Nursing home in Lancaster, Texas
Millbrook Healthcare and Rehabilitation Center
Medicare and Medicaid
1850 W Pleasant Run Rd, Lancaster, TX 75146
(972) 275-1900
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home4
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Apr 23, 2026. CMS counts 14 health deficiencies in rating cycle 1.
- This nursing home14
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 27 health deficiencies on 10 inspection dates since Sep 30, 2023. By level of harm: 1 immediate jeopardy, 26 potential for harm.
- 1 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 26 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Apr 23, 2026 | F0565 | Honor the resident's right to organize and participate in resident/family groups in the facility.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0656 | 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 | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0638 | Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Apr 23, 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.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 24, 2026 |
| Dec 3, 2025 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 4, 2025 |
Show the other 17 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Dec 2, 2025 | F0656 | 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 | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 3, 2025 |
| Dec 2, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 3, 2025 |
| Dec 1, 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 2, 2025 |
| Sep 9, 2025 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 26, 2025 |
| May 7, 2025 | F0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 23, 2025 |
| May 7, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 23, 2025 |
| May 7, 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 23, 2025 |
| Feb 11, 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 17, 2025 |
| Feb 11, 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 17, 2025 |
| Feb 11, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 17, 2025 |
| Feb 11, 2025 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 17, 2025 |
| Feb 11, 2025 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 17, 2025 |
| Feb 11, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 17, 2025 |
| Oct 11, 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.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Oct 14, 2024 |
| Jan 10, 2024 | F0850 | Hire a qualified full-time social worker in a facility with more than 120 beds.Administration Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 5, 2024 |
| Jan 10, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 5, 2024 |
| Nov 29, 2023 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction Dec 29, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.08 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.12 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home69.7%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 1 penalty for this nursing home: 1 fine totaling $13,565, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 124 |
|---|---|
| Average residents per day | 78.1 |
| Ownership | For profit - Limited Liability company |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | The Ensign Group (344 facilities) |
| Legal business name | HAMILTON COUNTY HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Jul 25, 2008 |
| County | Dallas |
| CMS certification number | 676188 |
Also in Lancaster
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Windsor Gardens | 150 | For profit - Corporation | ||
| Avir at Lancaster | 110 | Government - Federal | ||
| Lancaster Nursing & Rehabilitation | 120 | For profit - Limited Liability company |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Crescent Medical Center Lancaster | Acute Care Hospitals | Yes |