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VILLA HAVEN HEALTH AND REHABILITATION CENTER Inspection Report, Violations & Safety Grade (BRECKENRIDGE, Texas)

300 S JACKSON ST, BRECKENRIDGE, Texas 76424

Phone: 2545593386

CMS Overall:5/5

Overview & Bed Count

Certified Beds
92
Avg Residents/Day
35
Ownership
Government - Hospital district
Provider Type
Medicare and Medicaid
County
Stephens
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health5/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityTexas AvgDifference
RN Hours per Resident per Day0.370.44-0.07
Total Nurse Hours per Resident per Day3.573.42+0.15
CMS Staffing Rating2/51.9/5-
Nursing Staff Turnover64.7%50.8%-

Health Citation History

9 health citations on record

DateCategoryDescriptionSeverity
2026-03-13Administration DeficienciesProvide behavior health training consistent with the requirements and as determined by a facility assessment.E – Moderate Harm Potential
2026-03-13Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2025-12-27Administration DeficienciesFollow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.C – Minimal Harm Potential
2024-12-19Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2024-12-19Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-07-18Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2023-11-02Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E – Moderate Harm Potential
2023-11-02Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2023-11-02Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential

Fire Safety Citation History

9 fire safety citations on record

DateCategoryDescriptionSeverity
2026-03-13Emergency Preparedness DeficienciesImplement emergency and standby power systems.F – Moderate Harm Potential
2026-03-13Gas, Vacuum, and Electrical Systems DeficienciesHave a battery powered remote alarm panel in a location accessible by operating personnel.F – Moderate Harm Potential
2026-03-13Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2026-03-13Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2026-03-13Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.C – Minimal Harm Potential
2024-12-19Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.C – Minimal Harm Potential
2023-11-02Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2023-11-02Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.F – Moderate Harm Potential
2023-11-02Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.C – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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