Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Trails Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents experienced prolonged periods with unemptied bedside commodes and urinals, despite requiring staff assistance for toileting. Observations and interviews confirmed that staff did not consistently empty these items during regular rounds, resulting in urine remaining for several hours. Facility policy required frequent checking and emptying, but this was not followed, as acknowledged by nursing and administrative staff.
A resident with severe cognitive impairment and multiple health issues expressed a desire to change his code status from DNR to Full Code during a care plan meeting. However, the facility failed to update his medical records, resulting in the absence of life-saving measures when he was found unresponsive. Interviews revealed discrepancies in documentation, with staff admitting to errors in recording the resident's wishes.
A resident's request to change his code status from DNR to Full Code was not accurately documented, leading to the failure to provide CPR when he was found unresponsive. Despite expressing his desire to change during a care plan meeting, the social worker's documentation error was not corrected, resulting in staff following the outdated DNR status.
Two residents requiring CPAP therapy did not receive care consistent with professional standards, as staff failed to maintain clean air filters and properly dry CPAP masks and headgear. One resident's CPAP machine had a dirty filter, while another's machine was missing a filter entirely. Staff cleaned masks but did not allow them to air dry, and there was a lack of documentation and training regarding filter maintenance.
Laundry staff delivered clean linens to residents using an uncovered cart, with clothing for multiple residents exposed in the hallway. Interviews with the LM, DON, ADM, and ADON-A confirmed that facility policy requires linens to be covered during transport to prevent contamination, but this was not followed by a new staff member. The facility's policy and staff statements emphasized the importance of keeping linens covered to prevent cross-contamination.
A resident with congestive heart failure who was cognitively intact was not given a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) when she transitioned from Medicare Part A skilled nursing services to private pay. Staff interviews confirmed the required notice was not provided due to human error, and the facility did not have the SNF ABN on file as required by Medicare guidelines.
A resident's quarterly MDS was incorrectly coded for significant weight loss due to inconsistent and inaccurate weight documentation, including the use of different scales, improper weighing techniques, and failure to update electronic records. Key staff were unaware of the discrepancy, and facility policies for weight assessment were not consistently followed, resulting in an inaccurate assessment.
The facility failed to ensure proper storage of respiratory equipment for two residents, leading to potential risks of cross-contamination and illness. Observations and staff interviews revealed inconsistencies in storing nasal cannulas, tubing, and CPAP masks, despite existing policies and in-services.
The facility failed to establish an infection prevention and control program with an antibiotic stewardship program, lacking protocols and a system to monitor antibiotic use. The DON, acting as the infection preventionist, reported that antibiotic use was tracked through the electronic health record, but there was no comprehensive list of residents on antibiotics, and no licensed pharmacist was involved in monitoring antibiotic use.
Failure to Timely Empty Bedside Commodes and Urinals
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents by not ensuring that bedside commodes and urinals were emptied in a timely manner. For one resident, who was cognitively intact and required supervision or touch assistance for toileting hygiene, observations revealed that her bedside commode contained urine and a brief for several hours after use. The resident reported that it was common for urine to remain in her commode due to staff not making regular rounds, despite staff being present in her room multiple times since her last use. Another resident, also cognitively intact but dependent on staff for toileting hygiene, was found to have a urinal containing urine for several hours. The resident stated that his urinal typically was not emptied until shift change, and observations confirmed the presence of full and partially full urinals throughout the morning and early afternoon. Staff interviews indicated that CNAs were expected to make rounds every two hours to check and empty bedside commodes and urinals, but this was not consistently done due to other duties or lack of awareness. Facility policy required frequent checking and timely emptying of urinals and commodes, especially for residents who preferred to keep these items at their bedside. Both nursing and administrative staff acknowledged that failure to empty these items could result in odors and flies, and confirmed that all nursing staff were responsible for this task. The deficiency was directly observed and confirmed through resident and staff interviews, as well as review of facility policy.
Failure to Update Code Status Leads to Lack of Emergency Care
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who required emergency care, as per professional standards. The resident, a male with severe cognitive impairment and multiple health issues including dementia, heart disease, and COPD, had previously expressed a desire to change his code status from DNR to Full Code during a care plan meeting. However, this change was not documented correctly in his medical records, leading to the absence of life-saving measures when he was found unresponsive. Interviews with family members and staff revealed discrepancies in the documentation of the resident's code status. Family members and the social worker present at the care plan meeting confirmed that the resident initially expressed a desire to change his code status to Full Code. However, the social worker admitted to making a mistake in the documentation, failing to update the resident's records accurately. The Director of Nursing (DON) and other staff members did not document the resident's expressed wishes, resulting in the continuation of the DNR status. The facility's policy on charting and documentation requires accurate and complete records of any changes in a resident's condition or care plan. The failure to update the resident's code status in the medical records was a significant oversight, leading to the facility's inability to provide the necessary emergency care. This deficiency was identified as an Immediate Jeopardy, indicating a serious threat to the health and safety of residents.
