Millbrook Healthcare and Rehabilitation CenterCMS ratings, inspections and fines
- Address
- 1850 W Pleasant Run Rd, Lancaster, TX 75146
- CCN
- 676188
- Ownership type
- For-profit, limited liability company
- Certified beds
- 124
- Chain
- The Ensign Group
- Residents per day
- 78
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Millbrook Healthcare and Rehabilitation Center an overall rating of 1 of 5 stars. The last standard survey was on 23 Apr 2026. The latest survey cycle has 14 health citations. The median for nursing homes in Texas is 8. CMS lists 1 fine of $13,565 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Dallas County median | Texas median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 1 | 2.0 | 3.0 | 3.0 |
| Health inspection rating | 2 | 2.0 | 3.0 | 2.8 |
| Staffing rating | 1 | 2.0 | 2.0 | 2.9 |
| Quality measure rating | 4 | 4.0 | 4.0 | 3.6 |
A median is the middle value of the homes in the group: 81 homes in the county, 1,177 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Texas median |
|---|---|---|---|
| Cycle 1 (latest) | 23 Apr 2026 | 14 | 8 |
| Cycle 2 | 11 Feb 2025 | 10 | 8 |
| Cycle 3 | No date | 3 | 8 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J0 | L0 | |
| Actual harm that is not immediate jeopardy | G0 | H0 | I0 |
| No actual harm, potential for more than minimal harm | F0 | ||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 14 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 23 Apr 2026 | F0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0638 | Assure that each resident’s assessment is updated at least once every 3 months. | D | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0693 | 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. | D | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 24 Apr 2026 |
| 23 Apr 2026 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E | Standard survey | 24 Apr 2026 |
| 3 Dec 2025 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint investigation | 4 Dec 2025 |
| 2 Dec 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Complaint investigation | 3 Dec 2025 |
| 2 Dec 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint investigation | 3 Dec 2025 |
| 1 Dec 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Complaint investigation | 2 Dec 2025 |
| 9 Sep 2025 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | Complaint investigation | 26 Sep 2025 |
Survey cycle 2: 10 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 7 May 2025 | F0583 | Keep residents' personal and medical records private and confidential. | D | Complaint investigation | 23 May 2025 |
| 7 May 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint investigation | 23 May 2025 |
| 7 May 2025 | F0761 | 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. | D | Complaint investigation | 23 May 2025 |
| 11 Feb 2025 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard survey | 17 Feb 2025 |
| 11 Feb 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident. | E | Standard survey | 17 Feb 2025 |
| 11 Feb 2025 | F0641 | Ensure each resident receives an accurate assessment. | D | Standard survey | 17 Feb 2025 |
| 11 Feb 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 17 Feb 2025 |
| 11 Feb 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 17 Feb 2025 |
| 11 Feb 2025 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 17 Feb 2025 |
| 11 Oct 2024 | F0584 | 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. | D | Complaint investigation | 14 Oct 2024 |
Survey cycle 3: 3 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 10 Jan 2024 | F0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. | E | Standard survey | 5 Feb 2024 |
| 10 Jan 2024 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 5 Feb 2024 |
| 29 Nov 2023 | F0880 | Provide and implement an infection prevention and control program. | K | Complaint investigation | 29 Dec 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 29 Nov 2023 | Fine | $13,565 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Texas median | Texas average (CMS) |
|---|---|---|---|
| All nurse staff | 3.08 | 3.30 | 3.39 |
| Registered nurses (RN) | 0.12 | 0.40 | 0.43 |
| Licensed practical nurses (LPN) | 1.16 | 0.95 | |
| Nurse aides | 1.80 | 2.00 | |
| All nurse staff, weekends | 2.76 | 2.90 | 2.98 |
- Nurse staff turnover in a year
- 69.7%
- Nurse staff turnover, Texas median
- 52.1%
- RN turnover in a year
- No data
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Texas median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.0% | 14.9% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.0% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.4% | 0.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.8% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | 0.7% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 21.0% | 12.4% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.3% | 3.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 0.0% | 8.3% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- For-profit, limited liability company
- Legal business name
- Hamilton County Hospital District
- Chain
- The Ensign Group (342 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Bluebonnet Healthcare, Inc. | Operational/managerial control | 1 Dec 2023 | |
| Bluebonnet Healthcare, Inc. | Adp of the snf | 27 Oct 2025 | |
| Ensign Services Inc | Adp of the snf | 18 Apr 2022 |
The site shows organisations only. It does not show the names of persons.
Other homes in Dallas County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Windsor Gardens | Lancaster | 2 of 5 | 13 | $13,877 | 15 Jan 2026 | |
| Avir at Lancaster | Lancaster | 2 of 5 | 13 | $42,851 | 15 Jan 2026 | |
| Lancaster Nursing & Rehabilitation | Lancaster | 1 of 5 | 8 | $56,554 | 8 Jan 2026 | |
| Desoto Nursing & Rehabilitation Center | Desoto | 3 of 5 | 12 | $8,281 | 12 Feb 2026 | |
| Five Points Nursing and Rehabilitation | Desoto | 2 of 5 | 10 | $0 | 29 May 2025 | |
| Park Village Healthcare and Rehabilitation | Desoto | 2 of 5 | 15 | $221,389 | 14 May 2026 | |
| Methodist Transitional Care Center-Desoto LLC | Desoto | 3 of 5 | 10 | $27,993 | 27 Jun 2025 | |
| Williamsburg Village Healthcare CampusSpecial Focus candidate | Desoto | 2 of 5 | 32 | $150,370 | 10 Mar 2026 | |
| The Lennwood Nursing and Rehabilitation | Dallas | 1 of 5 | 11 | $29,969 | 11 Dec 2025 | |
| Duncanville Healthcare and Rehabilitation Center | Duncanville | 1 of 5 | 17 | $26,118 | 14 Aug 2025 | |
| The Villages of Dallas | Dallas | 3 of 5 | 7 | $31,303 | 16 Apr 2026 | |
| The Laurenwood Nursing and Rehabilitation | Duncanville | 4 of 5 | 6 | $38,522 | 4 Jun 2026 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Texas Health and Human Services: complaint and incident intakeThe complaint page of the State Survey Agency for Texas, from the CMS list of agencies.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Millbrook Healthcare and Rehabilitation Center (CCN 676188). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/millbrook-healthcare-and-rehabilitation-center-lancaster-tx-676188/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Millbrook Healthcare and Rehabilitation Center last inspected?
- The latest inspection with a citation in the CMS record was on 23 Apr 2026. It was a standard survey. It gave 9 citations. The standard survey before the last one was on 11 Feb 2025.
- Who operates Millbrook Healthcare and Rehabilitation Center?
- The CMS record gives the ownership type as for-profit, limited liability company. CMS lists the home in the chain The Ensign Group. The CMS ownership file names Bluebonnet Healthcare, Inc. for operational or managerial control. This site does not show the names of persons.
- Is Millbrook Healthcare and Rehabilitation Center a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 6 homes in Texas as Special Focus Facilities and 30 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.