Health inspection·December 2, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 6 residents, reviewed for care plans. 1. The facility failed to follow the care plan and assess Resident #1 for pain at the start of each shift since 09/17/25. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.Findings Included:Record review of Resident #1's face sheet, dated 09/25/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had diagnoses of Dementia (decline in memory, thinking, problem-solving, and reasoning), Cognitive Communication Deficit (difficulty with communication), Type 2 Diabetes (body cannot use insulin properly or produce it), Essential Hypertension (high blood pressure), Heart Failure, Muscle Weakness, Peripheral Vascular Disease (blood vessels typically in the legs become narrowed or blocked), and a history of falling.Record review of Resident #1's Initial MDS Assessment, dated 09/09/5, reflected Resident #1 had a BIMS score of 07, which indicated Resident #1 had severe cognitive impairment. The MDS Assessment noted a pain assessment was completed upon admission, and no pain was noted.Record review of Resident #1's Care Plan reflected the following: Has acute/chronic pain r/t PVDDate initiated 09/08/2025Monitor/document for probable cause of each pain episode. Remove/limit causeswhere possible.Pain assessment every shift.In an interview on 09/25/25 at 2:40 PN, the DON Trainee stated if the care plan stated Resident #1 was to be assessed for pain every shift, then staff should have assessed for pain every shift, and those assessments would have been documented. She stated the nursing staff would be responsible for checking and documenting the pain level of residents. The DON Trainee stated the risk of not completing pain assessments as noted on the care plan was the resident could be in pain and staff would not be aware. The DON Trainee stated she would provide verification of the documented pain levels. Record review of a document titled, Weights and Vitals Summary dated 09/25/25, reflected the following dates and times for pain level checks:09/08/25 16:03 (4:03 PM) Pain Level noted as 009/09/25 16:19 (4:19 PM) Pain Level noted as 009/10/25 16:12 (4:12 PM) Pain Level noted as 009/11/25 16:12 (4:12 PM) Pain Level noted as 009/12/25 15:34 (3:34 PM) Pain Level noted as 009/13/25 6:06 (6:06 AM) Pain Level noted as 009/14/25 7:11 (7:11 AM) Pain Level noted as 009/15/25 15:23 (3:23 PM) Pain Level noted as 009/16/25 15:44 (3:44 PM) Pain Level noted as 009/17/25 15:23 (3:23 PM) Pain Level noted as 009/18/25 15:40 (3:40 PM) Pain Level noted as 009/19/25 15:36 (3:36 PM) Pain Level noted as 109/20/25 10:20 (10:20 AM) Pain Level noted as 009/23/25 11:52 (11:52 AM) Pain Level noted as 609/23/25 15:00 (3:00 PM) Pain Level noted as 0In an interview on 09/25/25 at 4:02 PM, the Administrator stated that care planning was on the nursing side, but everything on the care plan should be (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676188 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Millbrook Healthcare and Rehabilitation Center 1850 W Pleasant Run Rd Lancaster, TX 75146 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)