Failure to Update Code Status Documentation
Penalty
Summary
The facility failed to accurately document a resident's request to change his code status from DNR (Do Not Resuscitate) to Full Code. This oversight occurred despite the resident expressing his desire to change his code status during a care plan meeting attended by family members and facility staff. The social worker documented the resident's request to change to Full Code in the care plan meeting notes but did not update the resident's medical records to reflect this change. Consequently, when the resident was found unresponsive, no life-saving measures, including CPR, were administered, as the staff followed the outdated DNR status. The resident involved was an elderly male with multiple health conditions, including dementia, heart disease, and liver failure. Despite his severe cognitive impairment, he was able to make himself understood and comprehend verbal content. During the care plan meeting, there was a discussion about his code status, and although initially influenced by a family member, the resident expressed a desire to remain a DNR. However, the social worker mistakenly documented a change to Full Code, which was not corrected in the medical records. Interviews with family members and staff revealed discrepancies in the understanding and documentation of the resident's code status. Family members recalled the resident's request to change to Full Code, while staff, including the Director of Nursing, maintained that the resident wished to remain a DNR. The lack of proper documentation and communication led to the failure to provide CPR when the resident was found unresponsive, resulting in his death.
Failure to Maintain and Clean CPAP Equipment According to Standards
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required CPAP therapy, as evidenced by improper maintenance and cleaning of CPAP equipment. For one resident with critical illness myopathy and obstructive sleep apnea, observations revealed a dirty air filter in the CPAP machine, which was originally white but had become grey with a heavy accumulation of dust. The resident was unable to recall when the filter was last changed, and there were no date markings to indicate when the CPAP machine was last cleaned or serviced. Staff were observed towel-drying the resident's CPAP mask instead of allowing it to air dry, contrary to manufacturer guidelines and facility policy. For another resident with a thoracic vertebrae fracture and obstructive sleep apnea, the CPAP machine was found to be missing an air filter entirely. The resident's mask and headband were observed to be damp and stored in a closed plastic bag after cleaning, rather than being allowed to air dry. Staff interviews confirmed that the filter was not checked or replaced, and there was no documentation or prompts in the treatment administration record (TAR) regarding filter maintenance. The facility did not keep replacement filters or parts on site, instead relying on third-party vendors or family members to supply them. Staff training focused on daily washing of CPAP masks but did not adequately address filter maintenance. The facility's policy required following manufacturer instructions for cleaning and maintaining CPAP equipment, including regular filter checks and proper drying of components. However, the lack of specific orders, unclear documentation, and insufficient staff education led to failures in maintaining the CPAP machines according to professional standards and the residents' care plans.
Failure to Maintain Infection Control During Linen Transport
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the laundry department, specifically regarding the handling and transport of clean linens. Observation revealed that laundry staff delivered clean linens to residents using an uncovered linen cart, with clothing for multiple residents hanging openly. This occurred while other residents, staff, and visitors were present in the hallway. Interviews with laundry staff and management confirmed that the facility's policy requires clean linens to be covered during transport to prevent contamination, but this procedure was not followed by a new laundry staff member during the observed delivery. Further interviews with the Laundry Manager, DON, ADM, and ADON-A consistently indicated that the facility's policy is to keep clean linens covered or bagged during transport to prevent cross-contamination and maintain cleanliness. The facility's written policy also states that clean linen must be protected from dust and soiling during transport and storage. The failure to adhere to these procedures was acknowledged by staff and management, who recognized that not covering linens could result in contamination.
Failure to Provide SNF ABN Upon Discharge from Medicare Part A
Penalty
Summary
The facility failed to provide advance notice of change in services and charges not covered under Medicare for one resident reviewed for Medicaid and Medicare Coverage Liability Notices. Specifically, the facility did not issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 when the resident was discharged from Medicare Part A skilled nursing services and transitioned to private pay. The resident, a woman with congestive heart failure and no cognitive impairment, was admitted under Medicare Part A and later chose to discontinue skilled nursing services and pay privately, leaving unused Medicare Part A days. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, confirmed that the SNF ABN was not provided due to human error. The facility did not have the required SNF ABN on file with the resident's acknowledgement. Review of the facility's guidelines referenced the Medicare Claims Processing Manual, which requires written notice standards to be met when a resident's coverage changes. The omission was attributed to staff oversight in a situation where the resident voluntarily moved from Medicare Part A to private pay.
