Villa Haven Health And Rehabilitation Center
Inspection Findings
F-Tag F0844
F 0844 Level of Harm - Potential for minimal harm Residents Affected - Many
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
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
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
VILLA HAVEN HEALTH AND REHABILITATION CENTER in BRECKENRIDGE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRECKENRIDGE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VILLA HAVEN HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.