Villa Haven Health And Rehabilitation Center
VILLA HAVEN HEALTH AND REHABILITATION CENTER in BRECKENRIDGE, TX — inspection on December 27, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, interviews, and record review, the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility.
The facility failed to notify the State Agency of a change in the facility's administrator.
This failure could result in the inability to connect with the appropriate leadership of the facility.
Findings included:
Record review of TULIP on 12/27/2025 at 8:30 a.m., reflected the name of the administrator of the facility did not match the ADM of the facility. In an observation on 12/27/25 at 12:11 p.m. of the facility posting on the wall near the nurse's station, the Administrator, abuse coordinator, named as ADM, was not the name in TULIP. In an interview on 12/27/25 at 12:27 p.m. with the ADM, she introduced herself as the facility Administrator.
This was not the name of the individual named in TULIP.
The ADM stated she started as the Administrator of this facility in March 2023. In an interview on 12/27/25 at 3:21 p.m. with CNA A, she stated that she started work at the facility in the past two to three months and the ADM is who she reported to with any report of abuse or neglect because ADM was the abuse coordinator. In an interview on 12/27/25 at 5:42 p.m. with the DON, she stated she started work at the facility on 10/6/25 and the ADM had been the only administrator since she had been there.
The DON stated she thought it would be the ADM that is responsible for letting the state agency know who the administrator was.In a follow-up interview on 12/27/25 at 6:43 p.m. with the ADM, she stated the change in TULIP of the facility's administrator should have been made by the previous owners because she had filled out a form and given it to them.
The ADM stated she knew she had to update the name of the administrator in TULIP because it was part of her license, and she would get it done.
Record review of the Facility Summary Report undated revealed the name of the administrator did not match the ADM.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
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