D
Avir at Lancaster
48/100 score
0.77 hrs RN staffing
10 deficiencies
Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146
- Provider number (CCN)
- 676188
- Certification
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified beds
- 124
- Phone
- (972) 275-1900
- CMS data as of
- July 1, 2026
F
What the records show
CMS rates Millbrook Healthcare and Rehabilitation Center 2 out of 5 stars overall, with 3 of 5 for health inspections, 1 of 5 for staffing, 4 of 5 for quality measures. Federal inspectors cited 22 health deficiencies across the last three survey cycles, most recently surveyed in 2025, 1 at actual-harm level or higher. CMS enforcement records list 1 fine totalling $13,565.
Facility Assessment
Inspectors recorded 1 citation at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Reviews, Ratings and Official Records
This page reviews Millbrook Healthcare and Rehabilitation Center using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.
Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.
Ratings and Grade Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.12 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
22
Outstanding
0
Actual harm or worse (G–L)
1
|
|
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
|
Overall: ★★☆☆☆ (2/5)
Health inspection: ★★★☆☆ (3/5)
Quality: ★★★★☆ (4/5)
Staffing: ★☆☆☆☆ (1/5)
|
|
NursingHomeGrade Score
|
31/100 |
Loaded into NursingHomeGrade on August 7, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.
Staffing Compared With State and National Levels
| This facility | 0.12 hrs |
|---|---|
| TX median | 0.38 hrs |
| National average | 0.69 hrs |
Total nursing staff turnover: 69.7%
Staffing figures are the values CMS published in its file processed July 1, 2026, drawn from payroll-based journal reporting.
Inspection Records Covered
- Most recent standard health survey: February 11, 2025.
- Citations shown below span 3 recorded inspection cycles.
- Survey dates on file range from October 19, 2022 to December 3, 2025.
Source records: CMS Care Compare profile for provider 676188 ↗ · the federal files we load and when.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 immediate jeopardy issue found among 22 total deficiencies. 22 corrected.
Most recent inspection (February 11, 2025)
E
Potential harm — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 17, 2025
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 17, 2025
E
Potential harm — pattern
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2025
E
Potential harm — pattern
F0695
Status: Corrected
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 2, 2025
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 17, 2025
E
Potential harm — pattern
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2025
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 17, 2025
D
Potential harm — isolated
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 4, 2025
D
Potential harm — isolated
F0628
Status: Corrected
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 26, 2025
E
Potential harm — pattern
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 17, 2025
D
Potential harm — isolated
F0550
Status: Corrected
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 17, 2025
Inspection cycle 2 (January 10, 2024)
E
Potential harm — pattern
F0850
Status: Corrected
Hire a qualified full-time social worker in a facility with more than 120 beds.
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2024
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2024
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 23, 2025
D
Potential harm — isolated
F0761
Status: Corrected
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 — Deficient, Provider has date of correction, corrected May 23, 2025
D
Potential harm — isolated
F0583
Status: Corrected
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 23, 2025
D
Potential harm — isolated
F0584
Status: Corrected
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 — Deficient, Provider has date of correction, corrected October 14, 2024
Inspection cycle 3 (November 29, 2023)
K
Immediate jeopardy — pattern
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 29, 2023
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 22, 2022
E
Potential harm — pattern
F0812
Status: Corrected
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 22, 2022
E
Potential harm — pattern
F0756
Status: Corrected
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 — Deficient, Provider has date of correction, corrected October 22, 2022
D
Potential harm — isolated
F0842
Status: Corrected
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 — Deficient, Provider has date of correction, corrected October 22, 2022
Fines and Enforcement Actions
Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.
| Date | Action | Amount or length |
|---|---|---|
| November 29, 2023 | Fine | $13,565 |
1 fine totalling $13,565.
Source: CMS Penalties file (dataset g6vv-u9sr).
Ownership and Contact Information
- Facility name
- Millbrook Healthcare and Rehabilitation Center
- Legal business name
- HAMILTON COUNTY HOSPITAL DISTRICT
- Address
- 1850 W Pleasant Run Rd, Lancaster, TX 75146
- Phone
- (972) 275-1900
- Provider number (CCN)
- 676188
- Ownership type
- For profit - Limited Liability company
- Medicare/Medicaid certified since
- July 25, 2008
- Official record
- CMS Care Compare profile ↗
- Details verified against CMS data dated
- July 1, 2026
The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.
How We Stay Independent
NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.
Learn about our data methodology →Nearby facilities in Lancaster
Compare local nursing homes using the same CMS-backed grading method.
F
Lancaster Nursing & Rehabilitation
17/100 score
0.50 hrs RN staffing
15 deficiencies
D
WINDSOR GARDENS
40/100 score
0.37 hrs RN staffing
13 deficiencies
F
DESOTO NURSING & REHABILITATION CENTER
21/100 score
0.27 hrs RN staffing
13 deficiencies
F
Five Points Nursing and Rehabilitation
34/100 score
0.34 hrs RN staffing
10 deficiencies
Sources and Methodology
- CMS Provider Information (file processed July 1, 2026) — ratings, staffing, ownership, certification and contact details. Dataset 4pq5-n9py ↗
- CMS Health Deficiencies — inspection citations, scope and severity, correction status. Dataset r5ix-sfxw ↗
- CMS Penalties — fines and payment denials with the dates CMS recorded them. Dataset g6vv-u9sr ↗
- CMS Ownership — owning and managing organisations. Dataset y2hd-n93e ↗
The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.
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