Federal inspection record · CMS data as of October 1, 2026
Villa Haven Health And Rehabilitation Center
300 S Jackson St, Breckenridge, TX · (254) 559-3386
- Certified beds
- 92
- Residents per day
- 35
- Ownership
- Government
- Chain
- Fundamental Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- March 18, 1994
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change (already 5)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Villa Haven Health And Rehabilitation Center carries 19 inspection points. That is fewer than 93% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
9 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Infection Control3E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Administration2E
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- C
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Resident Assessment and Care Planning2E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service1D
- D
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.
Nutrition and Dietary1E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspection history
2026-03-13
3 health deficiencies · 5 fire-safety deficiencies
Top issue: Administration (2 deficiencies)
2024-12-19
2 health deficiencies · 1 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2023-11-02
4 health deficiencies · 3 fire-safety deficiencies
Top issue: Infection Control (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 34 min of nursing staff time a day, 22 min of it from a registered nurse.
This home
3 h 34 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 65% of nursing staff and 80% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.2 pts better | 0.8 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.3 pts worse | 2.3 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.6 pts better | 100.0% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 100.0% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.4 pts worse | 5.6% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.6 pts worse | 2.9% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts better | 1.2% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.1 pts worse | 17.9% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.5 pts better | 4.3% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.5 pts better | 7.4% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.6 pts better | 11.2% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.5 pts better | 12.0% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.9 pts better | 1.8% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11.3 pts better | 100.0% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit11.2 pts worse | 23.4% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine7.2 pts better | 92.6% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission7 pts better | 18.5% | 25.5% | 23.4% |
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Who owns and runs it
14 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Childress County Hospital District | 5% Or Greater Direct Ownership Interest · Organization | 100% | 11 facilities |
| 300 South Jackson LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Breckeridgetx LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Empower Healthcare Management LLC | Adp Of The SNF · Organization | 0% | 4 facilities |
| Empower Opco LLC | Adp Of The SNF · Organization | 0% | 4 facilities |
| Gray, Deanne | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Gray, Deanne | Adp Of The SNF · Individual | 0% | 1 facilities |
| Holcomb, Holly | Corporate Officer · Individual | 0% | 12 facilities |
| Mistretta, Cassandra | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 11 facilities |
| Pfeifer, Mary | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Prater, William | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Prater, William | Adp Of The SNF · Individual | 0% | 1 facilities |
| Stratton, Emilee | Corporate Officer · Individual | 0% | 11 facilities |
| Texas Senior Realty Ventures LLC | Adp Of The SNF · Organization | 0% | 4 facilities |
·
Fire safety
9 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Services3C
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Smoke2E
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous2F
- F
Have simulated fire drills held at unexpected times.
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Emergency Preparedness1F
- F
Implement emergency and standby power systems.
Gas, Vacuum, and Electrical Systems1F
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
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Other homes nearby
-
Premier Health Care Center
Ranger, TX
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- —
- Fines
- $14,069
-
Avir at Woodlands
Eastland, TX · Avir Health Group
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 30 min
- Fines
- $85,613
-
Avir at Cisco
Cisco, TX · Avir Health Group
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 25 min
- Fines
- $0