Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Estates during CMS and state inspections, most recent first.
A dietary service failure occurred when staff served residents portions that did not match approved recipe serving sizes. During meal service, aides used #16 2-oz scoops for rice, refried beans, and pureed taco items, resulting in servings that were only half of the required amount for rice and beans and far below the required portion for pureed tacos. In a satellite kitchen, staff reported using the required scoop, but only #12 and one #16 scoop were available, and an aide stated the same scoop was being used for all food items.
Staff failed to follow hand hygiene and glove practices while assisting residents with meals, including feeding more than one resident at a time, handling food and personal items, and not cleaning hands after removing gloves. Staff also allowed a resident’s urinary catheter drainage bag to remain on the floor and later on the resident’s lap while in the dining area. An LPN and other staff were observed assisting residents without consistent ABHS use between residents.
Incomplete psychotropic medication consents were found for two residents, with forms missing diagnosis selections, side effect information, and consent acknowledgements for meds such as alprazolam, divalproex, paroxetine, quetiapine, and mirtazapine. For another resident with depression and dementia, the record showed an order for Abilify but no evidence of a psychotropic consent signed by the resident or POA. The DON, Facility Administrator, nurse manager, and SDN confirmed the consent forms were incomplete or missing.
Resident Not Invited to Care Plan Conferences: A resident with a recent health decline and BIMS score of 6/15 was not invited to multiple care plan conferences and did not attend them, while the POA/family participated by phone or declined the meeting. Record review showed no resident signature or documentation that the resident was invited, and interviews confirmed the facility was basing attendance on BIMS score even though staff acknowledged residents do not give up the right to participate in their care plan.
Inaccurate MDS Medication Reporting: A resident with Type 2 DM and other diagnoses had quarterly MDS entries that reported insulin injections in Section N, but the MAR showed no insulin administration and the only relevant order was for weekly semaglutide (Ozempic). The MDS Coordinator confirmed the resident received Ozempic, not insulin, and that no corrections or modifications had been submitted for the MDS assessments.
The facility failed to invite a resident to quarterly care plan meetings and instead relied on family/POA participation and BIMS score to decide attendance. Interviews confirmed residents do not give up the right to attend, but the resident was not documented as invited or present. The facility also failed to update another resident’s care plan after Abilify was started; the care plan lacked a specific antipsychotic problem, goal, and interventions despite the resident having depression and non-Alzheimer’s dementia.
Two residents experienced significant weight loss due to the facility's failure to consistently provide prescribed nutritional supplements. Despite being at risk for impaired nutritional status, the residents' supplements were often unavailable, leading to ongoing weight loss. Staff interviews confirmed issues with supplement supply and communication between departments.
The facility failed to maintain the dignity of three residents during dining by not serving all residents at the same table their meal at the same time. This resulted in residents having to watch their tablemates eat while they waited for their own meals, causing frustration and distress.
A resident with severe cognitive impairment had not received routine dental services since 2021, despite having a care plan indicating the need for dental exams. Facility staff were unaware of the lapse, and there was no documentation of the family's refusal of dental services.
Incorrect Portion Sizes Served During Meal Service
Penalty
Summary
The facility failed to ensure residents were served the approved menu serving sizes. Record review showed that facility policies stated residents would receive diets ordered by their physicians and that menu selections were to be approved by a qualified dietitian. The recipes reviewed specified serving sizes for multiple menu items, including pureed beef soft tacos, Spanish rice, pureed Spanish rice, refried beans, pureed refried beans, lasagna, pureed lasagna, breadsticks, Caesar salad, chopped or soft chilled steamed vegetables, pureed chilled steamed vegetables, fresh fruit cup, pureed soft canned fruit, crispy beef tacos, beef soft tacos, shredded lettuce and diced tomatoes, paprika rice, seven up cake, and pureed seven up cake. During observation in the kitchen, dietary staff used blue handled #16 dishers, which were confirmed by the Dietary Manager to be 2-ounce scoops, to portion food for multiple residents. For residents receiving rice and refried beans, staff served 1 scoop of each item, which was only half of the 4-ounce serving size listed in the recipes. For residents receiving pureed tacos, staff served 1 scoop, which was far less than the 10.68-ounce portion required by the recipe. This occurred for residents receiving both regular and pureed meals, including residents served tacos, rice, and refried beans from the steam table. The Dietary Manager confirmed that the scoops used were the wrong size to provide the amounts directed by the menu recipes and stated that 2 scoops of pureed taco should have been served because 1 scoop was not enough. The manager also stated that a chart with disher sizes is usually posted in the kitchen but was not present. In a separate satellite kitchen, dietary staff stated they used the required scoop for the meal, but all available service scoops were green #12 scoops and one blue #16 scoop. A dietary aide stated the green 1/3 cup scoops were for all food items and the blue 1/4 cup scoop was for residents who do not eat a lot of food. The Dietary Manager later stated that dietary aides were not certain which scoops to use during service and that training was needed to get everyone on the same process of serving.
