Millbrook Healthcare And Rehabilitation Center

Millbrook Healthcare And Rehabilitation Center was recognized and ceritified in 2008 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Millbrook Healthcare And Rehabilitation Center which is located in 1850 W Pleasant Run Rd Lancaster, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Millbrook Healthcare And Rehabilitation Center is being offered ceritified services and products in Texas.
Address:   1850 W Pleasant Run Rd
       Lancaster, TX 75146

Phone:   (972) 275-1900

County: Dallas
Federal Provider Number: 676188
Participates in: Medicare And Medicaid
Certified Date: Friday, July 25, 2008 (16 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Nexion Health At Lancaster Inc
Ownership Type: For Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationNexion Health Of Texas, Inc5% Or More Ownership Interest
OrganizationNexion Health Leasing, Inc.5% Or More Ownership Interest
OrganizationNexion Health, Inc.5% Or More Ownership Interest
PersonFrancis KirleyW-2 Managing Employee
PersonFrancis KirleyDirector/officer
PersonFrancis Kirley5% Or More Ownership Interest
PersonJohn FallonDirector/officer
PersonBretton BoltW-2 Managing Employee
PersonBretton BoltDirector/officer
PersonBretton Bolt5% Or More Ownership Interest

Provider Resides in Hospital: No
Number of Federally Certified Beds: 91
Number of Residents in Federally Certified Beds: 91 (100% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Both
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Thursday, June 12, 2014
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Health
Deficiency: F0364 (Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right tempe)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 17, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 17, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 12, 2014
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 11, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 6, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 8, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 6, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, June 6, 2013
Survey Type: Health
Deficiency: F0246 (Reasonably accommodate the needs and preferences of each resident.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 8, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 5, 2013
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, June 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, June 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0456 (Keep all essential equipment working safely.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, June 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, May 9, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, June 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 0
Number of Substantiated Complaints: 0
Number of Fines: 0
Number of Payment Denials: 0
Total Number of Penalties: 0
Total Amount of Fines in Dollars: USD 0
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This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (4 out of 5 stars)
Quality Rating (4 out of 5 stars)
Staffing Rating (1 out of 5 stars)
RN Staffing Rating (1 out of 5 stars)
Overall Rating (3 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
7%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
9%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
20%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
3%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
7%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
19%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
89%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
91%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
8%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
6%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
26%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
44%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
73%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
4%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
75%
84%

N/A
Data not available.

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Millbrook Healthcare And Rehabilitation Center [Federal No:676188] near 1850 W Pleasant Run Rd, Lancaster TX

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