Cycle 1
Health 2024-12-19 · Fire 2024-12-19
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Breckenridge, TX
Villa Haven Health And Rehabilitation Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
300 S Jackson St, Breckenridge, TX
(254) 559-3386
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
30
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
1994-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
1.29
Licensed practical nurse staffing
Aide hours / resident day
2.17
Nurse aide staffing
Weekend hours
3.36
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
97.9%
1.7 pts worse
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
2.7%
0.4 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
18.9%
4.2 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
10.8%
7.8 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.6% |
15.4%
5.8 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
16.1%
1.2 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.2% |
15.0%
11.8 pts better
|
19.8%
16.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.2%
3.2 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
12.0%
2 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
25.9%
3.6 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-09-08 · Fire 2022-09-08
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2024-12-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-11-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-11-02
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-20
C · Minimal harm
2023-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-20
Inspection history
Recent health citations
C · Minimal harm
2025-12-27
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2026-01-14
E · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-06
E · Potential for more than minimal harm
2023-11-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-21
E · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-20
E · Potential for more than minimal harm
2022-09-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-09-23
B · Minimal harm
2022-09-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-09-23
Penalties and ownership
What sits behind the stars
Ownership
Childress County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Childress County Hospital District
Operational/Managerial Control · Organization
Holcomb, Holly
Corporate Officer · Individual
Holcomb, Holly
W-2 Managing Employee · Individual
Smith, Kasha
W-2 Managing Employee · Individual
Stratton, Emilee
Corporate Officer · Individual
Stratton, Emilee
W-2 Managing Employee · Individual
Villa Haven Health Care LLC
Operational/Managerial Control · Organization
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#3
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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