Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146
Phone: 9722751900
CMS ratings and facility information
Millbrook Healthcare and Rehabilitation Center is a Medicare-certified nursing facility in Lancaster, Dallas County, Texas. CMS data for this profile was updated August 2026. Ratings and facility details can change; confirm current information with CMS and the facility.
| CMS overall rating | 1 of 5 stars |
|---|---|
| Health inspection rating | 2 of 5 |
| Staffing rating | 1 of 5 |
| Quality measures rating | 4 of 5 |
| Certified beds | 124 |
| Ownership | For profit - Limited Liability company |
| CMS certification number | 676188 |
Staffing
| Total nurse hours per resident day | 3.08 |
|---|---|
| RN hours per resident day | 0.12 |
| Nurse aide hours per resident day | 1.8 |
| Total nursing staff turnover percent | 69.7 |
Resident outcome measures
| Measure | Value | Unit | Period |
|---|---|---|---|
| Hospitalizations | 1.97 | events_per_1000_resident_days | 20250101-20251231 |
| Emergency-department visits | 2.13 | events_per_1000_resident_days | 20250101-20251231 |
| Falls with major injury | 1.83 | percent | 2025Q2-2026Q1 |
| Pressure ulcers | 1.32 | percent | 2025Q2-2026Q1 |
| Urinary tract infections | 0.38 | percent | 2025Q2-2026Q1 |
| Antipsychotic medication use | 0 | percent | 2025Q2-2026Q1 |
Health inspection citations
| Survey date | Tag | Citation | Severity |
|---|---|---|---|
| 2026-04-23 | 0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E |
| 2026-04-23 | 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E |
| 2026-04-23 | 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E |
| 2026-04-23 | 0880 | Provide and implement an infection prevention and control program. | E |
| 2026-04-23 | 0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E |
| 2026-04-23 | 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
| 2026-04-23 | 0638 | Assure that each resident’s assessment is updated at least once every 3 months. | D |
| 2026-04-23 | 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2026-04-23 | 0693 | 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. | D |
| 2025-02-11 | 0558 | Reasonably accommodate the needs and preferences of each resident. | E |
| 2025-02-11 | 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E |
| 2025-02-11 | 0880 | Provide and implement an infection prevention and control program. | E |
| 2025-02-11 | 0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D |
| 2025-02-11 | 0641 | Ensure each resident receives an accurate assessment. | D |
| 2025-02-11 | 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D |
| 2024-01-10 | 0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. | E |
| 2024-01-10 | 0880 | Provide and implement an infection prevention and control program. | D |
Penalties
| Date | Type | Amount |
|---|---|---|
| 2023-11-29 | Fine | ,565 |
Ownership records
| Name | Type | Role |
|---|---|---|
| MADISON, KRISTEN | Individual | MANAGING CONTROL - GOVERNING BODY |
| SHARMA, NEERAJ | Individual | MANAGING CONTROL - GOVERNING BODY |
| BURNAM, SOON | Individual | CORPORATE OFFICER |
| HOOPER, GRADY | Individual | CORPORATE OFFICER |
| KEETCH, CHAD | Individual | CORPORATE OFFICER |
| BLUEBONNET HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL |
| MADISON, KRISTEN | Individual | OPERATIONAL/MANAGERIAL CONTROL |
| SHARMA, NEERAJ | Individual | OPERATIONAL/MANAGERIAL CONTROL |
| BLUEBONNET HEALTHCARE, INC. | Organization | ADP OF THE SNF |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF |
| MADISON, KRISTEN | Individual | ADP OF THE SNF |
| SHARMA, NEERAJ | Individual | ADP OF THE SNF |
Compare nursing homes in Dallas County, Texas.
Source: Centers for Medicare & Medicaid Services Care Compare data. Data snapshot: August 2026. Read Our Data & Methodology. This directory does not provide medical or legal advice.