Facility WatchInspection records for every certified US nursing home
Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd Lancaster, TX 75146 (972) 275-1900
CCN
676188
Certified beds
124
Ownership
For profit - Limited Liability company
Chain
THE Ensign Group
Nurse staffing
3.21
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.15 hours per resident per day
Nursing staff turnover: 62% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected December 3, 2025
1 citation · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected December 4, 2025
Inspected December 2, 2025
2 citations · from a complaint investigation · Health
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected December 3, 2025
Inspected December 1, 2025
1 citation · from a complaint investigation · Health
E
F0695No actual harm with potential for more than minimal harm · Pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected December 2, 2025
Inspected September 9, 2025
1 citation · from a complaint investigation · Health
D
F0628No actual harm with potential for more than minimal harm · Isolated
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has date of correction · corrected September 26, 2025
Inspected May 7, 2025
3 citations · from a complaint investigation · Health
D
F0583No actual harm with potential for more than minimal harm · Isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected May 23, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected May 23, 2025
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 23, 2025
Inspected February 11, 2025
6 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected February 17, 2025
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected February 17, 2025
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected February 17, 2025
E
F0558No actual harm with potential for more than minimal harm · Pattern
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected February 17, 2025
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected February 17, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 17, 2025
Inspected October 11, 2024
1 citation · from a complaint investigation · Health
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected October 14, 2024
Inspected January 10, 2024
2 citations · from a complaint investigation · Health
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 5, 2024
E
F0850No actual harm with potential for more than minimal harm · Pattern
Hire a qualified full-time social worker in a facility with more than 120 beds.
Deficient, Provider has date of correction · corrected February 5, 2024
Inspected November 29, 2023
1 citation · from a complaint investigation · Health
K
F0880Immediate jeopardy to resident health or safety · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 29, 2023
Inspected October 19, 2022
4 citations · Health
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected October 22, 2022
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected October 22, 2022
E
F0756No actual harm with potential for more than minimal harm · Pattern
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected October 22, 2022
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected October 22, 2022
Penalties
Date
Type
Amount
November 29, 2023
Fine
$13,565
Ownership transfers
Effective
Seller
Buyer
12/01/2023
Bluebonnet Healthcare, Inc.
Hamilton County Hospital District
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.