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Nursing HomeMedicaid Investigative

Millbrook Healthcare and Rehabilitation Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1850 West Pleasant Run Road, Lancaster, TX 75146124 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.7/5

based on 187 Google reviews

5
4
3
2
1

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (14 vs median 8.0)
  • High staff turnover (66%)

Below average in Texas · Critically understaffed (RN) · Below chain average · $13,565 in fines

Source: Medicare data

What this means for your family

This facility is an excellent choice for rehabilitation, particularly for post-surgical recovery, due to their highly-rated therapy team. While the facility is noted for being exceptionally clean and welcoming, families should proactively establish a communication plan with the nursing staff to ensure you are promptly notified of any changes in your loved one's condition.

Google Reviews

Google Reviews

187 reviews on Google
Millbrook Healthcare and Rehabilitation Center is highly regarded for its exceptional physical therapy team and a front-desk staff that is frequently praised for being welcoming and professional. While many families report a clean, pleasant-smelling environment, some past reviews have raised serious concerns regarding communication delays and nursing professionalism during ownership transitions.

Quality Themes

Tap a score for details
Food4.0Staff9.0Clean8.0ActivitiesN/AMedsN/AMemoryN/AComms5.0ValueN/A

Strengths

  • Exceptional physical therapy and rehab services
  • Welcoming and professional front-desk staff
  • Clean and well-maintained facility
  • Compassionate and attentive nursing and aide staff

Concerns

  • Communication delays regarding resident health status (mentioned by 2 reviewers)
  • Unpleasant odors in certain areas of the building (mentioned by 2 reviewers)
  • Staffing professionalism and organization during ownership changes (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.22022(10)4.52023(26)4.62024(9)4.92025(118)5.02026(7)

Distribution · 170 analyzed

5
157
4
5
3
2
2
0
1
6
34 reviews posted between Apr 21, 2025Apr 26, 2025 · 34 were 5-star
14 reviews posted between Jul 15, 2025Jul 16, 2025 · 14 were 5-star

How They Respond to Reviews

0%response rate
Good

The owner provides personalized responses that frequently use the reviewer's name and acknowledge specific staff members mentioned. While positive reviews are met with warmth, negative reviews are addressed with a mix of empathy and defensive rebuttals.

Questions for Your Tour

  • 1We've heard wonderful things about the physical therapy and rehab services here; could you tell us more about how that program supports resident recovery?
  • 2How does the nursing team ensure that family members are kept updated and informed about any changes in a resident's health status?
  • 3What steps are being taken to ensure consistent staffing levels and professional organization across all shifts?
  • 4We noticed the facility is very well-maintained; how often are the common areas and resident rooms deep-cleaned to ensure a fresh environment?
  • 5Could you describe what a typical day looks like for residents, including meal times and scheduled social activities?
  • 6How does the clinical team handle medical emergencies or urgent health changes during the overnight hours?

Personalized based on this facility's data


Key Review Excerpts

The Physical Therapists at Millbrook are far and beyond my expectations. I’m getting better daily after total hip replacement.

Rehab patient · 2026★★★★★

I was not aware of the things I would need to apply for Medicaid and I was afraid to complete it incorrectly. [...] the business office manager went above and beyond to ensure My mom would have a place

Long-term resident's family · 2022★★★★★

Just walked into this facility wondering if I was going to be slammed in the face with smell of urine and/or bleach at the door, since this is my</em> my experience everytime I have to go to a LLC facility. But to my pleasant surprise, not only does it smell really nice like a hotel, it’s not overpowering and very pleasant to the nose.

Visitor · 2025★★★★★
Source: 187 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.15hrs
20%
Registered nurses for medical care
Total Nursing
3.27hrs
80%
All nurses + aides combined
Staff Turnover
62%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

13

measures

Mixed Results

4

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
15.4%
TX
9.4%
Dallas
10.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility8.4%
Better than Avg
Here
8.4%
US
19.5%
TX
18.4%
Dallas
16.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility5.4%
Mixed vs Avgs
Here
5.4%
US
12.1%
TX
2.5%
Dallas
2.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
TX
96.9%
Dallas
95.6%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility19.3%
Mixed vs Avgs
Here
19.3%
US
19.4%
TX
14.2%
Dallas
16.2%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
TX
98.0%
Dallas
97.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility90.9%
Better than Avg
Here
90.9%
US
79.7%
TX
88.0%
Dallas
78.8%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility93.3%
Better than Avg
Here
93.3%
US
81.8%
TX
89.2%
Dallas
86.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
TX
1.5%
Dallas
1.3%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

14deficiencies
1penalties
Well above state avg (9.1)
11 complaint-triggered
$13,565 in fines

Families have filed multiple complaints against this facility, resulting in 11 complaint-triggered deficiencies out of 28 total violations across 10 surveys. The most recurring problems involve infection control, medication management, and resident rights issues including privacy and dignified treatment. While all deficiencies show correction dates, the pattern of repeated infections control violations and ongoing family complaints suggests persistent care quality concerns that warrant careful consideration during any visit.

Dec 3, 2025Complaint
1
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Dec 2, 2025Complaint
2
0656Potential for harm · PatternCorrected

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.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Dec 1, 2025Complaint
1
0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Sep 9, 2025Complaint
1
0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

May 7, 2025Complaint
3
0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0761Potential for harm · IsolatedCorrected

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.

Feb 11, 2025Routine
7
0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0558Potential for harm · PatternCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Federal Penalties

Fine

Nov 29, 2023

$13,565

Ownership & Operations

Who Operates This Facility

Owner / Operator

Hamilton County Hospital District

Organization Type

for profit

Management Company

BLUEBONETT HEALTHCARE, INC

Administrator

KRISTEN MADISON

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 2.9/5 · Rank 54 of 84

Ownership & Management

Key personnel

Madison, KristenContracted Managing EmployeeHooper, GradyOfficer / DirectorBluebonnet Healthcare, INC.ManagerBurnam, SoonManagerMadison, KristenManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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