nursing home in Lancaster, TX
Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146 · (972) 275-1900
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★2
- Staffing★★★★★1
- Quality measures★★★★★4
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Millbrook Healthcare and Rehabilitation Center at a glance
Millbrook Healthcare and Rehabilitation Center is a 124-bed for-profit nursing home in Lancaster, Texas (Dallas County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the Texas average of 2.7.
Residents receive about 3.1 hours of nursing care per day (0.1 of them from registered nurses), worse than the state average of 3.4 hours.
Its most recent standard health inspection (April 23, 2026) found 14 health citations. The Texas average is 9.4.
Federal regulators fined it 1 time in the past three years, totaling $13,565.
Nursing staff turnover is 69.7% per year (state average 55.3%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 124
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- The Ensign Group
- Medicare-certified since
- July 25, 2008
- Resident/family council
- Resident
- County
- Dallas County
- CMS Certification Number
- 676188
Ratings
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 2.7 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 2 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 1 / 5 | 1.9 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 4 / 5 | 3.7 / 5 | 3.6 / 5 | Average |
| Long-stay quality rating (higher is better) | 5 / 5 | 4 / 5 | 3.8 / 5 | Better |
| Short-stay (rehab) quality rating (higher is better) | 4 / 5 | 3.2 / 5 | 3.3 / 5 | Better |
Staffing
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.08 hrs | 3.39 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.12 hrs | 0.43 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 1.80 hrs | 2.01 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 2.76 hrs | 2.98 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 69.7% | 55.3% | 45.8% | Worse |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 14 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 5 | 4 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 105 | 102 | 80.6 | Worse |
Penalties
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $13,565 | $44,141 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 1 | 2 | 1 | Average |
Size
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 124 | 113 | 107 | |
| Average residents per day | 78 | 76 | 86 | |
| Occupancy | 63% | 67.6% | 80.9% |
Long-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 1.8% | 3.3% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 1.3% | 3.8% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 0% | 9.6% | 15.4% | Better |
| Long-stay residents with a urinary tract infection (lower is better) | 0.4% | 0.8% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.3% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 10% | 15.8% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 21% | 14% | 14.1% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 1.7% | 3% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 5.5% | 2.4% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 7.7% | 18% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 17.1% | 13.4% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 98% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 96.6% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 0% | 1.5% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 90.9% | 88% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 95% | 88.9% | 82% | Better |
Inspection citations
State inspectors cited this home for 27 health deficiencies and 3 fire safety deficiencies in the inspection records CMS currently publishes. 1 citation involved actual harm, including 1 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| April 23, 2026 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected April 24, 2026 |
| April 23, 2026 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected April 24, 2026 |
| April 23, 2026 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | E Potential harm, pattern | Corrected April 24, 2026 |
| April 23, 2026 Standard | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Tag F0565 | E Potential harm, pattern | Corrected April 24, 2026 |
| April 23, 2026 Standard | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Tag F0921 | E Potential harm, pattern | Corrected April 24, 2026 |
| April 23, 2026 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected April 24, 2026 |
| April 23, 2026 Standard | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Tag F0638 | D Potential harm, isolated | Corrected April 24, 2026 |
| April 23, 2026 Standard | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected April 24, 2026 |
| April 23, 2026 Standard | 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. Quality of Life and Care Deficiencies · Tag F0693 | D Potential harm, isolated | Corrected April 24, 2026 |
| December 3, 2025 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected December 4, 2025 |
| December 2, 2025 Complaint | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | E Potential harm, pattern | Corrected December 3, 2025 |
| December 2, 2025 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected December 3, 2025 |
| December 1, 2025 Complaint | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | E Potential harm, pattern | Corrected December 2, 2025 |
