• CMS rates this facility 1/5 stars (below average)
• Has 124 certified beds with an average of 80.3 residents per day (65% occupancy)
• Last health inspection found 14 deficiencies (inspected Feb 11, 2025)
• Has been fined a total of $13,565 across 1 fine(s)
• Total nursing staff: 3.16 hours per resident per day
• Staff turnover rate: 65.8% (high)
• Part of the The Ensign Group chain (324 facilities)
Millbrook Healthcare and Rehabilitation Center is a 1-star Medicare and Medicaid certified nursing home in Lancaster, Texas with 124 certified beds. It has been operating since 2008. The facility scored below average compared to Texas facilities.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide safe and appropriate respiratory care for a resident when needed.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Keep residents' personal and medical records private and confidential.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure 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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Ensure each resident receives an accurate assessment.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Honor 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.
Hire a qualified full-time social worker in a facility with more than 120 beds.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Staffing hours per resident per day. The black line shows the national average.
Quality measures as percentages of residents. Lower is better for all measures.
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| HAMILTON COUNTY HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | Dec 1, 2023 |
| BLUEBONNET HEALTHCARE, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | N/A | Dec 1, 2023 |
| BURNAM, SOON | OPERATIONAL/MANAGERIAL CONTROL | Individual | N/A | Dec 1, 2023 |
| MADISON, KRISTEN | OPERATIONAL/MANAGERIAL CONTROL | Individual | N/A | Dec 1, 2023 |
| HOOPER, GRADY | CORPORATE OFFICER | Individual | N/A | Dec 1, 2023 |
| MADISON, KRISTEN | CONTRACTED MANAGING EMPLOYEE | Individual | N/A | Dec 1, 2023 |
This chain operates 324 facilities. View all →