Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146
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Follow this homeMillbrook Healthcare and Rehabilitation Center is a nursing home in Lancaster, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionApril 23, 2026 (6 months ago)
- Health citations since November 29, 202327 (Texas average 28)
- Fines in the past three years1, $13,565 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Health inspection on April 23, 2026
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on April 24, 2026.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for F0656 2 times since 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for F0812 2 times since 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for F0880 4 times since 2023.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on April 24, 2026.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 24, 2026.
Citation F0638. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
CMS lists it as corrected on April 24, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 24, 2026.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 24, 2026.
CMS update of March 25, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on December 3, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 4, 2025.
CMS has cited this home for F0550 2 times since 2025.
Health inspection on December 2, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 3, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 3, 2025.
CMS has cited this home for F0755 2 times since 2025.
Health inspection on December 1, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on December 2, 2025.
Health inspection on September 9, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 26, 2025.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on May 7, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on May 23, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 23, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 23, 2025.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on February 11, 2025
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0558. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on February 17, 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 17, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 17, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on February 17, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on February 17, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on February 17, 2025.
Fire safety inspection on February 11, 2025
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 17, 2025.
Health inspection on October 11, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 14, 2024.
CMS update of May 29, 2024
Name
CMS lists a new legal business name for this home.
CMS update of April 25, 2024
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
Fine
CMS changed the fine from November 29, 2023 from $13,533 to $13,565.
CMS update of March 28, 2024
Name
CMS lists a new legal business name for this home.
Health inspection on January 10, 2024
2 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 2 citations
Citation F0850. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Hire a qualified full-time social worker in a facility with more than 120 beds.
CMS lists it as corrected on February 5, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 5, 2024.
Fire safety inspection on January 10, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on January 11, 2024.
Citation K0521. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on January 12, 2024.
Health inspection on November 29, 2023
1 citationCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
152 of 1,177 Texas homes (13%) got a citation at the immediate jeopardy level in 2023.
CMS fine of $13,565 on November 29, 2023.
Show the 1 citation
Citation F0880. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 29, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (972) 275-1900
- Last standard health inspection
- April 23, 2026 (6 months ago)
- Certified beds
- 124
- Residents per day, on average
- 77.6
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Hamilton County Hospital District
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (27 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BLUEBONNET HEALTHCARE, INC.Operational/managerial control · not applicable · since 12/01/2023
- MADISON, KRISTENOperational/managerial control · not applicable · since 12/01/2023
- SHARMA, NEERAJOperational/managerial control · not applicable · since 09/04/2024
Questions
When was Millbrook Healthcare and Rehabilitation Center last inspected?
CMS lists April 23, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Millbrook Healthcare and Rehabilitation Center have?
CMS lists 27 health citations since November 29, 2023. CMS also calls these deficiencies.
Has Millbrook Healthcare and Rehabilitation Center been fined?
CMS lists 1 fine in the past three years, $13,565 in total.
What is the CMS star rating of Millbrook Healthcare and Rehabilitation Center?
Its CMS overall star rating is 2 of 5.
Is Millbrook Healthcare and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.