Hand Hygiene and Catheter Bag Placement Failures During Resident Care
Penalty
Summary
The facility failed to ensure infection control measures for hand hygiene were followed during resident feeding and glove use. During observation in the dining room, a nurse aide assisted two residents with meals at the same time and did not perform hand hygiene while moving between them, while handling food, or after removing gloves. The nurse aide donned gloves, fed one resident and then the other, handled a hamburger, chips, napkins, a menu, a pencil, and a cup of juice, and continued assisting both residents without washing hands or changing gloves. The nurse aide later removed gloves, handled a coffee cup for another resident, returned to the table, put on new gloves without hand hygiene, and continued feeding the same two residents. The nurse aide confirmed in interview that hand hygiene was not used during the meal assistance and after glove removal. The facility also failed to keep an indwelling urinary catheter drainage bag off the floor and below the level of the bladder for a resident in the dining area. One resident with a catheter was observed seated at a dining table with the catheter bag lying on the floor under a catheter cover, and later the bag was placed on the resident’s lap while the resident continued to sit at the table and was then pushed to the room with the catheter sitting on the lap. Staff observed the bag on the floor and on the lap, and one nurse aide stated the resident wanted things done the way they were done at home. The nurse aide also stated they did not know that urinary drainage bags should be kept below the level of the bladder. Additional observations in another dining area showed staff assisting multiple residents with meals without hand hygiene between residents. An LPN assisted residents at the table without gloves and without alcohol-based hand sanitizer available on the table, moved between residents, and later used hand sanitizer once before continuing to assist residents without further hand hygiene. Another staff member also assisted residents at the table, and no alcohol-based hand sanitizer was used between residents while feeding or after removing clothing protectors. Staff interviews confirmed that hand hygiene was not used during the meal process and that staff were aware of the observations.
Incomplete Psychotropic Medication Consents and Missing POA Consent
Penalty
Summary
The facility failed to obtain complete consents for psychoactive medications for two residents and failed to ensure that a resident’s POA provided informed consent for psychotropic medication use for another resident. The facility policy stated that consent for psychoactive medication must be completed prior to initiating the medication and reviewed or updated quarterly. Surveyors reviewed records, medication orders, and consent forms and found that the required consent forms were incomplete or missing key information. For one resident with COPD, anxiety, major depressive disorder, bipolar disorder, and cervical spondylosis with radiculopathy, the record showed orders for alprazolam, divalproex, paroxetine, and quetiapine. The consent forms for these medications were incomplete: the forms lacked checked diagnosis sections, side effect selections, and statement-of-consent selections, and one divalproex consent did not identify the diagnosis for which it was prescribed. The record also showed no evidence that consent had been obtained for a prior 30-day course of divalproex. The DON and Facility Administrator both confirmed the consents were not filled out completely. For a second resident with type 2 diabetes, chronic respiratory failure, and major depressive disorder, the record showed an order for mirtazapine for major depressive disorder. The consent form for mirtazapine was signed, but no diagnosis was selected and no statement-of-consent option was marked. For a third resident with depression and non-Alzheimer’s dementia who received an antipsychotic during the MDS lookback period, the record showed an order for Abilify for depression, but there was no evidence of a psychotropic consent signed by the resident or the POA. The nurse manager and SDN confirmed that a psychotropic consent form signed by the resident or POA was required.
