01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-13 | 3 | 2026-03-13 | 5 |
| Cycle 2 | 2024-12-19 | 2 | 2024-12-19 | 1 |
| Cycle 3 | 2023-11-02 | 4 | 2023-11-02 | 3 |
CMS CCN 6752792026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Villa Haven Health And Rehabilitation Center
300 S Jackson St · Breckenridge, TX 76424 · Stephens County
Certified beds92CMS provider file
Recent citation rows18current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
18 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-13 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2026-04-132026-03-13 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-13 · HEALTHF0949Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Correction field: Deficient, Provider has date of correction · 2026-04-06 · complaint2026-03-13 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-04-132026-03-13 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-04-132026-03-13 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2026-04-132026-03-13 · FIREK0916Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2026-04-132025-12-27 · HEALTHF0844Severity C · widespread; potential for minimal harm
Administration Deficiencies
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Correction field: Deficient, Provider has date of correction · 2026-01-14 · complaint2024-12-19 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-12-23 · complaint2024-12-19 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-01-09 · complaint2024-12-19 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-12-202024-07-18 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-08-06 · complaint2023-11-02 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-11-20 · complaint2023-11-02 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-11-21 · complaint2023-11-02 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-11-20 · complaint2023-11-02 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2023-11-202023-11-02 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2023-11-202023-11-02 · FIREK0741Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2023-11-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHILDRESS COUNTY HOSPITAL DISTRICTOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2017
- HOLCOMB, HOLLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/29/2021
- STRATTON, EMILEEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/18/2018
- BRECKERIDGETX LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2025
- GRAY, DEANNEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/20/2023
- PFEIFER, MARYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2025
- PRATER, WILLIAMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2025
- MISTRETTA, CASSANDRAIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/24/2026
- 300 SOUTH JACKSON LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2025
- EMPOWER HEALTHCARE MANAGEMENT LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2025
- EMPOWER OPCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2025
- TEXAS SENIOR REALTY VENTURES LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/01/2025
- GRAY, DEANNEIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/20/2023
- PRATER, WILLIAMIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.45per resident day
RN hours0.45per resident day
Weekend nurse hours2.99per resident day
Staff turnover60.0%CMS reported field
06 / LOCAL RECORDS
Open the Texas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.