Home › Texas › Stephens County › Villa Haven Health and Rehabilitation Center
Villa Haven Health and Rehabilitation Center
300 S Jackson St, Breckenridge, TX 76424 · CMS Certification Number (CCN) 675279
At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 9 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 8 from complaints)
- Fire safety citations
- 9
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- March 13, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.7 | 3 |
| Health inspections | ★★★★★ 5 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | March 13, 2026 | 3 | 2 | 2 |
| Cycle 2 | December 19, 2024 | 6 | 2 | 6 |
CMS weighted health inspection score: 19 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
9 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
March 13, 2026: 2 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/06/2026 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/31/2026 |
December 27, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| C | F-0844 | Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Administration Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/14/2026 |
December 19, 2024: 2 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/09/2025 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/23/2024 |
July 18, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/06/2024 |
November 2, 2023: 3 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/20/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/21/2023 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/20/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
9 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 03/13/2026 | F | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 04/13/2026 |
| 03/13/2026 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 04/13/2026 |
| 03/13/2026 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/13/2026 |
| 03/13/2026 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/13/2026 |
| 03/13/2026 | F | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 04/13/2026 |
| 12/19/2024 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 12/20/2024 |
| 11/02/2023 | F | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
| 11/02/2023 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
| 11/02/2023 | C | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.45 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.45 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.02 | Not published | Not published |
| Nurse aide hours per resident per day | 1.98 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.99 | Not published | Not published |
| RN hours per resident per day, weekends | 0.34 | Not published | Not published |
| Total nursing staff turnover (%) | 60 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 100 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Childress County Hospital District
- Ownership type
- Government - Hospital district
- Chain
- Fundamental Healthcare (66 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 92
- Average residents per day
- 33.3
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- March 18, 1994
- County/parish
- Stephens
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
14 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| CHILDRESS COUNTY HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| HOLCOMB, HOLLY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRATTON, EMILEE | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BRECKERIDGETX LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GRAY, DEANNE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PFEIFER, MARY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PRATER, WILLIAM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MISTRETTA, CASSANDRA | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| 300 SOUTH JACKSON LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| EMPOWER HEALTHCARE MANAGEMENT LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| EMPOWER OPCO LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TEXAS SENIOR REALTY VENTURES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GRAY, DEANNE | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PRATER, WILLIAM | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Villa Haven Health and Rehabilitation Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.