Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
Surveyors found that food was not prepared or cooked according to recipes or required temperatures, with incomplete temperature logs and malfunctioning ovens contributing to undercooked meals. Food items in storage were not consistently labeled, dated, or sealed, and kitchen cleaning was inadequate, with food debris and spills observed on equipment, floors, and ceilings. These deficiencies affected all residents receiving meals from the kitchen.
The facility did not ensure that kitchen ovens were maintained in safe and working condition, resulting in food not being cooked to required temperatures, incomplete temperature logs, and verified resident complaints about food quality. Staff and maintenance confirmed ongoing oven malfunctions, and some menu items could not be safely served due to these deficiencies.
Two residents with Type 2 Diabetes received rapid-acting insulin after meals instead of before, contrary to facility policy and manufacturer guidelines. Nursing staff confirmed this practice, resulting in two medication errors out of 25 observed administrations and an 8% medication error rate, exceeding the acceptable threshold.
Two residents with Type 2 Diabetes did not receive their rapid-acting insulin as ordered, with nursing staff administering insulin after meals instead of before, as required by facility policy and physician orders. Staff interviews confirmed this was a routine practice, and the DON acknowledged these were significant medication errors.
The facility failed to notify medical practitioners of positive COVID-19 test results in a timely manner for two residents and incorrectly notified a practitioner of another resident's test result. One resident's positive result was not addressed by the practitioner due to a lack of documentation, and another resident's practitioner was notified nearly a month late. Additionally, a resident who tested negative was incorrectly reported as positive, leading to an unnecessary medication order.
A resident received Paxlovid for COVID-19 treatment despite not testing positive for the virus. A miscommunication led to the resident's medical practitioner receiving incorrect information, resulting in an unnecessary prescription. The resident's roommate was the one who tested positive, but the medication was administered to the wrong individual.
A resident with multiple diagnoses experienced a decline in functional abilities and was ordered both PT and OT services by a physician. However, the facility failed to provide the ordered OT services due to an oversight, as confirmed by the DON and a COTA. The resident's decline was attributed to a lack of independent activity and increased anxiety about transfers.
The facility failed to perform proper hand hygiene during catheter care for a resident. Two NAs did not adhere to hand hygiene protocols, touching various surfaces and handling supplies without sanitizing their hands. Interviews confirmed these lapses, and the DON acknowledged the lack of a specific catheter care policy.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient monitoring or preventive measures to address these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing the necessary supervision to safeguard residents from potential accidents.
Deficiencies in Food Preparation, Storage, and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that food was prepared, cooked, stored, and served in accordance with professional standards and facility policies. During food preparation, the Dietary Manager (DM) did not follow recipes as written, including not weighing ingredients, using incorrect ingredient substitutions, and failing to measure or time cooking steps. The DM also did not ensure that food items reached the required minimum internal cooking temperatures, as evidenced by multiple instances where turkey, squash, and sweet potatoes were not cooked to the appropriate temperatures before being placed on the steam table or served. Temperature logs were incomplete, with many days missing required entries, and some food items, such as fish, were documented as being cooked below the required temperature. Staff interviews confirmed that food temperatures were often not checked or recorded, and that malfunctioning ovens contributed to undercooked food being served. The facility also failed to properly label, date, and seal food items in storage. Observations revealed multiple opened containers of food in refrigerators and dry storage that were not labeled with the date of opening or use-by dates, and some items were not sealed. The DM confirmed that all items should have been labeled, dated, and sealed according to facility policy, but this was not consistently done. Additionally, resident complaints were documented regarding food being overcooked, undercooked, not warm enough, and not fresh, and facility investigations verified these complaints. Cleaning and sanitation practices in the kitchen were also deficient. Cleaning logs did not include tasks for key equipment and areas, such as oven surfaces, behind cooking equipment, or ceilings. Observations found food debris, spills, and stains on kitchen equipment, floors, and ceilings, as well as a buildup of debris and a gray fuzzy substance behind the range. The DM and staff confirmed that these areas should have been clean, but were not. These failures in food preparation, storage, and kitchen cleanliness had the potential to affect all residents consuming food from the kitchen.