Inaccurate Resident Assessment Due to Inconsistent Weight Documentation
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her status, specifically regarding weight loss. The quarterly MDS for one resident was incorrectly coded to indicate significant weight loss, based on inaccurate weights documented in the facility's electronic health record system. Multiple weights were recorded for the resident over a short period, with significant fluctuations due to inconsistent weighing practices, such as using different types of scales and varying resident positions during weighing. Some weights were recorded on loose paper and not entered into the electronic system, leading to discrepancies in the data used for the MDS assessment. Staff interviews revealed a lack of awareness among key personnel, including the kitchen manager, MDS coordinator, and DON, about the resident being flagged for weight loss. The weights used for dietary management differed from those entered into the electronic system, and the staff responsible for weighing residents noted that improper use of scales and resident positioning could result in inaccurate measurements. Observations confirmed that the mechanical scale could produce inaccurate results if the resident's foot was placed on a bar under the seat, further contributing to the inconsistencies. The facility's policies required weights to be recorded in both the unit's weight record chart and the individual's medical record, with significant changes to be retaken for confirmation. However, these procedures were not consistently followed, resulting in the use of incorrect weights for the resident's assessment. Despite the inaccurate coding, the resident did not experience actual significant weight loss and was not at risk of harm due to weight loss at the time of the survey.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents, leading to potential risks of cross-contamination and illness. Resident #1, who required oxygen therapy and a CPAP machine, had her nasal cannulas and tubing hanging over her wheelchair back support and her CPAP mask sitting on a mini refrigerator without any plastic bag for storage. Interviews with multiple staff members, including LVNs and CNAs, revealed inconsistencies in their knowledge and practices regarding the proper storage of respiratory equipment. None of the staff members could recall when they were last trained on oxygen storage, and they acknowledged that improper storage could affect residents' health, safety, and wellbeing. Resident #2, who did not initially require respiratory treatments but was later ordered to use oxygen therapy as needed, also had his CPAP mask sitting on his bedside table without a plastic bag for storage. During an interview, Resident #2 mentioned he had no concerns or issues with his care. The Director of Nursing (DON) confirmed that nurses were responsible for storing oxygen tubing, nasal cannulas, and CPAP masks in drawers and bags when not in use. However, the DON did not document checking the storage practices and stated that residents' health, safety, and wellbeing could not be affected by improper storage. Record reviews indicated that staff were in-serviced on oxygen tank storage and changing out oxygen supplies on two occasions. The facility's policy required oxygen cannulas and tubing used PRN to be kept in a plastic bag when not in use. An email from the DON stated that the same storage policy would apply to CPAP storage. Despite these policies and in-services, the observations and interviews revealed that the facility failed to consistently implement proper storage practices for respiratory equipment, potentially placing residents at risk.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. The facility did not have a pharmacist review for antibiotic stewardship, and there were no protocols incorporated into the overall infection prevention and control program. Additionally, there was 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. The facility also lacked tracking measures of outcome surveillance related to antibiotic use. This deficiency was identified through interviews and record reviews, revealing that the facility's documentation was contained in the electronic health record but lacked a comprehensive list of residents on antibiotics and did not include a licensed pharmacist to assess, monitor, and communicate antibiotic use. The Director of Nursing (DON), who was also the infection preventionist, reported that the facility monitored antibiotic use through the electronic health record, which tracked the number of antibiotics prescribed, the prescriber, the length of time the prescription was utilized, and the diagnosis leading to the prescription for each individual resident. However, the facility did not have a list of residents on antibiotics, and the team evaluated antibiotic usage daily without a licensed pharmacist's involvement. The facility's Infection Control Policy included surveillance tools and data analysis methods, but these were not effectively implemented to monitor antibiotic use and resistance. The Administrator confirmed that the team discussed antibiotic therapy in morning meetings but relied on the DON for maintaining infection control without a pharmacist's oversight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cleburne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Manor Nursing Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Ridgeview Rehabilitation And Skilled Nursing | 1.9 mi | ★★★★★ | 6 | 0 |
| Town Hall Estates Keene, Inc. | 5.7 mi | ★★★★★ | 0 | 0 |
| Alvarado Meadows Nursing & Rehabilitation | 12 mi | ★★★★★ | 4 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 12.6 mi | ★★★★★ | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.