Millbrook Healthcare and Rehabilitation Center
Grade D — 64/100 composite score
CMS Star Ratings
Certified Beds
124
Ownership
For profit - Limited Liability company
Total Fines
$49,665
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
HAMILTON COUNTY HOSPITAL DISTRICT
100%
BLUEBONNET HEALTHCARE, INC.
BURNAM, SOON
MADISON, KRISTEN
HOOPER, GRADY
MADISON, KRISTEN
Penalties & Fines (2)
| Date | Type | Description | Amount |
|---|---|---|---|
| Nov 29, 2023 | Fine | — | $13,565 |
| Feb 10, 2023 | Fine | — | $36,100 |
Health Inspection Deficiencies (21)
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
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.
Pharmacy Service Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
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.
Resident Rights Deficiencies
Hire a qualified full-time social worker in a facility with more than 120 beds.
Administration Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
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Frequently Asked Questions
What is the CareGrader rating for Millbrook Healthcare and Rehabilitation Center?
Millbrook Healthcare and Rehabilitation Center in Lancaster, Texas has a CareGrader grade of D (Below Average), with a composite score of 63.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.
What is the CMS star rating for Millbrook Healthcare and Rehabilitation Center?
Millbrook Healthcare and Rehabilitation Center has an overall CMS star rating of 1 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.
How many health deficiencies does Millbrook Healthcare and Rehabilitation Center have?
Millbrook Healthcare and Rehabilitation Center has 21 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.
Has Millbrook Healthcare and Rehabilitation Center been fined?
Yes. Millbrook Healthcare and Rehabilitation Center has $49,665 in total fines from CMS enforcement actions across 2 penalties.
How many beds does Millbrook Healthcare and Rehabilitation Center have?
Millbrook Healthcare and Rehabilitation Center has 124 certified beds with approximately 80 current residents (65% occupancy). The facility is located at 1850 W Pleasant Run Rd, Lancaster, Texas 75146. It is a for profit - limited liability company facility.
Data Disclaimer
Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.