Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd · Lancaster, TX · 75146 · 9722751900
124 certified beds For profit - Limited Liability company Chain: The Ensign Group
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
RN staffing in the bottom 10% nationally
0.15 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
62% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.27 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.15 | 0.55–0.75 |
| Weekend hours / resident-day | 2.76 | ≈ weekday level |
| Nursing turnover / year | 62% | median 45% |
| Fines (3-yr window) | 1 · $13,565 |
Inspection citations (22 in the current record)
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Potential for harm · D December 3, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 4, 2025 · Resident Rights
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Potential for harm · E December 2, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · E December 2, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 3, 2025 · Pharmacy Service
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Potential for harm · E December 1, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 2, 2025 · Quality of Life and Care
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Potential for harm · D September 9, 2025 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected September 26, 2025 · Resident Rights
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Potential for harm · D May 7, 2025 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected May 23, 2025 · Resident Rights
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Potential for harm · D May 7, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 23, 2025 · Pharmacy Service
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Potential for harm · D May 7, 2025 · found via complaint
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.
Corrected May 23, 2025 · Pharmacy Service
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Potential for harm · D February 11, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected February 17, 2025 · Resident Rights
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Potential for harm · E February 11, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected February 17, 2025 · Resident Rights
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Potential for harm · D February 11, 2025
Ensure each resident receives an accurate assessment.
Corrected February 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 11, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected February 17, 2025 · Quality of Life and Care
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Potential for harm · E February 11, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 17, 2025 · Nutrition and Dietary
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Potential for harm · E February 11, 2025
Provide and implement an infection prevention and control program.
Corrected February 17, 2025 · Infection Control
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Potential for harm · D October 11, 2024 · found via complaint
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.
Corrected October 14, 2024 · Resident Rights
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Potential for harm · E January 10, 2024
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected February 5, 2024 · Administration
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Potential for harm · D January 10, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected February 5, 2024 · Infection Control
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Immediate jeopardy · K November 29, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 29, 2023 · Infection Control
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Potential for harm · E October 19, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected October 22, 2022 · Pharmacy Service
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Potential for harm · E October 19, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 22, 2022 · Nutrition and Dietary
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Potential for harm · D October 19, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected October 22, 2022 · Resident Assessment and Care Planning
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Potential for harm · D October 19, 2022
Provide and implement an infection prevention and control program.
Corrected October 22, 2022 · Infection Control
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 29, 2023 | Fine | $13,565 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676188 · certified since July 25, 2008. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.