Millbrook Healthcare and Rehabilitation Center

CCN 676188 · HAMILTON COUNTY HOSPITAL DISTRICT · For profit - Limited Liability company · THE ENSIGN GROUP chain · 124 certified beds · Dallas · TX


Millbrook Healthcare and Rehabilitation Center is a 124-bed nursing home in Lancaster, Texas. CMS has certified it for Medicare and Medicaid since 2008-07-25. It averages 78.1 residents a day.

What harm was found in the violations cited at Millbrook Healthcare and Rehabilitation Center?

CMS lists 27 health-inspection deficiencies for Millbrook Healthcare and Rehabilitation Center, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is K; the most recent health inspection was 2026-04-23.

Survey dateTagDeficiencySeverity
2026-04-23F0565, F0656, F0812, F0880, F0921Honor the resident's right to organize and participate in resident/family groups in the facility. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.E
2026-04-23F0609, F0638, F0689, F0693Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Assure that each resident’s assessment is updated at least once every 3 months. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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
2025-12-03F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D
2025-12-02F0656, F0755Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E
2025-12-01F0695Provide safe and appropriate respiratory care for a resident when needed.E
2025-09-09F0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.D
2025-05-07F0583, F0755, F0761Keep residents' personal and medical records private and confidential. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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
2025-02-11F0558, F0812, F0880Reasonably accommodate the needs and preferences of each resident. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program.E
2025-02-11F0550, F0641, F0677Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Ensure each resident receives an accurate assessment. / Provide care and assistance to perform activities of daily living for any resident who is unable.D
2024-10-11F0584Honor 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
2024-01-10F0850Hire a qualified full-time social worker in a facility with more than 120 beds.E
2024-01-10F0880Provide and implement an infection prevention and control program.D
2023-11-29F0880Provide and implement an infection prevention and control program.K

Why was Millbrook Healthcare and Rehabilitation Center fined?

DateTypeAmount
2023-11-29Fine$13,565

How is Millbrook Healthcare and Rehabilitation Center staffed relative to the TX average?

MeasureThis facilityTX average
Total nurse staffing hours per resident per day3.078393.38539
Total nursing staff turnover (%)69.755.3
Average number of residents per day78.175.8

Who owns Millbrook Healthcare and Rehabilitation Center, and what chain is it in?

Millbrook Healthcare and Rehabilitation Center is registered with CMS as For profit - Limited Liability company, operates under the legal business name HAMILTON COUNTY HOSPITAL DISTRICT and belongs to the THE ENSIGN GROUP chain.

RoleOwnerAssociation date
MANAGING CONTROL - GOVERNING BODYMADISON, KRISTEN, SHARMA, NEERAJsince 09/04/2024
CORPORATE OFFICERBURNAM, SOON, HOOPER, GRADY, KEETCH, CHADsince 03/01/2011
OPERATIONAL/MANAGERIAL CONTROLBLUEBONNET HEALTHCARE, INC., MADISON, KRISTEN, SHARMA, NEERAJsince 09/04/2024
ADP OF THE SNFBLUEBONNET HEALTHCARE, INC., ENSIGN SERVICES INC, MADISON, KRISTEN, SHARMA, NEERAJsince 04/18/2022

Were you or a family member harmed at Millbrook Healthcare and Rehabilitation Center?