Resident Not Invited to Care Plan Conferences
Penalty
Summary
The facility failed to ensure that Resident Rights were honored as written for one sampled resident. The resident rights document stated that residents have the right to review and make changes to their own plan of care, to make choices about aspects of life in the facility, to be informed of health status and medical condition, and to participate in planning their own care. Record review showed that the resident was not invited to multiple care plan conferences and did not attend them, while family members or the resident’s representative participated instead. The Quarterly Care Plan Conference Summary dated 10/14/2025 stated that the resident was not invited to the care plan conference and did not attend. The Care Plan Acknowledgement Form dated 10/14/2026 showed the care plan was conducted over the phone with the POA/HPOA, with no resident signature and no evidence the resident attended or was invited. Additional Care Plan Acknowledgement Forms dated 11/4/2025 and 1/6/2026 stated the family declined the care conference and the IDT met to discuss the resident’s care, but there was no evidence the resident was invited or present. A Care Plan Conference Summary dated 3/3/2026 also stated the resident had not been invited to the care plan conference. The resident’s condition and ability to participate were discussed during interviews and record review. The resident had a BIMS score of 6/15 on 12/30/2025 and had increased confusion after a recent health decline, but during interview on 06/22/2026 the resident was able to discuss hospitalizations, meals, some medications, activities, infections, and diagnoses, yet had no knowledge of care plans or care plan meetings and stated no awareness of having attended any in the past. Staff interviews confirmed that residents do not give up the right to attend care plan meetings, but the facility had been basing invitations on BIMS score and, in practice, often held conferences by phone with the POA or family without the resident’s attendance or documented invitation.
Inaccurate MDS Medication Reporting
Penalty
Summary
The facility failed to submit an accurate MDS for the medication regimen for Resident 5. Resident 5 was admitted with diagnoses including Type 2 diabetes mellitus, acute respiratory failure, lymphedema, and chronic lymphocytic leukemia. Review of the resident’s quarterly MDS showed that Section N reported insulin injections during the 7 days before the assessment, including 2 insulin injections on one quarterly MDS and 1 insulin injection on another quarterly MDS. Record review of the resident’s medication orders in PCC showed an order for semaglutide (Ozempic) 1 mg weekly for weight loss related to Type 2 diabetes, and no order for insulin. Review of the MARs for January, February, March, and April 2026 showed no insulin products were administered. The prescribing information for Ozempic stated semaglutide reduces blood sugar by stimulating insulin secretion, does not contain insulin, and can be administered with insulin. During interview, the MDS Coordinator confirmed the facility reported the resident as receiving insulin injections for the January and April MDS assessments even though the resident received Ozempic and did not receive insulin, and stated the corporate home office had previously advised reporting it that way. The MDS Coordinator also stated no corrections or modifications had been submitted for the January or April 2026 MDS assessments.
Care Plan Meeting Invitations and Antipsychotic Care Plan Not Addressed
Penalty
Summary
The facility failed to ensure that residents and their resident representatives were invited to quarterly care plan meetings for Resident 22. Record review showed multiple care plan conference summaries and scheduling documents in which the family or POA was contacted or attended, but there was no documentation that Resident 22 was invited or attended the conferences. Several entries specifically noted that the family declined the conference or that the meeting was held with the family only, and one summary stated that Resident 22 had not been invited to the care plan conference. Facility interviews confirmed that residents were not being given an opportunity to attend care plan conferences and that invitations were being based on BIMS score rather than on the resident’s right to participate. Resident 22’s record also showed that the resident attended Resident Council meetings frequently, and facility leadership acknowledged that residents have a right to participate in their care plan meetings. During interviews, the SSD, MR, FA, and DON all confirmed that residents do not give up this right. The DON stated that the facility was inviting resident representatives or POAs, but not the residents themselves, and that there was no documentation in the chart confirming that Resident 22 had been invited and either declined or chose not to attend. The FA stated that invitations were dependent upon BIMS score, and that residents with lower scores were not invited because they would not understand the meeting. The facility also failed to revise the care plan for Resident 51 after an antipsychotic was initiated. Resident 51 had diagnoses of depression and non-Alzheimer’s dementia, and the MDS showed that the resident received an antipsychotic during the lookback period. The physician order summary showed an order for Abilify 2 mg daily for depression, with an order date of 5/4/26. Review of the current care plan showed a general reference to medications with black box warnings, but there was no specific care plan problem, goal, or interventions related to the antipsychotic medication. The MDS-P confirmed that when an antipsychotic is initiated and falls within the MDS lookback period, it should be added to the care plan, and agreed that Resident 51’s care plan was missing the antipsychotic-related problem/need, goal, and interventions.