to in these cases. This failure to follow protocol could potentially place residents at risk of harm.
Failure to Ensure Hair Restraints in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not ensuring that staff wore appropriate hair restraints while preparing food. During an observation, it was noted that an individual, referred to as [NAME] A, was preparing meals without a hair restraint, specifically while sampling a pan of rice. This oversight was acknowledged by [NAME] B, who admitted it was a mistake and that [NAME] A usually wore a hair net. [NAME] A confirmed that he forgot his hat at home and recognized the importance of wearing a hair net to prevent cross-contamination and hair from getting into the residents' food. The facility's policy on personal hygiene, dated 9/4/2015, mandates the use of clean hats or other hair restraints to ensure food safety. The Administrator confirmed that all staff in the service prep area should wear hair coverings to maintain food sanitation. Despite quarterly training on this requirement, the responsibility for ensuring compliance was assigned to [NAME] B. The failure to adhere to these guidelines could potentially compromise the integrity of food sanitation, as noted by the Administrator.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA B during the care of a resident on Enhanced Barrier Precautions (EBP). The resident, a male with a history of cerebral infarction, acute endocarditis, muscle weakness, and lack of coordination, was admitted with a PICC line for IV antibiotic therapy. Despite the presence of an isolation sign and cart outside the resident's room, CNA B did not don any personal protective equipment (PPE) when providing incontinence care. She failed to change her gloves and sanitize her hands after handling the resident's soiled brief, subsequently touching various items in the room with contaminated gloves. Interviews with staff revealed a lack of understanding and adherence to EBP protocols. CNA C incorrectly believed that only gloves were required for EBP, while CNA B admitted to not knowing the appropriate PPE to wear, despite the presence of clear signage. LVN W and the Director of Nursing (DON) provided correct information regarding the necessity of wearing gowns, gloves, and masks for residents with indwelling devices or wounds, emphasizing the importance of changing gloves and performing hand hygiene during high-contact care activities. The facility's policies on hand hygiene and EBP were reviewed, highlighting the requirement for staff to be trained and regularly in-serviced on these protocols. The policies specified the use of gowns and gloves during high-contact activities, such as changing briefs, to prevent the spread of infections. Despite these policies, the incident with CNA B demonstrated a failure in implementing these procedures, potentially placing residents and staff at risk for cross-contamination and infection spread.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Broadmoor At Creekside Park | 5.1 mi | ★★★★★ | 11 | 1 |
| The Heights Of North Houston | 5.3 mi | ★★★★★ | 4 | 1 |
| Park Manor Of Cypress Station | 5.5 mi | ★★★★★ | 3 | 0 |
| Paradigm Northwest | 5.6 mi | ★★★★★ | 20 | 3 |
| The Woodlands Nursing And Rehabilitation Center | 5.9 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.