Millbrook Healthcare And Rehabilitation Center

Penalties

• Nov 29, 2023 — Fine ($13,565)

Inspection findings

1. Apr 23, 2026 Health · 9 findings
   • Not serious Scope/severity E

     F0565 Resident Rights Deficiencies

     Honor the resident's right to organize and participate in resident/family groups in the facility.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0638 Resident Assessment and Care Planning Deficiencies

     Assure that each resident’s assessment is updated at least once every 3 months.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Apr 24, 2026 · CMS health inspection

2. Dec 3, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Dec 4, 2025 · CMS health inspection

3. Dec 2, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Dec 3, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 3, 2025 · CMS health inspection

4. Dec 1, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 2, 2025 · CMS health inspection

5. Sep 9, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Sep 26, 2025 · CMS health inspection

6. May 7, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected May 23, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 23, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 23, 2025 · CMS health inspection

7. Feb 11, 2025 Health · 7 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Feb 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Feb 17, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 17, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Feb 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 17, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Feb 17, 2025 · CMS fire safety

8. Oct 11, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Oct 14, 2024 · CMS health inspection

9. Jan 10, 2024 Health · 4 findings
   • Not serious Scope/severity E

     F0850 Administration Deficiencies

     Hire a qualified full-time social worker in a facility with more than 120 beds.

     Corrected Feb 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 5, 2024 · CMS health inspection

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jan 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jan 11, 2024 · CMS fire safety

10. Nov 29, 2023 Health · 1 finding
    • Serious Scope/severity K Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 29, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 12/01/2023
• HOOPER, GRADY — corporate officer, NOT APPLICABLE, since 12/01/2023
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• MADISON, KRISTEN — managing control - governing body, NOT APPLICABLE, since 12/01/2023
• MADISON, KRISTEN — adp of the snf, NOT APPLICABLE, since 12/01/2023
• MADISON, KRISTEN — operational/managerial control, NOT APPLICABLE, since 12/01/2023
• SHARMA, NEERAJ — managing control - governing body, NOT APPLICABLE, since 09/04/2024
• SHARMA, NEERAJ — adp of the snf, NOT APPLICABLE, since 09/04/2024
• SHARMA, NEERAJ — operational/managerial control, NOT APPLICABLE, since 09/04/2024
• BLUEBONNET HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 10/27/2025
• BLUEBONNET HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 12/01/2023
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 04/18/2022