Your report for Heritage Trails Nursing and Rehabilitation Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove 69% of peers1,167 rated homes · average 2.8★
- Johnson CountyAbove 63% of peers9 rated homes · average 3.2★
- United StatesAbove 61% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point4★+1.2 vs TX avg
- StaffingCan add or remove a star2★−0.1 vs TX avg
- Quality measuresCan add or remove a star4★+0.2 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles4★Above 67% of peersTX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 37% of peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 37% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.86hrsAbove only 11% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.40hrsAbove 55% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better48%Above 58% of peersTX avg51%RN turnover22%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$67,124Above only 24% of peersTX avg$55,368Fines · denials7 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMay 2023 – May 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
May 8, 2025Cycle 1worst D · no actual harm
- F584Honor 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.Resident RightsD · isolatedCorrected Jun 15, 2025
Sep 19, 2024Cycle 2worst J · immediate jeopardy$24,500
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareJ · isolatedCorrected Sep 20, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningJ · isolatedCorrected Sep 20, 2024
Jul 11, 2024Cycle 2worst E · no actual harm
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jul 25, 2024
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Jul 25, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Jul 25, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 25, 2024
May 1, 2024Cycle 2worst D · no actual harm
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 17, 2024
Apr 17, 2024Cycle 2worst F · no actual harm
- F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected May 28, 2024
Nov 21, 2023Cycle 3worst G · actual harm$7,225
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Dec 10, 2023
May 25, 2023Cycle 3worst E · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jun 30, 2023
- F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Jun 30, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.86hrs
- Registered nursesRN hours only0.40hrs
- Licensed practical nursesLPN hours0.93hrs
- Nurse aidesCNA hours1.53hrs
- Weekend nursingAll staff on Saturdays and Sundays2.52hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better48%Above 58% of peersTX avg 51%
- RN turnoverRegistered nurses only22%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy122 certified beds · ~87 residents a day71%Above 57% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $67,124In fines
- 7Fines
- 0Payment denials
- $55,368TX avg in fines
Actions on record
- Sep 19, 2024Civil money penalty$24,500
- Feb 12, 2024Civil money penalty$4,938
- Jan 22, 2024Civil money penalty$14,434
- Jan 8, 2024Civil money penalty$4,140
- Jan 2, 2024Civil money penalty$3,496
- Dec 11, 2023Civil money penalty$8,391
- Nov 21, 2023Civil money penalty$7,225
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Eduro Healthcare37 facilities in the chain2.3★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Maverick County Hospital District
- Cleburne Nursing and Rehab Center LLC
- Michael Bewsey
- Alma Martinez
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 675748 · 301 LINCOLN PARK DR, CLEBURNE, TX, 76033.
- Percentiles compare this facility with every rated nursing home in Texas and Johnson County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
