Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146 · CCN 676188
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★★☆ 4
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 124
- Avg residents/day
- 80.3
- Phone
- 9722751900
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-02-11 | 14 | 9.1 | 9.5 | +4.9 worse |
| 2 | 2024-01-10 | 3 | 9.4 | 9.8 | -6.4 better |
| 3 | 2022-10-19 | 5 | 8.1 | 9.3 | -3.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident assessment and care planning | 2 |
| Resident rights | 5 |
| Nutrition and dietary | 1 |
| Pharmacy service | 3 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.16 | 65.8% |
| RN staffing (reported) | 0.15 | — |
| Total nurse staffing (adjusted) | 3.13 | — |
Fines & penalties
- Total fines
- $13,565
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- THE ENSIGN GROUP
- Facilities in chain
- 329
- Chain avg overall
- 3.20 / 5
Inspection citations (22)1 immediate jeopardy
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-12-03 · Health · corrected 2025-12-04
Potential for more than minimal harm
- EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-12-02 · Health · corrected 2025-12-03
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-12-02 · Health · corrected 2025-12-03
Potential for more than minimal harm
- EF0695Provide safe and appropriate respiratory care for a resident when needed.2025-12-01 · Health · corrected 2025-12-02
Potential for more than minimal harm
- DF0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.2025-09-09 · Health · corrected 2025-09-26
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2025-05-07 · Health · corrected 2025-05-23
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-05-07 · Health · corrected 2025-05-23
Potential for more than minimal harm
- DF0761Ensure 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.2025-05-07 · Health · corrected 2025-05-23
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-02-11 · Health · corrected 2025-02-17
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2025-02-11 · Health · corrected 2025-02-17
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2025-02-11 · Health · corrected 2025-02-17
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-02-11 · Health · corrected 2025-02-17
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-02-11 · Health · corrected 2025-02-17
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-02-11 · Health · corrected 2025-02-17
Potential for more than minimal harm
- DF0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.2024-10-11 · Health · corrected 2024-10-14
Potential for more than minimal harm
- EF0850Hire a qualified full-time social worker in a facility with more than 120 beds.2024-01-10 · Health · corrected 2024-02-05
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-01-10 · Health · corrected 2024-02-05
Potential for more than minimal harm
- KF0880Provide and implement an infection prevention and control program.2023-11-29 · Health · corrected 2023-12-29
Immediate jeopardy
- EF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2022-10-19 · Health · corrected 2022-10-22
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-10-19 · Health · corrected 2022-10-22
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-10-19 · Health · corrected 2022-10-22
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2022-10-19 · Health · corrected 2022-10-22
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| HAMILTON COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2023-12-01 |
| BLUEBONNET HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-01 |
| BURNAM, SOON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-01 |
| MADISON, KRISTEN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-01 |
| HOOPER, GRADY | Individual | CORPORATE OFFICER | — | 2023-12-01 |
| MADISON, KRISTEN | Individual | CONTRACTED MANAGING EMPLOYEE | — | 2023-12-01 |
Other facilities in Lancaster
| Name | Overall | Beds |
|---|---|---|
| AVIR AT LANCASTER | ★★☆☆☆ | 110 |
| Lancaster Nursing & Rehabilitation | ★☆☆☆☆ | 120 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.