01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-20 | 0 | 2025-08-20 | 2 |
| Cycle 2 | 2024-07-11 | 7 | 2024-07-11 | 9 |
| Cycle 3 | 2023-05-25 | 5 | 2023-05-25 | 3 |
CMS CCN 6757482026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Heritage Trails Nursing And Rehabilitation Center
301 Lincoln Park Dr · Cleburne, TX 76033 · Johnson County
Certified beds122CMS provider file
Recent citation rows26current CMS citation release
Penalty rows7current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
26 rows in the current release
3 rows carry G–L scope/severity codes; 2 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-08-20 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-09-062025-08-20 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-09-062025-05-08 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-15 · complaint2024-09-19 · HEALTHF0678Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Correction field: Deficient, Provider has date of correction · 2024-09-20 · complaint2024-09-19 · HEALTHF0842Severity J · isolated immediate jeopardy
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-09-20 · complaint2024-07-11 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2024-07-252024-07-11 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-07-252024-07-11 · HEALTHF0695Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-07-252024-07-11 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-07-252024-07-11 · FIREK0200Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2025-04-062024-07-11 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2025-03-282024-07-11 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-04-012024-07-11 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-04-012024-07-11 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-04-012024-07-11 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-062024-07-11 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-04-062024-07-11 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-04-062024-07-11 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-03-052024-05-01 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-05-17 · complaint2024-04-17 · HEALTHF0881Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2024-05-28 · complaint2023-11-21 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2023-12-10 · complaint2023-05-25 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-06-302023-05-25 · HEALTHF0791Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Correction field: Deficient, Provider has date of correction · 2023-06-302023-05-25 · FIREK0351Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2023-07-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-09-19 | Fine | $24,500 | 0 |
| 2024-02-12 | Fine | $4,938 | 0 |
| 2024-01-22 | Fine | $14,434 | 0 |
| 2024-01-08 | Fine | $4,140 | 0 |
| 2024-01-02 | Fine | $3,496 | 0 |
| 2023-12-11 | Fine | $8,391 | 0 |
| 2023-11-21 | Fine | $7,225 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MAVERICK COUNTY HOSPITAL DISTRICTOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 10/01/2022
- MARTINEZ, ALMAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2022
- CLEBURNE NURSING AND REHAB CENTER LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2022
- BEWSEY, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.76per resident day
RN hours0.55per resident day
Weekend nurse hours2.40per resident day
Staff turnover53.2%CMS reported field
06 / LOCAL RECORDS
Open the Cleburne ledger →