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility staff failed to implement interventions to manage weight loss for two residents, leading to a deficiency in providing adequate nutrition. Resident 1, admitted with diagnoses including dementia and difficulty swallowing, experienced significant weight loss over several months. Despite being identified as at risk for impaired nutritional status, Resident 1's prescribed nutritional supplements were frequently not administered due to unavailability, as documented in the Treatment Administration Records and Progress Notes. The facility's failure to ensure the availability and administration of these supplements contributed to the resident's continued weight loss. Resident 2, also diagnosed with dementia and difficulty swallowing, faced similar issues with nutritional management. The resident's care plan highlighted the risk of impaired nutritional status, yet the prescribed house supplements were often not given due to supply issues. Progress Notes indicated that the supplements were not administered on multiple occasions because they were either pending from the kitchen or not available. This lack of consistent nutritional support resulted in ongoing weight loss for Resident 2. Interviews with facility staff, including the Health Information Manager, Clinical Coordinator, Certified Dietary Manager, and Medication Aides, confirmed the recurring problem of supplement unavailability. The dietary department was responsible for preparing the supplements, but nursing staff were tasked with notifying them of shortages. However, communication and supply chain issues led to frequent shortages, particularly for evening doses, exacerbating the residents' nutritional deficiencies.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain the dignity of three residents during dining by not serving all residents at the same table their meal at the same time. This resulted in residents having to watch their tablemates eat while they waited for their own meals. Specifically, Resident #43, who had severe cognitive impairment, had to wait 20 minutes to receive their breakfast after their tablemates were served. Similarly, Resident #87, also with severe cognitive impairment, expressed frustration and loudly questioned the delay in receiving their meal while others were being served. Resident #60, who was cognitively intact, also reported dissatisfaction with the staggered meal service, stating it could take up to 20 minutes for everyone at their table to receive their meal, which they found distressing and undignified. Observations during meal service confirmed these issues. During breakfast service, Resident #43 was the last to be served at their table, receiving their meal 20 minutes after the first resident at the table was served. Resident #87 was observed loudly questioning the delay in receiving their meal while others were being served. During the noon meal service, Resident #60 was served last at their table, after staff had served residents at other tables. Interviews with staff, including Medication Aides, Registered Nurses, and the Social Services Director, revealed that staff were trained to serve all residents at one table before moving to another table, acknowledging that failing to do so was a dignity issue. Despite the facility's open-concept dining plan, which allowed residents to come to the dining room as they wished, staff acknowledged the importance of serving all residents at a table simultaneously to maintain dignity. The Director of Nursing and the Social Services Director both emphasized that serving all residents at a table before moving to another table was the expected practice. However, the Administrator did not view the issue as a dignity concern, citing the open-concept dining plan. This discrepancy in understanding and implementation of meal service protocols contributed to the observed deficiencies in maintaining resident dignity during dining.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident with severe cognitive impairment. The resident, who was admitted in April 2021, had not seen a dentist since June 2021, despite having a care plan that indicated the need for dental exams to meet their overall dental needs. The resident's care plan also noted that the resident had poor dental condition and was missing a majority of their teeth, with upper partials in place. However, there were no orders for dental appointments in the resident's Order Summary Report, and the resident's quarterly Nutritional Risk assessment did not address the dental status. Interviews with facility staff revealed that dental appointments were arranged by the Social Services Director (SSD) and the Administrator, and that the facility utilized a contract dental company that visited every six months. The SSD stated that residents were seen by the dentist quarterly and that the resident's family had chosen not to enroll the resident with a new dental provider, preferring the original provider. However, there was no documentation of this conversation or the family's refusal of dental services. The SSD confirmed that the resident had not been seen by a dentist for routine care since 2021. The Director of Nursing (DON) and the Administrator both expressed surprise that the resident had not been seen by a dentist in three years. The DON stated that they would have expected arrangements to be made for the resident to receive dental services within that time frame. The Administrator added that if a resident chose not to sign up with the new dental provider, they would continue to be seen by the original provider, but acknowledged the difficulty in securing appointments with the original provider, who did not accept scheduled appointments and required residents to wait in line.
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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 Gering
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northfield Retirement Communities Care Center | 3.7 mi | ★★★★★ | 2 | 0 |
| Monument Healthcare And Nursing Center | 4.4 mi | ★★★★★ | 1 | 0 |
| Mitchell Care Center | 10.7 mi | ★★★★★ | 0 | 0 |
| Chimney Rock Villa | 18.9 mi | ★★★★★ | 1 | 0 |
| Cascades At Skyview | 31.6 mi | ★★★★★ | 18 | 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 August 2026) and official state health department websites.