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Data from CMS, Census Bureau & CareScout. Not affiliated with the U.S. government.

© 2026 NursingHomes.us. All data from CMS.gov.
HomeTexasMillbrook Healthcare and Rehabilitation Center

Millbrook Healthcare and Rehabilitation Center

1850 W Pleasant Run Rd, Lancaster, TX 751469722751900
1/5Much Below Average
Accepts Medicare Accepts Medicaid Sprinkler System
Health
2/5
Staffing
1/5
Quality
4/5
Beds
124
certified
1 fine(s) totaling $13,565

Key Findings

• 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.

Beds
124
Avg Residents/Day
80.3
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
In Hospital
No
First Approved
Jul 25, 2008
Sprinklers
Yes
Council
Resident
County
Dallas
Last Inspection
Feb 11, 2025
Deficiencies (Cycle 1)
14
Weighted Score
145.3
Infection Citations
0

Deficiency Citations (24)

F0550Potential for Harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey: Dec 3, 2025Corrected: NoCycle: 1
F0656Potential for Harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey: Dec 2, 2025Corrected: NoCycle: 1
F0755Potential for Harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey: Dec 2, 2025Corrected: NoCycle: 1
F0695Potential for Harm

Provide safe and appropriate respiratory care for a resident when needed.

Survey: Dec 1, 2025Corrected: NoCycle: 1
F0628Potential for Harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Survey: Sep 9, 2025Corrected: NoCycle: 1
F0583Potential for Harm

Keep residents' personal and medical records private and confidential.

Survey: May 7, 2025Corrected: NoCycle: 1
F0755Potential for Harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey: May 7, 2025Corrected: NoCycle: 1
F0761Potential for Harm

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.

Survey: May 7, 2025Corrected: NoCycle: 1
F0550Potential for Harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey: Feb 11, 2025Corrected: NoCycle: 1
F0558Potential for Harm

Reasonably accommodate the needs and preferences of each resident.

Survey: Feb 11, 2025Corrected: NoCycle: 1
F0641Potential for Harm

Ensure each resident receives an accurate assessment.

Survey: Feb 11, 2025Corrected: NoCycle: 1
F0677Potential for Harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey: Feb 11, 2025Corrected: NoCycle: 1
F0812Potential for Harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey: Feb 11, 2025Corrected: NoCycle: 1
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Feb 11, 2025Corrected: NoCycle: 1
F0584Potential for Harm

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.

Survey: Oct 11, 2024Corrected: NoCycle: 2
F0850Potential for Harm

Hire a qualified full-time social worker in a facility with more than 120 beds.

Survey: Jan 10, 2024Corrected: NoCycle: 2
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Jan 10, 2024Corrected: NoCycle: 2
F0880Immediate Jeopardy

Provide and implement an infection prevention and control program.

Survey: Nov 29, 2023Corrected: NoCycle: 3
F0580Immediate Jeopardy

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey: Feb 10, 2023Corrected: NoCycle: 3
F0757Immediate Jeopardy

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey: Feb 10, 2023Corrected: NoCycle: 3
F0756Potential for Harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey: Oct 19, 2022Corrected: NoCycle: 3
F0812Potential for Harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey: Oct 19, 2022Corrected: NoCycle: 3
F0842Potential for Harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey: Oct 19, 2022Corrected: NoCycle: 3
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Oct 19, 2022Corrected: NoCycle: 3
Total Fines
$13,565
Number of Fines
1
Payment Denials
0
Total Penalties
1

Penalty History

FineNov 29, 2023
$13,565

Staffing hours per resident per day. The black line shows the national average.

Nurse Aide1.89 hrs
National avg: 2.35 hrs
LPN1.12 hrs
National avg: 0.86 hrs
RN0.15 hrs
National avg: 0.68 hrs
Total Nursing3.16 hrs
National avg: 3.89 hrs
Weekend Total2.63 hrs
National avg: 0.00 hrs
Physical Therapist0.27 hrs
National avg: 0.07 hrs
Total Turnover
65.8%
RN Turnover
0.0%
Administrators Left
0

Quality measures as percentages of residents. Lower is better for all measures.

Ownership Type
For profit - Limited Liability company
Recent Change
No

Owners & Managers (6)

NameRoleTypeOwnership %Since
HAMILTON COUNTY HOSPITAL DISTRICT5% OR GREATER DIRECT OWNERSHIP INTERESTOrganization100%Dec 1, 2023
BLUEBONNET HEALTHCARE, INC.OPERATIONAL/MANAGERIAL CONTROLOrganizationN/ADec 1, 2023
BURNAM, SOONOPERATIONAL/MANAGERIAL CONTROLIndividualN/ADec 1, 2023
MADISON, KRISTENOPERATIONAL/MANAGERIAL CONTROLIndividualN/ADec 1, 2023
HOOPER, GRADYCORPORATE OFFICERIndividualN/ADec 1, 2023
MADISON, KRISTENCONTRACTED MANAGING EMPLOYEEIndividualN/ADec 1, 2023

Nearby Nursing Homes

All Texas facilities

Windsor Gardens

Lancaster, TX · 150 beds

For profit$13,877 in fines
Health
Staffing
Quality
3996 ft

Avir at Lancaster

Lancaster, TX · 110 beds

For profit$39,757 in finesAbuse
Health
Staffing
Quality
1.7 mi

Lancaster Nursing & Rehabilitation

Lancaster, TX · 120 beds

For profit$55,760 in fines
Health
Staffing
Quality
2.0 mi

Frequently Asked Questions

What is the CMS rating for Millbrook Healthcare and Rehabilitation Center?▾
Millbrook Healthcare and Rehabilitation Center has an overall CMS rating of 1 out of 5 stars, with a health inspection rating of 2/5, staffing rating of 1/5, and quality measures rating of 4/5. This facility is rated below average.
Has Millbrook Healthcare and Rehabilitation Center had any health inspection violations?▾
Millbrook Healthcare and Rehabilitation Center had 14 deficiency citations in its most recent health inspection (Feb 11, 2025). The facility has been fined a total of $13,565 across 1 fine(s).
What are the staffing levels at Millbrook Healthcare and Rehabilitation Center?▾
Millbrook Healthcare and Rehabilitation Center provides 3.16 total nursing staff hours per resident per day, including 0.15 RN hours, 1.12 LPN hours, and 1.89 nurse aide hours. The total staff turnover rate is 65.8%.
How many beds does Millbrook Healthcare and Rehabilitation Center have?▾
Millbrook Healthcare and Rehabilitation Center has 124 certified beds with an average of 80.3 residents per day, resulting in approximately 65% occupancy. The facility is For profit - Limited Liability company owned and is part of the The Ensign Group chain.
Are there other nursing homes near Millbrook Healthcare and Rehabilitation Center?▾
Yes, there are 3 other nursing homes in Lancaster, Texas with an average rating of 1.8/5. You can compare all facilities on the Lancaster nursing homes page.

Part of The Ensign Group

This chain operates 324 facilities. View all →