Villa Haven Health and Rehabilitation Center
Breckenridge, Texas · CCN 675279
20 surveys since 2010, 3 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 59
- Surveys
- 20
- Harm or worse
- 3
- Immediate jeopardy
- 2
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 92
- Ownership
- Government - Hospital district
- Chain
- FUNDAMENTAL HEALTHCARE
- County
- Stephens · rural
- Medicare-certified since
- 1994
CMS ratings
- Overall
- 5
- Health inspection
- 5
- Staffing
- 1
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=12, floor 20).
Last survey on record
Mar 13, 2026
241 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.45 | 3.24 |
| Registered-nurse hours per resident day | 0.45 | — |
| Annual nurse turnover | 60.0% | 54.3% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D333.3% | E555.6% | F— |
| No harm, potential for minimal | A— | B— | C111.1% |
Most frequently cited here
In CMS’s current monthly file.
- F8803×
Provide and implement an infection prevention and control program.
- F6561×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6571×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F7611×
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.
- F8121×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
In the surveyor’s words
From the most serious findings on record at Villa Haven Health and Rehabilitation Center, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF801Jun 3, 2021
Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 1 (Dietary Manager) reviewed for qualified dietary staff. The facility failed to ensure the facility's only Dietary Manager (DM) met the requirements for a dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings: In an observation and interview at 06/01/2021 at 9:34 AM of the facility's only kitchen revealed Texas Food Handler Certificates were displayed and there was no certificate for a Dietary Manager. […]
- No harm, potential for more than minimal, patternF949Mar 13, 2026
Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 17 of 17 staff (ADMN, DON, SW, AD, DM, MAINT, DOT, HKS, RN C, RN D, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I and CNA J) reviewed for behavioral health training. The facility failed to ensure the ADMN, DON, SW, AD, DM, MAINT, DOT, HKS, RN C, RN D, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I and CNA J upon hire were trained for Behavioral Health or an assessment tool to behavioral health. This failure could place residents at risk of receiving care from incompetent/untrained staff. […]
- No harm, potential for more than minimal, patternF880Dec 19, 2024
48883 Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff (LVN-A, CNA-B, CNA-C) reviewed for infection control procedures. 1. The facility failed to ensure the CNA-B and CNA-C performed proper hand hygiene in between changing gloves during incontinent care. 2. The facility failed to ensure the LVN-A performed proper hand hygiene in between changing gloves during wound care and prior to reaching into medication cart. 3. The facility failed to ensure the CNA-B and CNA-C wore gown during foley catheter care. […]
- No harm, potential for more than minimal, patternF656Nov 2, 2023
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 3 of 3 (Resident #6, Resident #19, and Resident #30) residents reviewed for comprehensive care plans. 1. The facility failed to develop care plans based on assessed needs with measurable objectives and timeframes in areas such as risk for dehydration, exposure to infections, falls, skin breakdown, pain, and impaired nutrition, decline in psychosocial wellbeing, PASRR positive status, incontinence, presence of an ostomy, decreased vision, inability to perform ADL's, impaired… […]
- No harm, potential for more than minimal, patternF812Nov 2, 2023
Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to properly label food items in the refrigerators. The facility failed to separate spoiled food from other food items in the refrigerators. The facility failed to seal items to protect them from freezer burn in freezers. The facility failed to discard expired food items in the dry food storage areas. The facility failed to wash dishes at a safe temperature in a low temperature setting dishwashing machine. The facility staff failed to practice good hand hygiene while preparing and serving food. […]
Read 23 findings in full →The most serious and the most recent: 23 of 59 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 13, 2026Standard and complaint2 findings
- Dec 27, 2025Complaint1 finding
- Dec 19, 2024Standard and complaint2 findings
- Jul 18, 2024Complaint1 finding
- Nov 2, 2023Standard and complaint3 findings
- Sep 8, 2022Standard and complaint2 findings
- Jun 3, 2021Standard and complaint1 finding
- Feb 26, 2020Standard5 findings
Show the 12 earlier surveys
- Mar 20, 2019Standard2 findings
- Feb 1, 2018Standard2 findings
- Nov 9, 2016Standard1 finding
- Jan 22, 2016Standard2 findings
- Jun 5, 2015Complaint5 findings · 2 harm
- Oct 30, 2014Standard5 findings
- Apr 7, 2014Complaint1 finding
- Dec 12, 2013—7 findings
- Feb 1, 2013—10 findings · 1 harm
- Sep 17, 2012—1 finding
- Dec 8, 2011—5 findings
- Oct 21, 2010—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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