Nursing homes › Texas › Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146 · 9722751900 · 124 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.08 (Texas median: 3.27). RN hours: 0.12. Weekend total: 2.76. Nursing staff turnover: 70%.
All-time on record: 22 deficiency citations, including 1 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2025-12-03 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | complaint | corrected 2025-12-04 |
| 2025-12-02 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | complaint | corrected 2025-12-03 |
| 2025-12-02 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | complaint | corrected 2025-12-03 |
| 2025-12-01 | Provide safe and appropriate respiratory care for a resident when needed. | E | complaint | corrected 2025-12-02 |
| 2025-09-09 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | complaint | corrected 2025-09-26 |
| 2025-05-07 | Keep residents' personal and medical records private and confidential. | D | complaint | corrected 2025-05-23 |
| 2025-05-07 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | complaint | corrected 2025-05-23 |
| 2025-05-07 | 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. | D | complaint | corrected 2025-05-23 |
| 2025-02-11 | Reasonably accommodate the needs and preferences of each resident. | E | Health | corrected 2025-02-17 |
| 2025-02-11 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2025-02-17 |
| 2025-02-11 | Provide and implement an infection prevention and control program. | E | Health | corrected 2025-02-17 |
| 2025-02-11 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2025-02-17 |
| 2025-02-11 | Ensure each resident receives an accurate assessment. | D | Health | corrected 2025-02-17 |
| 2025-02-11 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | corrected 2025-02-17 |
| 2024-10-11 | 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. | D | complaint | corrected 2024-10-14 |
| 2024-01-10 | Hire a qualified full-time social worker in a facility with more than 120 beds. | E | Health | corrected 2024-02-05 |
| 2024-01-10 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2024-02-05 |
| 2023-11-29 | Provide and implement an infection prevention and control program. | K | complaint | corrected 2023-12-29 |
| Date | Type | Amount |
|---|---|---|
| 2023-11-29 | Fine | $13,565 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| MADISON, KRISTEN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 12/01/2023 |
| SHARMA, NEERAJ | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/04/2024 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 12/01/2023 |
| HOOPER, GRADY | Corporate Officer | Individual | NOT APPLICABLE | since 12/01/2023 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| BLUEBONNET HEALTHCARE, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 12/01/2023 |
| MADISON, KRISTEN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 12/01/2023 |
| SHARMA, NEERAJ | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/04/2024 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 676188. Corrections: data@carerecords.org.