Millbrook Healthcare and Rehabilitation Center

1850 W Pleasant Run Rd
Lancaster, TX, 75146
9722751900
CCN: 676188
2
Overall
3
Health
1
Staffing
4
Quality
ChainTHE ENSIGN GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
HAMILTON COUNTY HOSPITAL DISTRICT5% OR GREATER DIRECT OWNERSHIP INTEREST100%
MADISON, KRISTENCONTRACTED MANAGING EMPLOYEENOT APPLICABLE
HOOPER, GRADYCORPORATE OFFICERNOT APPLICABLE
BLUEBONNET HEALTHCARE, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
BURNAM, SOONOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MADISON, KRISTENOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2023-11-29Fine$14K
Health Deficiencies (22)
2025-12-03 · Health
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-12-02 · Health
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2025-12-01 · Health
E
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2025-09-09 · Health
D
F628 · Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
2025-05-07 · Health
D
F761 · Pharmacy Service Deficiencies
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
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2025-02-11 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-10-11 · Health
D
F584 · Resident Rights Deficiencies
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.
2024-01-10 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F850 · Administration Deficiencies
Hire a qualified full-time social worker in a facility with more than 120 beds.
2023-11-29 · Health
K
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2022-10-19 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.16
3.68
RN Hrs/Resident/Day
0.15
0.54
LPN Hrs/Resident/Day
1.12
0.81
CNA Hrs/Resident/Day
1.89
2.33
PT Hrs/Resident/Day
0.27
0.12
Data as of 2026-03-01