Villa Haven Health and Rehabilitation Center
300 S Jackson St, Breckenridge, TX 76424 · Stephens County · 92 certified beds · avg 33 residents/day · certified since Mar 18, 1994
Part of chain: FUNDAMENTAL HEALTHCARE (66 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (9)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 13, 2026 | E · Potential for harm, repeated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 27, 2025 | C · Minimal risk, facility-wide | The facility did not follow the rules about disclosing who owns it, or did not tell the state agency about changes in ownership or key administrative staff. · from a complaint |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 18, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 2, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 2, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Nov 2, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (2 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 3 | 0 | E |
| 2025 | 1 | 0 | C |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.48 | 3.46 | 3.95 | top 36% in Texas; bottom 36% in the U.S. |
| Registered Nurse hours | 0.46 | 0.44 | 0.69 | top 33% in Texas; bottom 31% in the U.S. |
| Weekend total nurse staffing | 3.02 | 3.04 | 3.50 | top 40% in Texas; bottom 32% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.34 | 0.48 | top 38% in Texas; bottom 39% in the U.S. |
| Total nursing staff turnover (%) | 60.0 | 55.3 | 45.8 | bottom 33% in Texas; bottom 17% in the U.S. |
| RN turnover (%) | 100.0 | 54.6 | 42.9 | bottom 8% in Texas; bottom 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.45, RN 0.45, weekend 2.99. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Childress County Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2017 |
| 300 South Jackson LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
| Breckeridgetx LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2025 |
| Empower Healthcare Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
| Empower Opco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
| Gray, Deanne | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/20/2023 |
| Gray, Deanne | Individual | ADP of the SNF | NOT APPLICABLE | 03/20/2023 |
| Holcomb, Holly | Individual | Corporate Officer | NOT APPLICABLE | 05/29/2021 |
| Mistretta, Cassandra | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/24/2026 |
| Pfeifer, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2025 |
| Prater, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2025 |
| Prater, William | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
| Stratton, Emilee | Individual | Corporate Officer | NOT APPLICABLE | 03/18/2018 |
| Texas Senior Realty Ventures LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What training do your staff receive for caring for residents with dementia or mental health conditions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who owns this facility, and has ownership or top management changed recently?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Premier Health Care Center | 22.6 mi | Ranger, TX | ★☆☆☆☆ | 2/5 | |
| Avir at Woodlands | 24.6 mi | Eastland, TX | ★☆☆☆☆ | 1/5 | |
| Avir at Cisco | 26.8 mi | Cisco, TX | ★★★★★ | 5/5 | |
| Avir at Graham | 29.1 mi | Graham, TX | ★★★★★ | 5/5 | |
| Graham Oaks Care Center | 30.0 mi | Graham, TX | ★☆☆☆☆ | 2/5 | abuse |
| Avir at Baird | 38.6 mi | Baird, TX | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675279.