Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa Haven Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Train Staff on Behavioral Health Needs: The facility failed to ensure 17 of 17 staff reviewed, including the ADMN, DON, SW, RNs, LVNs, CNAs, and other departments, had behavioral health training or an assessment tool related to behavioral health upon hire. Personnel file review showed no such training for these staff, and the ADMN stated she was responsible for ensuring staff were trained on resident behavioral health needs and that all staff should have received this training. The facility policy and assessment identified behavioral health needs among the resident census, including 2 residents with behavioral health needs.
Expired insulin syringes were found stored in the medication room after their expiration date. An LVN said the syringes could have caused infection if used, and the DON stated expired needle syringes were expected to be disposed of when they expired. The facility’s policy required sterile supplies to be routinely checked for expiration dates, but the expired items remained in a drawer.
The facility did not provide written notice to the State Agency about a change in administrator, as the name listed in the TULIP system did not match the current ADM. Staff interviews confirmed the ADM had been in the role for several months, but the state records were not updated to reflect this change.
The facility failed to maintain an effective infection prevention and control program, as staff did not perform proper hand hygiene between glove changes during care activities and failed to use gowns during foley catheter care. These deficiencies were observed in the care of residents with urinary incontinence, urinary tract infections, and unhealed pressure ulcers. Staff interviews revealed awareness of protocols, but lapses occurred, and the required EBP signage and PPE were not in place due to oversight.
A resident's care plan was not updated to reflect current dietary and advanced directive orders, despite having a diagnosis of dysphagia. The care plan inaccurately listed a pureed diet and Full Code status, while physician orders indicated a mechanical soft diet and DNR status. Staff interviews revealed a lack of responsibility in updating the care plan, with reliance on paper charts and meal tickets for accurate information.
A resident with diabetes and dementia experienced a lapse in infection control when an LVN failed to perform hand hygiene and used unclean surfaces during a blood sugar check. The LVN did not clean the medication cart or the resident's dressing table before placing supplies on them, and did not wash hands after the procedure. The facility's policy on cleaning and disinfecting glucometers was not adhered to, raising concerns about infection control practices.
Failure to Train Staff on Behavioral Health Needs
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in behavioral health for 17 of 17 staff reviewed, including the ADMN, DON, SW, AD, DM, MAINT, DOT, HKS, RN C, RN D, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I, and CNA J. Record review of personnel files showed these staff had no behavioral health training or assessment tool related to behavioral health upon hire, despite their varying hire dates and roles within the facility. During interview, the ADMN stated she was responsible for ensuring staff were trained on resident needs, including behavioral health, and that she assisted with the facility assessment, which included behavioral health. She stated the resident census included behavioral or mental health status and that all staff should have been trained on behavioral health. The ADMN also stated she was not aware there was a facility policy and was fulfilling it going forward. Record review of the facility policy titled Behavioral Health Services stated the facility was to ensure residents receive necessary behavioral health services, and the facility assessment signed by the ADMN identified that the facility cared for 2 residents with behavioral health needs and included mental health and behavior-related care requirements.
Expired insulin syringes found in medication room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles when five sealed sterile 30G x 5/16 1 mL insulin safety syringes with permanent needles were found in the medication room after their expiration date. During an observation of the medication room, the expired syringes were seen in a drawer. An LVN stated that expired needle insulin syringes could have caused infection if used and said she did not know why they were still in the medication room. She also stated that nurses and the supply aide were responsible for checking for and disposing of expired products. During interview, the DON stated her expectation was that expired needle syringes be disposed of when they reached the expiration date. She said she and the ADON checked the medication room twice monthly, but the expired syringes were not there when she had last checked. She stated nurses were responsible for checking expiration dates and disposing of expired goods, and she speculated that an agency nurse may have left the syringes in the medication room. Facility policy required sterile supplies to be routinely checked for expiration dates and replaced as necessary, and the facility document on expired products stated that expired sterile items should be removed immediately and disposed of.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's administrator. Record review of the TULIP system showed that the administrator listed did not match the current administrator (ADM) of the facility. Observations confirmed that the name posted in the facility as the administrator and abuse coordinator was not the same as the one recorded in TULIP. Interviews with the ADM revealed she had been serving as administrator since March 2023, but her name was not updated in the state system. Staff interviews further confirmed that the ADM was recognized as the administrator and abuse coordinator by employees, and the DON stated that the ADM had been the only administrator during her tenure. The ADM reported that she had completed the necessary form for the change and provided it to the previous owners, but the update was not made in TULIP. Review of the Facility Summary Report also showed a mismatch between the administrator's name and the ADM. No information about residents or their medical conditions was included in the report, and the deficiency centers solely on the failure to notify the State Agency of the change in facility administrator.
