Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Millbrook Healthcare and Rehabilitation Center
Lancaster, TX · 124 certified beds · Last Life Safety survey April 23, 2026
CMS Certification Number 676188 · first certified July 2008
Ownership
Operated by THE ENSIGN GROUP · For profit - Limited Liability company
- Ownership changed December 1, 2023 (change of ownership)from BLUEBONNET HEALTHCARE, INC.
Position within TX
3 citations — more than 14% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 0 citations; the earlier surveys in the window averaged 1.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 8 months from now. This facility’s last Life Safety survey was April 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Millbrook Healthcare and Rehabilitation Center
One email when it happens. No account; stop it any time with one click.
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 3 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0584 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.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 3 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 10, 2024 | 2 |
| February 11, 2025 | 1 |
| April 23, 2026 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2024-01-10 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2024-01-10 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-02-11 |
What the citations cover
- Miscellaneous Deficiencies 1
- Smoke Deficiencies 1
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 1 |
| Smoke Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 11, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 17, 2025) |
January 10, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 12, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (January 11, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.