Heritage Trails Nursing and Rehabilitation Center
Cleburne, Texas · CCN 675748
17 surveys since 2012. The first finding at harm level was recorded in 2017.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 33
- Surveys
- 17
- Harm or worse
- 7
- Immediate jeopardy
- 5
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 122
- Ownership
- For profit - Limited Liability company
- Chain
- EDURO HEALTHCARE
- County
- Johnson
- Medicare-certified since
- 1998
CMS ratings
- Overall
- 4
- Health inspection
- 4
- Staffing
- 2
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=16, floor 20).
Last survey on record
May 8, 2025
550 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 2.76 | 3.25 |
| Registered-nurse hours per resident day | 0.55 | — |
| Annual nurse turnover | 53.2% | 54.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $67,124 across 7 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J216.7% | K— | L— |
| Actual harm | G18.3% | H— | I— |
| No harm, potential for more than minimal | D541.7% | E325.0% | F18.3% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6952×
Provide safe and appropriate respiratory care for a resident when needed.
- F5821×
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- F5841×
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.
- F6001×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6411×
Ensure each resident receives an accurate assessment.
In the surveyor’s words
From the most serious findings on record at Heritage Trails Nursing and Rehabilitation Center, in the surveyor’s own words.
- Immediate jeopardy, isolatedF678Sep 19, 2024
Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel in accordance with professional standards for one (Resident #1) of four residents reviewed for CPR. The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. […]
- Immediate jeopardy, isolatedF842Sep 19, 2024
Based on Interviews and record reviews, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of four residents reviewed for accurate clinical records, in that: The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. […]
- Actual harm, isolatedF600Nov 21, 2023
Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 2 (RES # 1 and RES #2) of 15 residents who were reviewed for abuse. The facility failed to protect RES# 1 and RES # 2 from engaging in a resident-on-resident physical altercation on 10-3-2023 at 8:30 PM in the front lobby of the facility, which resulted in physical harm to both residents. This failure could place all residents at the facility at risk for physical harm. Findings included: Record review of the facility's PIR, dated 10-3-2023 at 8:45 PM, reflected a resident-on-resident altercation occurred on 10-3-2023 at 8:30 PM in the front lobby at the facility. […]
- No harm, potential for more than minimal, widespreadF881Apr 17, 2024
Based on interview and record review the facility failed to establish an infection prevention and control program that must include, at minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for an antibiotic stewardship program. The facility did not have pharmacist review for antibiotic stewardship. The facility did not have protocols incorporated in the overall infection prevention and control program and had no system of reports related to monitoring antibiotic usage and resistance data such as the rate of new antibiotic starts, types prescribed or days of antibiotic treatment per 1,000 resident days; antibiotic resistance based on laboratory data from, for example the last 18 months; or… […]
- No harm, potential for more than minimal, patternF755Aug 6, 2026
Based on interview and record review, the facility failed to provide pharmaceutical services (procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, 1 of 1 facilities reviewed for pharmacy services.The facility failed to identify that LVN A was preparing residents' medications ahead of the scheduled administration time and administering medications through CNAs to residents. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.The findings included:In an interview on 08/06/2026 at 2:17 p.m., CNA B stated that LVN A gave the… […]
Read 24 findings in full →The most serious and the most recent: 24 of 33 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 6, 2026Complaint1 finding
- May 8, 2025Complaint1 finding
- Sep 19, 2024Complaint2 findings · 2 harm
- Jul 11, 2024Standard4 findings
- May 1, 2024Complaint1 finding
- Apr 17, 2024Complaint1 finding
- Nov 21, 2023Complaint1 finding · 1 harm
- May 25, 2023Standard2 findings
Show the 9 earlier surveys
- Apr 20, 2022Complaint3 findings
- Oct 27, 2020Infection control2 findings
- Jul 20, 2018Standard3 findings
- Jun 21, 2018Complaint1 finding · 1 harm
- Jul 21, 2017Standard and complaint3 findings · 3 harm
- May 20, 2015Standard1 finding
- Jun 13, 2014Standard1 finding
- Jun 14, 2013—4 findings
- Jun 28, 2012—2 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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