Nursing HomeInspections

Millbrook Healthcare and Rehabilitation Center

Nursing home in Lancaster, TX

Medicare & Medicaid certified1★ overall (CMS)

Call (972) 275-1900Send a messageMap ↗

Public-record details

Address
1850 W Pleasant Run Rd, Lancaster, TX 75146
Phone
(972) 275-1900
Listed under
For-profit
Medicare CCN
676188
Overall star rating
1 of 5 ★☆☆☆☆
Health inspection rating
2 of 5
Staffing rating
1 of 5
Quality measures rating
4 of 5
Certified beds
124
Average residents per day
78
Ownership
For-profit, limited Liability company
Legal business name
Hamilton County Hospital District
Chain
The Ensign Group (342 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
Jul 25, 2008
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Resident or family council
Resident council
Sprinklers in all required areas
Yes

CMS certification number 676188. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Apr 23, 2026. CMS lists 27 health citations for this facility across its last three standard inspection cycles and complaint inspections (Nov 29, 2023 to Apr 23, 2026): 11 from complaint inspections, 1 at the “actual harm” level or higher, including 1 at “immediate jeopardy”.

InspectionCitationSeverity
Apr 23, 2026Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation		D
Potential for more than minimal harm, isolated
Apr 23, 2026Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning		D
Potential for more than minimal harm, isolated
Apr 23, 2026Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Apr 23, 2026Ensure 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		D
Potential for more than minimal harm, isolated
Apr 23, 2026Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights		E
Potential for more than minimal harm, pattern
Apr 23, 2026Develop 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		E
Potential for more than minimal harm, pattern
Apr 23, 2026Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary		E
Potential for more than minimal harm, pattern
Apr 23, 2026Provide and implement an infection prevention and control program.
Infection Control		E
Potential for more than minimal harm, pattern
Apr 23, 2026Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental		E
Potential for more than minimal harm, pattern
Dec 3, 2025Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights · complaint inspection		D
Potential for more than minimal harm, isolated
Dec 2, 2025Develop 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 · complaint inspection		E
Potential for more than minimal harm, pattern
Dec 2, 2025Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service · complaint inspection		E
Potential for more than minimal harm, pattern

Showing the 12 most recent of 27. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records 1 fine totalling $13,565 in the last three years.

Nov 29, 2023Fine: $13,565

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.08 hours
Registered nurse (RN) time per resident per day
0.12 hours
Nurse aide time per resident per day
1.80 hours
Total nurse staffing on weekends
2.76 hours
Nursing staff turnover (yearly)
70%
Administrators who left in the past year
0

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.

Other nursing homes in Lancaster

Avir at Lancaster1241 Westridge Ave · Lancaster, TX 75146 · (972) 227-5110 · Government-owned29 health citations in 3 inspection cycles · last standard inspection Jan 15, 2026 · $42,851 in CMS fines (3 yrs)Medicare & Medicaid certified2★ overall (CMS)Windsor Gardens2535 W Pleasant Run · Lancaster, TX 75146 · (972) 228-8029 · For-profit26 health citations in 3 inspection cycles · last standard inspection Jan 15, 2026 · $13,877 in CMS fines (3 yrs)Medicare & Medicaid certified2★ overall (CMS)Lancaster Nursing & Rehabilitation1515 N Elm St · Lancaster, TX 75134 · (972) 227-6066 · For-profit34 health citations in 3 inspection cycles · last standard inspection Jan 8, 2026 · $56,554 in CMS fines (3 yrs)Medicare & Medicaid certified1★ overall (CMS)

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