Infection Control Deficiencies in Hand Hygiene and PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) usage by staff members. Specifically, CNA-B and CNA-C did not perform hand hygiene between glove changes during incontinence care for a resident with urinary incontinence and a urinary tract infection. They also failed to wear gowns during foley catheter care for another resident with an indwelling catheter, which is required under Enhanced Barrier Precautions (EBP). Additionally, LVN-A did not perform hand hygiene between glove changes during wound care for a resident with multiple unhealed pressure ulcers. This lapse in protocol occurred while LVN-A was treating wounds on the resident's heel and sacrum, and before reaching into the medication cart to retrieve a cream for another treatment. These actions were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene in preventing the spread of infections. Interviews with the involved staff members revealed that they were aware of the infection control protocols but failed to adhere to them during the observed care activities. The facility's Infection Preventionist (IP) and Director of Nursing (DON) acknowledged the lapses in infection control practices and noted that the required EBP signage and PPE were not in place for a resident with an indwelling catheter, due to an oversight when the resident returned from the hospital.
Failure to Update Care Plan with Current Orders
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident #16, to include updated diet and advanced directive orders. The resident, who was admitted with a diagnosis of dysphagia, had a comprehensive care plan that did not reflect her current dietary needs or her advanced directive status. The care plan inaccurately listed her diet as pureed with thin liquids and her code status as Full Code, despite physician orders indicating a mechanical soft diet and a DNR status. Interviews with facility staff revealed a lack of responsibility and oversight in updating the care plan. The Licensed Vocational Nurse (LVN) stated that charge nurses did not revise care plans, and the Social Services Director (SSD) admitted to possibly forgetting to update the advanced directive due to indecisiveness from the resident's family. The Dietary Manager (DM) also acknowledged forgetting to update the care plan when the resident's diet changed. The Assistant Director of Nursing (ADON) and the Administrator (ADMN) confirmed that the care plans should reflect current orders, but they relied on paper charts and meal tickets for accurate information. The facility's policy on care plan processes emphasizes person-centered care and requires the Interdisciplinary Team (IDT) to review and revise care plans after each assessment. However, the failure to update Resident #16's care plan with the correct diet and advanced directive orders indicates a breakdown in this process. Staff interviews highlighted a reliance on paper charts and meal tickets rather than ensuring the care plan itself was accurate, which could potentially affect the resident's care and safety.
Infection Control Deficiency During Blood Sugar Check
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during a blood sugar check for Resident #1. LVN A did not perform hand hygiene before starting care, nor did she prepare a clean field to prevent cross-contamination. Supplies, including a glucometer and diabetic pins, were placed on a visibly dirty medication cart without being wiped down. LVN A then entered Resident #1's room, placed the supplies on the resident's dressing table without cleaning it, and proceeded with the blood sugar check. After obtaining a reading, LVN A left the room without washing her hands or performing hand hygiene, and when the glucometer fell on the floor, she picked it up and placed it back on the medication cart. Resident #1, a female with a history of diabetes mellitus, breast cancer, and dementia, required moderate assistance with daily activities and was frequently incontinent. The facility's policy on disinfection of patient care equipment, including blood glucose meters, was not followed, as LVN A acknowledged during an interview. The Director of Nursing was aware of concerns regarding infection control practices and expected nurses to follow proper procedures. The facility's policy emphasized the importance of cleaning and disinfecting glucometers between resident uses to prevent the transmission of bloodborne pathogens.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Breckenridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Premier Health Care Center | 22.6 mi | ★★★★★ | 3 | 1 |
| Avir At Woodlands | 24.6 mi | ★★★★★ | 15 | 0 |
| Avir At Cisco | 26.8 mi | ★★★★★ | 9 | 0 |
| Avir At Graham | 29.1 mi | ★★★★★ | 15 | 0 |
| Graham Oaks Care Center | 30 mi | ★★★★★ | 4 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.