1850 W Pleasant Run Rd, Lancaster, TX 75146 (opens Google Maps) · Dallas County · (972) 275-1900· 124 certified beds · avg 78 residents/day · certified since Jul 25, 2008 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
New to these records? How to read an inspection report →
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
▲ Immediate jeopardy, pattern · Nov 29, 2023 · F-0880 · triggered by a complaint
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Dec 29, 2023 (Deficient, Provider has date of correction)
Showing the latest 3 of 27 inspection findings. Open the full record below to read every finding.
The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. F-0565
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. F-0656
The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. F-0812
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 23, 2026 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| Apr 23, 2026 | E · Potential for more than minimal harm, pattern | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Apr 23, 2026 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Apr 23, 2026 | E · Potential for more than minimal harm, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Apr 23, 2026 | E · Potential for more than minimal harm, pattern | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921 |
| Apr 23, 2026 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| Apr 23, 2026 | D · Potential for more than minimal harm, isolated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. · F-0638 |
| Apr 23, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Apr 23, 2026 | D · Potential for more than minimal harm, isolated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · F-0693 |
| Dec 3, 2025 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550 |
| Dec 2, 2025 | E · Potential for more than minimal harm, pattern | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| Dec 2, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755 |
| Dec 1, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695 |
| Sep 9, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint · F-0628 |
| May 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · from a complaint · F-0583 |
| May 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755 |
| May 7, 2025 | D · Potential for more than minimal harm, isolated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint · F-0761 |
| Feb 11, 2025 | E · Potential for more than minimal harm, pattern | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Feb 11, 2025 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Feb 11, 2025 | E · Potential for more than minimal harm, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Feb 11, 2025 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · F-0550 |
| Feb 11, 2025 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Feb 11, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · F-0677 |
| Oct 11, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| Jan 10, 2024 | E · Potential for more than minimal harm, pattern | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. · F-0850 |
| Jan 10, 2024 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880 |
| Nov 29, 2023 | ▲ K · Immediate jeopardy, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880 |
Citations from standard inspections increased between the last two inspection cycles (6 → 9).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 1 | K ▲ |
| 2024 | 3 | 0 | E |
| 2025 | 14 | 0 | E |
| 2026 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
How to file a complaint about care →
1 fine totaling $13,565.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Nov 29, 2023 | Fine | $13,565 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.81 | 3.46 | 3.95 | bottom 12% in Texas; bottom 8% in the U.S. |
| Registered Nurse hours | 0.11 | 0.44 | 0.69 | bottom 1% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 2.52 | 3.04 | 3.50 | bottom 17% in Texas; bottom 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.11 | 0.34 | 0.48 | bottom 4% in Texas; bottom 2% in the U.S. |
| Total nursing staff turnover (%) | 69.7 | 55.3 | 45.8 | bottom 19% in Texas; bottom 6% in the U.S. |
| RN turnover (%) | — | 54.6 | 42.9 | — |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.08, RN 0.12, weekend 2.76.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.08 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 1/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Millbrook Healthcare and Rehabilitation Center. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bluebonnet Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2023 |
| Bluebonnet Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 10/27/2025 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2023 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/18/2022 |
| Hooper, Grady | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2023 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Madison, Kristen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2023 |
| Madison, Kristen | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2023 |
| Madison, Kristen | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2023 |
| Sharma, Neeraj | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/04/2024 |
| Sharma, Neeraj | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/04/2024 |
| Sharma, Neeraj | Individual | ADP of the SNF | NOT APPLICABLE | 09/04/2024 |
All 12 owning or managing parties CMS has on file are shown — none excluded.
CMS lists this facility under the chain The Ensign Group — 342 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking. Showing 8 of the 341 others, continuing from this facility's own place in that list.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Windsor Gardens | 0.8 mi | Lancaster, TX | ★★☆☆☆ | 2/5 | |
| Avir at Lancaster | 1.8 mi | Lancaster, TX | ★★☆☆☆ | 2/5 | |
| Lancaster Nursing & Rehabilitation | 2.0 mi | Lancaster, TX | ★☆☆☆☆ | 1/5 | |
| Desoto Nursing & Rehabilitation Center | 3.4 mi | Desoto, TX | ★★★☆☆ | 3/5 | |
| Five Points Nursing and Rehabilitation | 3.8 mi | Desoto, TX | ★★☆☆☆ | 3/5 | |
| Park Village Healthcare and Rehabilitation | 3.9 mi | Desoto, TX | ★★☆☆☆ | 1/5 | abuse |
| Methodist Transitional Care Center-Desoto LLC | 4.0 mi | Desoto, TX | ★★★☆☆ | 2/5 | |
| Red Oak Health and Rehabilitation Center | 5.0 mi | Red Oak, TX | ★★★☆☆ | 4/5 | |
| Williamsburg Village Healthcare Campus | 5.5 mi | Desoto, TX | ★★☆☆☆ | 1/5 | SFF |
| The Lennwood Nursing and Rehabilitation | 5.6 mi | Dallas, TX | ★☆☆☆☆ | 2/5 | |
| Duncanville Healthcare and Rehabilitation Center | 6.3 mi | Duncanville, TX | ★☆☆☆☆ | 1/5 | |
| The Villages of Dallas | 6.4 mi | Dallas, TX | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
CMS records place this facility in Dallas, TX — 81 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 676188.
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