Villa Haven Health And Rehabilitation Center

Villa Haven Health And Rehabilitation Center was recognized and ceritified in 1994 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Villa Haven Health And Rehabilitation Center which is located in 300 S Jackson St Breckenridge, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Villa Haven Health And Rehabilitation Center is being offered ceritified services and products in Texas.
Address:   300 S Jackson St
       Breckenridge, TX 76424

Phone:   (254) 559-3386

County: Stephens
Federal Provider Number: 675279
Participates in: Medicare And Medicaid
Certified Date: Friday, March 18, 1994 (30 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Villa Haven Health Care Llc
Ownership Type: For Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationHunt Valley Holdings Llc5% Or More Ownership Interest
OrganizationFundamental Clinical Consulting, LlcOperational/managerial Control
OrganizationThi Of Baltimore, Inc.5% Or More Ownership Interest
OrganizationThi Of Texas Llc5% Or More Ownership Interest
PersonDari WellsW-2 Managing Employee
PersonDari WellsDirector/officer
PersonCharles StephensonW-2 Managing Employee
PersonCharles StephensonDirector/officer
PersonLeonard Grunstein5% Or More Ownership Interest
PersonMurray Forman5% Or More Ownership Interest

Provider Resides in Hospital: No
Number of Federally Certified Beds: 92
Number of Residents in Federally Certified Beds: 40 (44% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Resident
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Monday, April 7, 2014
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 14, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0274 (Review or revise the resident's care plan after any major change in physical or mental health.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0517 (Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missi)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 12, 2013
Survey Type: Health
Deficiency: F0518 (Train all employees on what to do in an emergency, and carry out unannounced staff drills.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, January 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0047 (Properly located and lighted "Exit" signs.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, March 28, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0046 (Emergency lighting that can last at least 1 1/2 hours.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 12, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, March 7, 2013
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, March 28, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0517 (Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missi)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0167 (Allow residents to easily view the results of the nursing home's most recent inspection.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, February 1, 2013
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 15, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 17, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, October 5, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, December 8, 2011
Survey Type: Health
Deficiency: F0248 (Provide activities to meet the interests and needs of each resident.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, January 12, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 8, 2011
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, January 12, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 8, 2011
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, January 12, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 8, 2011
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, January 12, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 8, 2011
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, January 12, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 31, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 31, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0045 (Proper backup exit lighting.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, January 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, January 12, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 31, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, January 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 6, 2011
Survey Type: Fire Safety
Deficiency: K0061 (Properly working alarms on sprinkler valves.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 31, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 1
Number of Substantiated Complaints: 4
Number of Fines: 1
Number of Payment Denials: 1
Total Number of Penalties: 2
Total Amount of Fines in Dollars: USD 1,300


Date of inspection that triggered the penalty: Friday, February 1, 2013
Penalty Type: Fine
Fine Amount: 1,300

Date of inspection that triggered the penalty: Friday, February 1, 2013
Penalty Type: Payment Denial
Date on which Medicare/Medicaid payment for new admissions was suspended: Friday, March 1, 2013
Number of days for which Medicare/Medicaid payment was suspended: 14
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (2 out of 5 stars)
Quality Rating (2 out of 5 stars)
Staffing Rating (3 out of 5 stars)
RN Staffing Rating (2 out of 5 stars)
Overall Rating (2 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
7%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
9%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
20%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
3%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
7%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
19%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
89%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
91%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
8%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
6%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
26%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
44%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
73%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
4%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
75%
84%

N/A
Data not available.

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Villa Haven Health And Rehabilitation Center [Federal No:675279] near 300 S Jackson St, Breckenridge TX

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