Cycle 1
Health 2025-08-20 · Fire 2025-08-20
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cleburne, TX
Heritage Trails Nursing And Rehabilitation Center
4-star overall rating with 4-star inspections with $67,124 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
301 Lincoln Park Dr, Cleburne, TX
(817) 558-8999
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
1998-05-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.53
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,337
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.28
Baseline 23.16% · Performance 21.45% · Measure score 2.28 · Achievement 0 · Improvement 2.28
Healthcare-associated infections
2.80
Baseline 7.03% · Performance 7.00% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Total nurse turnover
4.49
Performance 45.33% · Measure score 4.49 · Achievement 4.49 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.09 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 15.19% · Lower 95% interval 7.69% |
| Discharge to community | 59.8% |
50.57%
9.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 52.46% · Lower 95% interval 48.4% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 9 · Denominator 21 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 6 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 41 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 0.65% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 153 |
| Staff flu vaccination coverage | 37.76% |
42%
4.2 pts worse
|
Numerator 54 · Denominator 143 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 7 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
97.9%
3.3 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.4% · Q3 1.3% · Q4 3.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
2.7%
1.8 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.3% · Q3 5.6% · Q4 7.1% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
3.3%
0.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 0.0% · Q4 4.3% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
18.9%
11.5 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 28.6% · Q3 29.4% · Q4 21.7% · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
10.8%
6.4 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 15.3% · Q3 20.0% · Q4 15.1% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.3% |
15.4%
2.9 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 11.2% · Q3 29.8% · Q4 8.7% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
16.1%
1.1 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.1% · Q3 13.8% · Q4 17.9% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
0.8%
1.7 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.1% · Q3 1.3% · Q4 3.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.4% |
15.0%
2.6 pts better
|
19.8%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 7.3% · Q3 13.7% · Q4 15.3% · 4Q avg 12.4% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.2%
1.8 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.6% · Q3 4.3% · Q4 2.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
89.7%
2.1 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 92.0% · Q3 89.7% · Q4 88.0% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
12.0%
4.7 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 8.8% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 4.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.0% |
88.0%
4 pts worse
|
79.7%
4.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.9%
6.4 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 20.6% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-06
E · Potential for more than minimal harm
2025-08-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-06
F · Potential for more than minimal harm
2024-07-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-01
F · Potential for more than minimal harm
2024-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-06
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-07-11
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-06
E · Potential for more than minimal harm
2024-07-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-07-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-07-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-06
E · Potential for more than minimal harm
2024-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-06
F · Potential for more than minimal harm
2023-05-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-08
F584 · Resident Rights Deficiencies
Health
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 2025-06-15
J · Immediate jeopardy
2024-09-19
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-09-20
J · Immediate jeopardy
2024-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-07-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-05-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-05-28
G · Actual harm
2023-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-10
E · Potential for more than minimal harm
2023-05-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
$24,500
2024-09-19
Fine
Fine · fine $24,500
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,434
2024-01-22
Fine
Fine · fine $14,434
Fine
$4,140
2024-01-08
Fine
Fine · fine $4,140
Fine
$3,496
2024-01-02
Fine
Fine · fine $3,496
Fine
$8,391
2023-12-11
Fine
Fine · fine $8,391
Fine
$7,225
2023-11-21
Fine
Fine · fine $7,225
Fine
Ownership
Maverick County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bewsey, Michael
Operational/Managerial Control · Individual
Cleburne Nursing And Rehab Center LLC
Operational/Managerial Control · Organization
Martinez, Alma
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Colonial Manor Nursing Center
Cleburne, TX
4-star overall rating with 3-star inspections with $35,539 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Ridgeview Rehabilitation And Skilled Nursing
Cleburne, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Town Hall Estates Keene, Inc.
Keene, TX
3-star overall rating with 3-star inspections with $78,402 in total fines with 8 recent health deficiencies
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