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Millbrook Healthcare And Rehabilitation Center
1850 W PLEASANT RUN RD
Lancaster, TX 75146
(972) 275-1900
General
Ratings
Deficiencies
Resident Stats
Staff Stats
| Certified Beds: | 124 |
| Number of Residents: | 69 |
| Percent of Occupied Beds: | 56% |
| Sprinkler Status: | Fully Sprinklered |
| Program Participation: | Medicare and Medicaid |
| Type of Ownership: | For profit - Corporation |
| Located Within a Hospital? | No |
| Multi Nursing Home Ownership? | Yes |
| Resident and Family Councils? | Both |
| Continuing Care Retirement Community? | No |
| Quality Indicator Survey? | No |
| Special Focus Facility? | No |
| Overall: |  |
| Health Inspection: | |
| Nurse Staffing: | |
| Quality Measures: |  |
| RN Only: |  |
| Date | Type | Category | Deficiency | Scope | Level of Harm | Date of Correction |
| 20081217 | Health | Pharmacy Service Deficiencies | Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | Isolated | Minimal harm or potential for actual harm | 20081218 |
| 20100305 | Health | Administration Deficiencies | Make sure that nurse aides show they have the skills to be able to care for residents. | Pattern | Minimal harm or potential for actual harm | 20100329 |
| 20100305 | Health | Mistreatment Deficiencies | Protect residents from mistreatment, neglect, and/or theft of personal property. | Pattern | Actual harm | 20100329 |
| 20100305 | Health | Mistreatment Deficiencies | 1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Pattern | Minimal harm or potential for actual harm | 20100329 |
| 20100305 | Health | Mistreatment Deficiencies | Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. | Pattern | Minimal harm or potential for actual harm | 20100329 |
| 20100305 | Health | Quality Care Deficiencies | Give each resident care and services to get or keep the highest quality of life possible. | Pattern | Actual harm | 20100329 |
| 20100305 | Health | Environmental Deficiencies | Make sure that the nursing home area is free of dangers that cause accidents. | Pattern | Minimal harm or potential for actual harm | 20100329 |
| 20100305 | Health | Nutrition and Dietary Deficiencies | Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Pattern | Minimal harm or potential for actual harm | 20100329 |
| 20100305 | Health | Nutrition and Dietary Deficiencies | Store, cook, and give out food in a safe and clean way. | Widespread | Minimal harm or potential for actual harm | 20100329 |
| Value | Notes | |
| Percent of long-stay residents given influenza vaccination during the flu season: | 70 | |
| Percent of long-stay residents who were assessed and given pneumococcal vaccination: | 77 | |
| Percent of long-stay residents whose need for help with daily activities has increased: | 18 | |
| Percent of long-stay residents who have moderate to severe pain: | 1 | |
| Percent of high-risk long-stay residents who have pressure sores: | 16 | |
| Percent of low-risk long-stay residents who have pressure sores: | 2 | |
| Percent of long-stay residents who were physically restrained: | 1 | |
| Percent of long-stay residents who are more depressed or anxious: | 14 | |
| Percent of low-risk long-stay residents who lose control of their bowels or bladder: | 46 | |
| Percent of long-stay residents who have/had a catheter inserted and left in their bladder: | 3 | |
| Percent of long-stay residents who spend most of their time in bed or in a chair: | 5 | |
| Percent of long-stay residents whose ability to move about in and around their room got worse: | 17 | |
| Percent of long-stay residents who had a urinary tract infection: | 8 | |
| Percent of long-stay residents who lose too much weight: | 10 | |
| Percent of short-stay residents given influenza vaccination during the flu season: | 50 | |
| Percent of short-stay residents who were assessed and given pneumococcal vaccination: | 49 | |
| Percent of short-stay residents who have delirium: | 0 | |
| Percent of short-stay residents who had moderate to severe pain: | 6 | |
| Percent of short-stay residents who have pressure sores: | 16 | |
| # of Residents: | 69 |
| # RN Hours per Resident: | 0.43 |
| # LPN Hours per Resident: | 0.93 |
| # CNA Hours per Resident: | 2.3 |
| Total Staff Hours per Resident: | 1.36 |
