For profit - Limited Liability company · 124 certified beds · CMS number 676188
Millbrook Healthcare and Rehabilitation Center, Lancaster, TX
CMS records 27 health deficiencies at Millbrook Healthcare and Rehabilitation Center in Lancaster, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Apr 23, 2026. The highest severity cited is K (immediate jeopardy to resident health or safety). 1 citation was at the immediate jeopardy level. CMS lists 1 fine totaling $13,565 in the last three years.
- 27deficiencies, 3 cycles (TX median 25)
- 14in the latest cycle (TX median 8)
- Khighest severity · Immediate jeopardy
- $13,565fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Millbrook Healthcare and Rehabilitation Center as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Millbrook Healthcare and Rehabilitation Center may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (14 deficiencies)
Standard inspection Apr 23, 2026. CMS counts 14 health deficiencies and 0 fire safety deficiencies in this cycle.
Apr 23, 2026 · Standard inspection
9 deficiencies, highest E
F921 · Safe, functional, sanitary building
Requirement cited (CMS): Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2026
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2026
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2026
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2026
F638 · Quarterly assessment reviews
Requirement cited (CMS): Assure that each resident’s assessment is updated at least once every 3 months.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
F565 · Resident and family councils
Requirement cited (CMS): Honor the resident's right to organize and participate in resident/family groups in the facility.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 24, 2026
Dec 3, 2025 · Complaint inspection
1 deficiency, highest D
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 4, 2025
Dec 2, 2025 · Complaint inspection
2 deficiencies, highest E
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 3, 2025
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 3, 2025
Dec 1, 2025 · Complaint inspection
1 deficiency, highest E
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 2, 2025
Sep 9, 2025 · Complaint inspection
1 deficiency, highest D
F628 · Discharge paperwork, notices, and bed-hold information
Requirement cited (CMS): Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 26, 2025
Previous cycle: 10 deficiencies (standard inspection Feb 11, 2025)
Standard inspection Feb 11, 2025. CMS counts 10 health deficiencies and 1 fire safety deficiency in this cycle.
May 7, 2025 · Complaint inspection
3 deficiencies, highest D
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 23, 2025
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 23, 2025
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 23, 2025
Feb 11, 2025 · Standard inspection
6 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 17, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 17, 2025
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 17, 2025
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 17, 2025
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 17, 2025
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 17, 2025
Oct 11, 2024 · Complaint inspection
1 deficiency, highest D
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 14, 2024
Earlier cycle: 3 deficiencies (standard inspection Jan 10, 2024)
Standard inspection Jan 10, 2024. CMS counts 3 health deficiencies and 2 fire safety deficiencies in this cycle.
Jan 10, 2024 · Standard + complaint inspection
2 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 5, 2024
F850 · Full-time social worker in larger homes
Requirement cited (CMS): Hire a qualified full-time social worker in a facility with more than 120 beds.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 5, 2024
Nov 29, 2023 · Complaint inspection
1 deficiency, highest K
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Dec 29, 2023
Tags cited in more than one inspection
5 tags cited on more than one inspection date at Millbrook Healthcare and Rehabilitation Center; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F880 Infection prevention and control program | 4 | Apr 23, 2026; Feb 11, 2025; Jan 10, 2024; Nov 29, 2023 |
| F550 Dignity and the right to exercise rights | 2 | Dec 3, 2025; Feb 11, 2025 |
| F656 Comprehensive person-centered care plan | 2 | Apr 23, 2026; Dec 2, 2025 |
| F755 Pharmacy services and a consultant pharmacist | 2 | Dec 2, 2025; May 7, 2025 |
| F812 Food safety and sanitation | 2 | Apr 23, 2026; Feb 11, 2025 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Nov 29, 2023 | Fine | $13,565 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.08 h (below the Texas median of 3.27 h)
- RN hours per resident per day
- 0.12 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.76 h
- Nursing staff turnover
- 69.7% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 1 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 4 of 5
CMS figures for Millbrook Healthcare and Rehabilitation Center, copied as published; Texas medians are ours.
Facility details
- Address
- 1850 W Pleasant Run Rd, Lancaster, TX 75146
- Phone
- (972) 275-1900
- County
- Dallas
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- The Ensign Group
- Certified beds
- 124
- Average residents per day
- 78.1
- In Medicare/Medicaid since
- Jul 25, 2008
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How do staff track and report infections among residents? (F880, cited 4 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 2 times)
- How are a resident's goals and preferences written into the care plan? (F656, cited 2 times)
- How are new medication orders filled, and how quickly can urgent medications arrive? (F755, cited 2 times)
Other nursing homes in Lancaster and the same chain
- Lancaster Nursing & Rehabilitation
Lancaster · 32 deficiencies - Avir at Lancaster
Lancaster · 31 deficiencies - Windsor Gardens
Lancaster · 27 deficiencies - The Eden of Las Colinas
Irving · 65 deficiencies - Northeast Rehabilitation and Healthcare Center
San Antonio · 57 deficiencies - Westpark Rehabilitation and Living
Euless · 54 deficiencies - Park Village Healthcare and Rehabilitation
DeSoto · 52 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.