| September 9, 2025 Complaint | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Tag F0628 | D Potential harm, isolated | Corrected September 26, 2025 |
| May 7, 2025 Complaint | 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. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected May 23, 2025 |
| May 7, 2025 Complaint | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Tag F0583 | D Potential harm, isolated | Corrected May 23, 2025 |
| May 7, 2025 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected May 23, 2025 |
| February 11, 2025 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | F Potential harm, widespread | Corrected February 17, 2025 |
| February 11, 2025 Standard | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | E Potential harm, pattern | Corrected February 17, 2025 |
| February 11, 2025 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected February 17, 2025 |
| February 11, 2025 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected February 17, 2025 |
| February 11, 2025 Standard | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected February 17, 2025 |
| February 11, 2025 Standard | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected February 17, 2025 |
| February 11, 2025 Standard | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected February 17, 2025 |
| October 11, 2024 Complaint | 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. Resident Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected October 14, 2024 |
| January 10, 2024 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | F Potential harm, widespread | Corrected January 11, 2024 |
| January 10, 2024 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | C No harm, widespread | Corrected January 12, 2024 |
| January 10, 2024 Standard | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Tag F0850 | E Potential harm, pattern | Corrected February 5, 2024 |
| January 10, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected February 5, 2024 |
| November 29, 2023 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | K Immediate jeopardy, pattern | Corrected December 29, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 1 federal penalty in the past three years, including $13,565 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| November 29, 2023 | Fine | $13,565 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| BLUEBONNET HEALTHCARE, INC. Organization | adp of the snf | NOT APPLICABLE | 10/27/2025 |
| ENSIGN SERVICES INC Organization | adp of the snf | NOT APPLICABLE | 04/18/2022 |
| MADISON, KRISTEN Individual | adp of the snf | NOT APPLICABLE | 12/01/2023 |
| SHARMA, NEERAJ Individual | adp of the snf | NOT APPLICABLE | 09/04/2024 |
| BURNAM, SOON Individual | corporate officer | NOT APPLICABLE | 12/01/2023 |
| HOOPER, GRADY Individual | corporate officer | NOT APPLICABLE | 12/01/2023 |
| KEETCH, CHAD Individual | corporate officer | NOT APPLICABLE | 03/01/2011 |
| MADISON, KRISTEN Individual | managing control - governing body | NOT APPLICABLE | 12/01/2023 |
| SHARMA, NEERAJ Individual | managing control - governing body | NOT APPLICABLE | 09/04/2024 |
| BLUEBONNET HEALTHCARE, INC. Organization | operational/managerial control | NOT APPLICABLE | 12/01/2023 |
| MADISON, KRISTEN Individual | operational/managerial control | NOT APPLICABLE | 12/01/2023 |
| SHARMA, NEERAJ Individual | operational/managerial control | NOT APPLICABLE | 09/04/2024 |
Other nursing homes near Millbrook Healthcare and Rehabilitation Center
Windsor Gardens
2535 W Pleasant Run, Lancaster, TX 75146 · under 1 mi
For-profit · 150 beds · Part of Cantex Continuing Care
★★★★★2Below averageAvir at Lancaster
1241 Westridge Ave, Lancaster, TX 75146 · 1.7 mi
Government · 110 beds · Part of Avir Health Group
★★★★★1Much below averageLancaster Nursing & Rehabilitation
1515 N Elm St, Lancaster, TX 75134 · 2 mi
For-profit · 120 beds · Part of Creative Solutions in Healthcare
★★★★★1Much below averageDesoto Nursing & Rehabilitation Center
1101 North Hampton Road, Desoto, TX 75115 · 3.4 mi
For-profit · 110 beds · Part of Creative Solutions in Healthcare
★★★★★3AverageFive Points Nursing and Rehabilitation
1901 North Hampton Road, Desoto, TX 75115 · 3.8 mi
For-profit · 120 beds · Part of Creative Solutions in Healthcare
★★★★★2Below averagePark Village Healthcare and Rehabilitation
207 E Parkerville Rd, Desoto, TX 75115 · 3.9 mi
For-profit · 150 beds · Part of The Ensign Group
- Abuse citation
★★★★★2Below average
Frequently asked questions
What is Millbrook Healthcare and Rehabilitation Center's rating?
Millbrook Healthcare and Rehabilitation Center has 1 out of 5 stars on the CMS overall star rating. The average for Texas nursing homes is 2.7 stars.
How many inspection citations did Millbrook Healthcare and Rehabilitation Center receive?
Its most recent standard health inspection found 14 citations, compared with a Texas average of 9.4. Every citation is listed on this page with its severity.
Does Millbrook Healthcare and Rehabilitation Center accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Millbrook Healthcare and Rehabilitation Center?
It is for profit - limited liability company and part of The Ensign Group. The ownership section on this page lists the owners and managers reported to CMS.
Where is Millbrook Healthcare and Rehabilitation Center and how do I contact it?
Millbrook Healthcare and Rehabilitation Center is at 1850 W Pleasant Run Rd, Lancaster, TX 75146. Phone: (972) 275-1900.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.