Failure to Maintain Safe and Functional Kitchen Ovens
Penalty
Summary
The facility failed to maintain its kitchen ovens in a safe and operating condition, which impacted the preparation and serving of food to all residents. Multiple recipes required specific cooking temperatures, but review of temperature logs showed that food temperatures were not consistently recorded for all meals, and some food items, such as oven fried fish and baked fish, were not cooked to the required internal temperature of 165 degrees Fahrenheit. Additionally, complaints from 12 residents regarding food being overcooked, undercooked, not warm enough, and not fresh were verified by the facility, and staff were found to be inadequately recording food temperatures and not completing temperature logs as expected. Observations of food preparation revealed that the Dietary Manager repeatedly had to return food items to the oven because they did not reach the required temperatures, and some food was dropped on the floor during the process. The ovens were unable to bring certain menu items, such as turkey, to the necessary internal temperature, resulting in those items not being served. Staff interviews confirmed ongoing issues with the ovens, including malfunctioning pilot lights and inaccurate temperature settings, and maintenance staff reported that repairs were delayed due to backordered parts and uncertainty about the functionality of replacement ovens in storage. The Administrator and Dietary Manager acknowledged the persistent oven issues and the impact on meal preparation.
Failure to Administer Insulin at Correct Times Results in Elevated Medication Error Rate
Penalty
Summary
The facility failed to ensure that medications, specifically rapid-acting insulin, were administered at the correct times for two residents diagnosed with Type 2 Diabetes. Observations and record reviews revealed that insulin was routinely given after meals rather than within the recommended timeframe before meals, as outlined in both facility policy and manufacturer instructions. For one resident, insulin was administered over an hour after breakfast, and for another, insulin was given nearly two hours after the scheduled time and after lunch. Both nurses involved confirmed during interviews that their usual practice was to perform blood glucose checks before meals but to administer insulin after the residents had eaten. These actions resulted in two medication errors out of 25 observed opportunities, leading to a medication error rate of 8%, which exceeds the acceptable threshold of less than 5%. The Director of Nursing confirmed that such insulin administration errors are considered significant and that insulin should be given as ordered and before meals. The facility's failure to adhere to its own policies and accepted standards for timely medication administration directly contributed to the identified deficiency.
Failure to Administer Insulin as Ordered Before Meals
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors related to insulin administration for two residents with Type 2 Diabetes. Facility policy and insulin manufacturer guidelines require that rapid-acting insulin, such as Novolog (Insulin Aspart), be administered within 15 minutes before a meal. However, observations and record reviews revealed that both residents received their insulin after meals, contrary to physician orders and best practice guidelines. For one resident, insulin was administered over an hour after the scheduled time and after the resident had already eaten lunch. For the other resident, insulin was given after breakfast, despite the blood sugar check being performed before the meal. Interviews with nursing staff confirmed that it was their usual practice to administer insulin after meals, rather than before as required. The Director of Nursing also acknowledged that these instances constituted significant medication errors and that insulin should be administered as ordered and prior to meals. The facility census at the time was 50, and the findings were based on direct observation, record review, and staff interviews.
Failure in Timely and Accurate COVID-19 Test Result Notification
Penalty
Summary
The facility failed to notify the medical practitioner of a positive COVID-19 test result in a timely manner for two residents and incorrectly notified the medical practitioner of another resident's COVID-19 test result. Resident 1 tested positive for COVID-19 on December 27, 2024, but there was no documentation that the medical practitioner addressed the Physician Visit/Communication Form regarding the positive test. The Director of Nursing confirmed that the medical practitioner's office had no record of receiving the form. Resident 4 also tested positive on the same day, but the medical practitioner was not notified until January 25, 2025, nearly a month later. Additionally, Resident 3, who tested negative for COVID-19, was incorrectly reported as positive to the medical practitioner, resulting in an unnecessary order for Paxlovid. The Director of Nursing confirmed the error in notification. These deficiencies highlight a failure in the facility's communication process regarding COVID-19 test results, impacting the timely and accurate notification of medical practitioners and potentially affecting resident care.
Unnecessary Administration of Paxlovid to a Resident
Penalty
Summary
The facility administered Paxlovid, a medication used to treat COVID-19, to Resident 3 despite the resident not testing positive for COVID-19. This was based on a miscommunication where a fax was sent to Resident 3's medical practitioner indicating that the resident had tested positive for COVID-19, which was incorrect. The medical practitioner then provided an order for Paxlovid, which was administered to Resident 3 from December 27, 2024, to January 3, 2025, as per the Electronic Medication Administration Record (EMAR). Resident 3's roommate, Resident 4, was the one who had tested positive for COVID-19 on December 27, 2024, as confirmed by the progress notes and EMAR. The Director of Nursing confirmed that Resident 3 received the doses of Paxlovid as indicated on the EMARs, which should not have occurred since Resident 3 was not positive for COVID-19. The administration of Paxlovid to Resident 3 was unnecessary and not in accordance with the medication's intended use, as confirmed by the Paxlovid.com website.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to ensure that Occupational Therapy (OT) services were provided to a resident as ordered by the physician. Resident 3, who had diagnoses including major depressive disorder, chronic obstructive pulmonary disorder, type 2 diabetes mellitus, and arthritis, experienced a decline in the ability to stand and transfer independently. Despite a physician's order for both Physical Therapy (PT) and OT on 03/08/2024, only PT services were initiated. The OT evaluation and treatment were not conducted, as confirmed by the Director of Nursing (DON) and a Certified Occupational Therapy Assistant (COTA). The oversight was due to the therapy department being unaware of the OT order, even though it was on the same page as the PT order. Interviews with Resident 3, the DON, and a Nurse Aide (NA) revealed that the resident's decline was attributed to a lack of independent activity, leading to increased weakness. The resident had become anxious about transfers and required more assistance. Despite being placed back on the therapy workload, the OT services were not provided as ordered. The DON confirmed that the OT evaluation ordered on 03/08/2024 was not performed, and the COTA acknowledged that the OT order was overlooked, resulting in the deficiency.
Failure to Perform Proper Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to perform proper hand hygiene during catheter care for a resident. During an observation, two nursing assistants (NAs) were seen completing catheter care without adhering to hand hygiene protocols. NA-B and NA-H initially performed hand sanitization and donned gloves but failed to maintain hand hygiene throughout the procedure. NA-H touched their face and a door handle before handling supplies, and both NAs did not perform hand hygiene after various tasks, including handling a dirty graduate, touching a bed remote that fell on the floor, and touching a garbage can. NA-B also failed to perform hand hygiene after wiping the resident's groin and before continuing with catheter care. Additionally, NA-B handled a cleansing bottle and returned it to the cabinet without sanitizing it or performing hand hygiene. Interviews with the Director of Nursing (DON) and the NAs confirmed these lapses in hand hygiene. The DON acknowledged that the facility did not have a specific policy for catheter care, only a competency. Both NAs admitted to not performing hand hygiene at critical points during the procedure. The resident involved was lying in bed and had a catheter drainage bag, which was handled without proper hand hygiene, potentially compromising the resident's care and safety.
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Illustrative
What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jefferson Community Health & Life Gardenside | 0.4 mi | ★★★★★ | 11 | 0 |
| Blue Valley Lutheran Nursing Home | 22.1 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Beatrice | 24.9 mi | ★★★★★ | 12 | 0 |
| Beatrice Health And Rehabilitaion | 25 mi | ★★★★★ | 0 | 0 |
| Wilber Care Center | 25.9 mi | ★★★★★ | 2 | 0 |
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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.