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Millbrook Healthcare And Rehabilitation Center

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About Millbrook Healthcare And Rehabilitation Center

General Information

Legal Business NameNexion Health At Lancaster Inc
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 25, 2008 (8 years)
Capacity124
Residents91
Percent Occupied73%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Millbrook Healthcare And Rehabilitation Center

Millbrook Healthcare And Rehabilitation Center
was reviewed by Medicare to have a rating of 4 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

July 2, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$3,900 fine
FManyPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.

July 1, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionProperly maintained smoke detectors.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionPortable fire extinguishers.

June 12, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
FManyPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
ESomePotential for HarmComplaint+Inspection1) Hire only people with 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.
ESomePotential for HarmComplaint+InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Millbrook Healthcare And Rehabilitation Center require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 40min
2hr 20min
ReportedExpected
CNA
55min
40min
ReportedExpected
LPN
40min
1hr 15min
ReportedExpected
RN
4hr 10min
4hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 40min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

11.8%
10.3%
10.3%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
60.0%
52.9%
65.9%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
57.9%
57.4%
39.1%
46.9%
Q1 2015Q2 2015Q3 2015TX
Low Risk Residents Who Lose Control of Their Bowel or Bladder
23.8%
25.3%
11.1%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
22.4%
26.7%
24.0%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
5.7%
0.0%
1.6%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
1.2%
2.4%
1.2%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
8.9%
3.6%
3.4%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
1.2%
1.2%
0.0%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
1.2%
1.2%
2.3%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
0.0%
0.0%
2.3%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
2.8%
2.5%
3.3%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

24.6%
45.6%
65.5%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
6.8%
6.5%
6.5%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
10.0%
14.3%
16.5%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
4.9%
5.7%
6.9%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
2.4%
3.5%
1.8%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened