Cycle 1
Health 2025-02-11 · Fire 2025-02-11
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lancaster, TX
Millbrook Healthcare and Rehabilitation Center
2-star overall rating with 3-star inspections with $13,565 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1850 W Pleasant Run Rd, Lancaster, TX
(972) 275-1900
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2008-07-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.15
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.15
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
66%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,561
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.55% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 9.13% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.47
Baseline 78.18% · Performance 67.69% · Measure score 1.47 · Achievement 0 · Improvement 1.47
Adjusted total nurse staffing
0
Baseline 3.21 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.96% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 2.13% · Lower 95% interval 6.27% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 69.35% |
95.27%
25.9 pts worse
|
Numerator 43 · Denominator 62 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 62 |
| Discharge self-care score | 38.71% |
53.69%
15 pts worse
|
Numerator 12 · Denominator 31 |
| Discharge mobility score | 29.03% |
50.94%
21.9 pts worse
|
Numerator 9 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 62 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.13% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 11.69% |
42%
30.3 pts worse
|
Numerator 18 · Denominator 154 |
| Discharge function score | 35.48% |
56.45%
21 pts worse
|
Numerator 11 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 13 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.0% · Q3 3.1% · Q4 1.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
2.7%
1.8 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.0% · Q3 3.9% · Q4 5.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
3.3%
0.2 pts worse
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.0% · Q3 1.8% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
18.9%
11.9 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.0% · Q3 7.1% · Q4 8.6% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.7% |
10.8%
8.1 pts better
|
16.7%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 2.2% · Q4 4.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.5% |
15.4%
16.1 pts worse
|
16.3%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
16.1%
7.5 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 33.3% · Q3 25.6% · Q4 9.8% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
15.0%
3.1 pts worse
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 26.2% · Q3 15.2% · Q4 13.6% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.5% · Q3 1.9% · Q4 0.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
89.7%
2.1 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 93.2% · Q3 86.2% · Q4 94.4% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.8% |
12.0%
10.2 pts better
|
12.0%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.8% · Observed 1.8% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
88.0%
2.9 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.8% |
25.9%
6.9 pts worse
|
23.9%
8.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.8% · Observed 35.7% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
3 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-10-19 · Fire 2022-10-19
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-17
F · Potential for more than minimal harm
2024-01-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-11
C · Minimal harm
2024-01-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-12
E · Potential for more than minimal harm
2022-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-23
E · Potential for more than minimal harm
2022-10-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-10-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-12-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-12-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-09-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-05-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-02-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-02-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-17
D · Potential for more than minimal harm
2024-10-11
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-01-10
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-05
K · Immediate jeopardy
2023-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
E · Potential for more than minimal harm
2022-10-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-10-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-10-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-22
Penalties and ownership
What sits behind the stars
$13,565
2023-11-29
Fine
Fine · fine $13,565
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bluebonnet Healthcare, Inc.
Operational/Managerial Control · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Hooper, Grady
Corporate Officer · Individual
Madison, Kristen
Operational/Managerial Control · Individual
Madison, Kristen
Contracted Managing Employee · Individual
Nearby options
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#2
Avir At Lancaster
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2-star overall rating with 2-star inspections with abuse icon flag with $39,757 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Lancaster Nursing & Rehabilitation
Lancaster, TX
1-star overall rating with 1-star inspections with $55,760 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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