Millbrook Healthcare And Rehabilitation Center
1850 WEST PLEASANT RUN ROAD, Lancaster, TX, 75146
Federal Quality Data
Official records from CMS Care Compare — reported by the facility and audited by the Centers for Medicare & Medicaid Services. We present them unmodified. Refreshed March 2026.
CMS Star Ratings
Facility & Staffing
- Ownership
- For profit - Limited Liability company · Chain: The Ensign Group
- Certified beds
- 124 · avg 80 residents/day
- Total nursing staff turnover
- 65.8% — higher than most Texas nursing homesTexas avg: 51.5% · National avg: 46.4% · per CMS Care Compare
- Administrators who left
- 0 departed — near the Texas averageTexas avg: 0.6 · National avg: 0.5 · per CMS Care Compare
Enforcement & Citations
- Fines (past 3 years)
- 1 fine · $13,565 total
State licensing & capacity
- License number
- 311771
- Service type
- Medicare/medicaid
- Licensed capacity
- 124 beds
- Bed type breakdown
- 28 Medicare-only · 96 Medicaid/Medicare
- Current license effective
- December 1, 2023
- Current license expires
- December 1, 2026
- Initial license date
- July 24, 2008
Texas HHSC licensing registry · as of April 16, 2026
Ownership & operations
- Licensee
- Hamilton County Hospital District (HOSPITAL DISTRICT/AUTHORITY)
- Operator / manager
- Bluebonett Healthcare, Inc
- Administrator
- Kristen Madison
Texas HHSC licensing registry · as of April 16, 2026
Federal ownership record
Chain affiliation
Part of the The Ensign Group chain — 329 facilities across 17 states. Chain-wide average overall rating 3.2 / 5.
Disclosed owners (5 on record)
- Bluebonnet Healthcare, Inc.
Operational/managerial Control · since 2023
- Grady Hooper
Corporate Officer · since 2023
- Hamilton County Hospital District
5% or Greater Direct Ownership Interest · 100% · since 2023
- Kristen Madison
Contracted Managing Employee · since 2023
- Soon Burnam
Operational/managerial Control · since 2023
Recent change of ownership
December 2023 (2 years ago) · acquired from Millbrook Healthcare And Rehabilitation Center
Transaction type: Change of Ownership
Source: CMS Provider Enrollment data — SNF Enrollments + All Owners + Chain Performance Measures + Change of Ownership, as of April 2026.
Federal inspection record
Immediate-jeopardy citations (CMS scope/severity J–L) are the most serious category federal inspectors issue — meaning a deficiency placed residents in immediate risk of serious harm. Ask the facility for the corrective-action plan filed with CMS, and consider contacting your state long-term care ombudsman for context.
Recent health-deficiency citations (most recent 8 of 22)
- D0550·Dec 3, 2025Complaint
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- E0755·Dec 2, 2025Complaint
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E0656·Dec 2, 2025Complaint
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E0695·Dec 1, 2025Complaint
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
- D0628·Sep 9, 2025Complaint
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D0761·May 7, 2025Complaint
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.
- D0755·May 7, 2025Complaint
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D0583·May 7, 2025Complaint
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Federal penalties
By year
- 20231 fine · $14K
Most recent events
- Nov 29, 2023Fine · $14K
Fire-safety citations
6 Life-Safety-Code citations on file. Most recent: Feb 11, 2025. Fire-safety inspections cover building-level Life Safety Code compliance, separate from the resident-care health survey.
Source: CMS Provider Data Catalog — Health Deficiencies, Fire Safety Deficiencies, and Penalties datasets, snapshot Mar 1, 2026.
About this community
Millbrook Healthcare And Rehabilitation Center is a 124-bed nursing home in Lancaster, Dallas County, operated under The Ensign Group and managed by Bluebonnet Healthcare, Inc. CMS rates it 2 stars overall — staffing is rated 1 star, the lowest tier, while quality measures score 4 stars. The facility is running at roughly 65% of licensed beds. The license is active through December 2026.
Written from CMS Care Compare and state licensing records · last updated April 19, 2026
What the data says
CMS rates staffing here at 1 star — the bottom tier among Texas nursing homes, a rating shared by about 38% of facilities statewide. Each resident receives approximately 189 minutes of total nursing care per day, about 52 minutes less than at a 4-star-staffing facility in Texas. Of those 189 minutes, only 9 are from a registered nurse. Residents here also tend to need more hands-on care than at a typical facility — less mobile or medically more complex on average — so those nursing hours stretch thinner than the raw numbers suggest.
Roughly 7 in 10 nursing staff left in the past year. At that rate, a long-stay resident will likely cycle through two or three primary caregivers over the course of a year.
The facility is running at about 65% of its 124 licensed beds — 80 residents on a typical day in a building built for 124. Paired with 1-star staffing and high turnover, that vacancy level is part of the broader operational picture.
Quality measures rate 4 stars on both long-stay and short-stay categories — meaning documented resident outcomes such as rates of falls, pressure wounds, and pain management score above most Texas peers, despite the staffing rating.
Written from CMS Care Compare and state licensing records · last updated April 19, 2026
Questions to ask when you tour
Staffing levels on nights and weekends
Weekend nursing hours here average 2.6 hours per resident per day — lower than the already-low weekday average; ask how many nurses and aides are on floor during overnight and weekend shifts.
RN presence during the day
CMS data shows only about 9 minutes of registered-nurse time per resident per day; ask which hours an RN is physically on-site and who handles clinical decisions after hours.
Staff retention and continuity
About 7 in 10 nursing staff left in the past year; ask how the facility assigns consistent caregivers to residents and what steps are underway to reduce turnover.
Current occupancy and admissions pace
The facility is operating at roughly 65% of its licensed 124 beds; ask whether that reflects a selective admissions process, recent discharges, or difficulty attracting referrals.
How quality scores stay high despite staffing
Quality measures rate 4 stars while staffing rates 1 star — ask specifically how care plans are monitored and who reviews resident outcomes week to week.
Resident Council activity
The facility has a Resident Council but no Family Council; ask how families are notified of concerns raised in council meetings and whether family input is formally collected.
Where this information comes from
- License, capacity, ownership, administrator: Texas HHSC licensing registry, snapshot as of April 16, 2026.
- Star ratings, staffing, fines, deficiencies: CMS Care Compare, processed March 1, 2026.
- Summary, insights, and tour questions: Written from the state licensing and CMS records above, last updated April 19, 2026.
Read our methodology for how this information is collected and verified.