Millbrook Healthcare and Rehabilitation Center
Nursing Home · Lancaster, TX
CMS certification number676188
Contact & location
1850 W Pleasant Run RdLancaster, TX 75146
Dallas County
- Phone
- (972) 275-1900
- ZIP code
- 75146 – all care providers
Facility details
- Certified beds
- 124
- Residents per day
- 78.1 (63% occupied)
- Ownership
- For profit - Limited Liability company
- Legal name
- Hamilton County Hospital District
- Chain
- The Ensign Group (342 facilities, avg 3.2★)
- Medicare certified since
- July 25, 2008
- Participates in
- Medicare and Medicaid
- Council
- Resident council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- 3.08 (state 3.39 · U.S. 3.86)
- Registered nurses (RN)
- 0.12 (state 0.43 · U.S. 0.69)
- Licensed practical nurses
- 1.16 (state 0.95 · U.S. 0.86)
- Nurse aides
- 1.80 (state 2.00 · U.S. 2.32)
- Weekend total
- 2.76 (state 2.98 · U.S. 3.42)
- Nursing staff turnover
- 69.7 (state 55.3 · U.S. 45.8)%
- RN turnover
- —
- Administrators who left
- 0 in the last year
Inspections
- Last standard inspection
- April 23, 2026
- Health deficiencies (last cycle)
- 14.0 (state 9.3 · U.S. 9.3)
- From complaints
- 5
- Citations on record (3 years)
- 27 health · 3 fire safety · includes immediate jeopardy
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2026-04-23 | Honor the resident's right to organize and participate in resident/family groups in the facility. F0565 · Resident Rights Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. F0921 · Environmental Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Assure that each resident’s assessment is updated at least once every 3 months. F0638 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2026-04-23 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. F0693 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-04-24 |
| 2025-12-03 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-04 |
| 2025-12-02 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-03 |
| 2025-12-02 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-03 |
| 2025-12-01 | Provide safe and appropriate respiratory care for a resident when needed. F0695 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-02 |
| 2025-09-09 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. F0628 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-09-26 |
| 2025-05-07 | Keep residents' personal and medical records private and confidential. F0583 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-23 |
| 2025-05-07 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-23 |
| 2025-05-07 | 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. F0761 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-23 |
| 2025-02-11 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-02-17 |
| 2025-02-11 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-02-17 |
| 2025-02-11 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-02-17 |
| 2025-02-11 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-02-17 |
| 2025-02-11 | Ensure each resident receives an accurate assessment. F0641 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-02-17 |
| 2025-02-11 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-02-17 |
| 2024-10-11 | 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. F0584 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-10-14 |
| 2024-01-10 | Hire a qualified full-time social worker in a facility with more than 120 beds. F0850 · Administration Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2024-02-05 |
| 2024-01-10 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-02-05 |
| 2023-11-29 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
K Immediate jeopardy to resident health or safety |
Corrected 2023-12-29 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
1 penalty in the last three years, including $13,565 in fines.
| Date | Type | Amount |
|---|---|---|
| 2023-11-29 | Fine | $13,565 |
Ownership & management
| Name | Role | Since |
|---|---|---|
| Bluebonnet Healthcare, INC. (organization) | Administrator · NOT APPLICABLE | |
| Ensign Services INC (organization) | Administrator · NOT APPLICABLE | |
| Madison, Kristen (individual) | Administrator · NOT APPLICABLE | |
| Sharma, Neeraj (individual) | Administrator · NOT APPLICABLE | |
| Burnam, Soon (individual) | Corporate Officer · NOT APPLICABLE | |
| Hooper, Grady (individual) | Corporate Officer · NOT APPLICABLE | |
| Keetch, Chad (individual) | Corporate Officer · NOT APPLICABLE | |
| Madison, Kristen (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Sharma, Neeraj (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Bluebonnet Healthcare, INC. (organization) | Operational/managerial Control · NOT APPLICABLE | |
| Madison, Kristen (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Sharma, Neeraj (individual) | Operational/managerial Control · NOT APPLICABLE |
Frequently asked questions
What is the rating of Millbrook Healthcare and Rehabilitation Center?
Millbrook Healthcare and Rehabilitation Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.
How many beds does Millbrook Healthcare and Rehabilitation Center have?
It has 124 certified beds and cares for about 78 residents per day.
Has Millbrook Healthcare and Rehabilitation Center been fined?
Yes. CMS lists 1 penalty totaling $13,565 in the last three years.
Who owns Millbrook Healthcare and Rehabilitation Center?
It is part of The Ensign Group and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.
What is the phone number of Millbrook Healthcare and Rehabilitation Center?
(972) 275-1900. The facility is located at 1850 W Pleasant Run Rd, Lancaster, TX 75146.
Other nursing homes in Lancaster
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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.