Millbrook Healthcare And Rehabilitation Center faces challenges in its CMS ratings, earning a D grade with a score of 41/100. The facility ranks in the 45th percentile among Texas nursing homes, suggesting significant room for improvement.
With 3.16 total nurse hours per resident per day, Millbrook Healthcare And Rehabilitation Center falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.
Recent CMS inspections identified 22 deficiencies at Millbrook Healthcare And Rehabilitation Center, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.16 | 3.8 | Below Average |
| Registered Nurses (RN) | 0.15 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 1.12 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 1.89 | 2.4 | Below Average |
| Weekend Total Nursing | 2.63 | 3.8 | Below Average |
| Weekend RN Hours | 0.14 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0550 Severity DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Dec 2, 2025 · Resident Rights Deficiencies
- Tag 0656 Severity EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Dec 1, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0755 Severity EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Dec 1, 2025 · Pharmacy Service Deficiencies
- Tag 0695 Severity EProvide safe and appropriate respiratory care for a resident when needed.Nov 30, 2025 · Quality of Life and Care Deficiencies
- Tag 0628 Severity DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Sep 8, 2025 · Resident Rights Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 2.6% | 4.5% | Better |
| Falls with major injury | 2.3% | 3.0% | Better |
| On antipsychotic medication | 2.7% | 14.5% | Better |
| Urinary tract infections | 0.0% | 2.5% | Better |
| ADL decline (daily activities) | 23.6% | 14.0% | Worse |
| Excessive weight loss | 3.5% | 7.5% | Better |
| New/worsened incontinence | 18.1% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $13,565
How This Grade Was Calculated
This facility's grade of D is based on a score of 41 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 2★ → 16 pts (max 40)
- Health Inspection Rating: 3★ → 15 pts (max 25)
- Staffing Rating: 1★ → 4 pts (max 20)
- Quality Measures Rating: 4★ → 12 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -1 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
Other Facilities in Texas
- FAvir at BeaumontBEAUMONT
- FAvir at New BraunfelsNew Braunfels
- A
- BKNOPP HEALTHCARE AND REHAB CENTER INCFREDERICKSBURG
- B