Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Of Bel Air during CMS and state inspections, most recent first.
Staff were observed handling ready-to-eat sandwiches with bare hands during meal service, including picking up, cutting, and plating the food without using gloves or utensils. This practice was confirmed by the Dietary Manager as not compliant with food safety standards, potentially affecting all residents receiving meals from the kitchen.
A resident reported that meals served in their room were often cold. Observations showed that food delivered in room trays was below the required hot holding temperature, with test tray items measured at 124–130°F, despite the hot box being at 167°F. Staff confirmed there was no specific policy for serving temperatures, and nine room trays were served at these substandard temperatures.
An LPN administered Lantus and Humalog insulin to a resident without priming the insulin pens as required by facility policy, resulting in two medication errors out of 25 observed administrations and an overall medication error rate of 8%.
Staff did not follow Enhanced Barrier Precautions (EBP) for a resident with a history of MDRO infection, failing to wear required gowns and gloves during high-contact care activities such as bathing and changing linens. Facility staff confirmed that PPE should have been used according to policy, but it was not implemented during these care events.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls due to the facility's failure to implement and revise fall prevention interventions. The care plan required two staff for transfers, but staff often used inappropriate equipment or attempted transfers alone, leading to falls and injury. Despite conducting Root Cause Analyses, the facility did not adequately re-educate staff or develop new interventions.
A facility failed to document a clinical rationale for not attempting gradual dose reductions for a resident's psychoactive medications, Sertraline and Ambien, as required by CMS guidelines. The resident's care plan indicated the use of these medications for anxiety, depression, and insomnia, but the attending physician did not provide a specific rationale for maintaining the current dosages. The facility also did not educate the resident on the risks and benefits of dose reductions, as confirmed by the DON.
A facility failed to implement Enhanced Barrier Precautions and proper hand hygiene during wound care for a resident with a chronic pressure wound. Additionally, a housekeeper did not correctly use PPE, potentially spreading COVID-19. Staff confirmed lapses in protocol adherence, including not wearing gowns during high-contact care and improper PPE procedures.
Failure to Prevent Bare Hand Contact with Ready-to-Eat Foods
Penalty
Summary
Facility staff failed to follow professional food safety standards by using bare hands to handle ready-to-eat food items during meal service. Specifically, during observation of a noon meal, a culinary lead was seen picking up cheese and meat/cheese sandwiches with bare hands, cutting them, and placing them on serving plates without using gloves or utensils. This practice was confirmed by the Dietary Manager as not compliant with required food safety protocols, which mandate minimizing bare hand contact with exposed food. The deficiency had the potential to affect all residents who consumed meals prepared in the kitchen, with a reported census of 98 residents at the time of the survey. The report references the 2016 Food Code, which requires the use of suitable utensils or single-use gloves to prevent contamination from hands, and documents that these standards were not followed during the observed meal service.
Failure to Serve Room Trays at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve room trays at a palatable and safe temperature, as required by federal and state regulations. Observations revealed that a resident who sometimes eats meals in their room reported that the food is cold most of the time. On the day of observation, the hot box used to transport and keep food warm was moved from the kitchen to the resident hallway and plugged in. When lunch trays were served, the hot box temperature was 167 degrees, but the actual food temperatures on a test tray were measured at 130 degrees for pork roast and macaroni and cheese, and 124 degrees for carrots. These temperatures were below the required 135 degrees for hot foods, as specified by the Nebraska Food Code. Interviews with the chef and the Certified Dietary Manager confirmed that the food temperatures were too low to be served and that the facility did not have a specific policy regarding serving temperatures, instead relying on the Nebraska Food Code as a guideline. The facility served nine room trays from the hot box at these substandard temperatures. The administrator also confirmed that hot food should be served at 135 degrees or higher and acknowledged that the food served was not at a palatable temperature.
Medication Error Rate Exceeds 5% Due to Improper Insulin Administration
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by both federal and facility policy. During observation of 25 medication administrations, two errors were identified, resulting in an 8% error rate. The errors were specifically related to the administration of insulin for one resident who had physician orders for Lantus and Humalog insulin. The facility's policy and competency forms outlined the correct procedure for insulin pen use, including the requirement to prime the pen before administration. On the observed occasion, an LPN prepared and administered both Lantus and Humalog insulin to the resident without priming either insulin pen, contrary to established procedures. The LPN acknowledged during interview that the pens were not primed prior to administration. This failure to follow proper insulin administration protocol constituted the medication errors that contributed to the facility's elevated medication error rate.
Failure to Implement PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to implement the required Personal Protective Equipment (PPE) protocols for a resident with a history of multidrug resistant organism (MDRO) infection, as outlined in the facility's Enhanced Barrier Precautions (EBP) policy. The policy required staff to wear gowns and gloves during high-contact care activities, such as bathing and changing linens, for residents on EBP. Observations revealed that a nursing assistant provided a whirlpool bath to the resident without wearing any PPE, despite signage indicating the need for gowns and gloves. Additionally, another nursing assistant was observed removing the resident's bed linens without wearing a gown or gloves, and carried the linens against her uniform when exiting the room. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the resident was on EBP due to an MDRO in the urine and that PPE should have been used during these care activities. The staff involved acknowledged that PPE was not worn as required during both bathing and linen changes. The resident required partial to extensive assistance with bathing and had EBP in place due to their infection history.
Failure to Implement and Revise Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and revise fall prevention interventions for a resident with multiple medical conditions, including Parkinson's disease, arthritis, osteoporosis, and severe cognitive impairment. The resident experienced several falls, indicating a lack of adherence to the care plan and inadequate supervision. The facility's Fall Prevention Management Standards required updating care plans and implementing interventions for residents identified at risk for falls, but these measures were not effectively executed. The resident's care plan initially required two staff members to assist with transfers, but this was not consistently followed. On multiple occasions, staff attempted to transfer the resident with only one person or used inappropriate equipment, such as the sit-to-stand lift, which was not suitable for the resident's condition. These actions led to several falls, including one where the resident sustained a hematoma to the back of the head. Despite the occurrence of falls and the completion of Root Cause Analyses, the facility did not adequately re-educate staff or develop new interventions to prevent further incidents. The Director of Nurses confirmed that staff did not receive necessary re-education after the initial fall, and subsequent falls were due to staff not following the care plan, which called for the use of a full body lift with two staff members for all transfers.
Lack of Documentation for Gradual Dose Reductions in Psychoactive Medications
Penalty
Summary
The facility failed to ensure that Resident 7's drug regimen was free from unnecessary drugs, as there was no physician-documented, resident-specific clinical rationale for not attempting gradual dose reductions for psychoactive medications. The facility's management standard required gradual dose reductions for all psychoactive medications, and the interdisciplinary team was responsible for ensuring these medications were necessary. However, the facility did not adhere to these standards for Resident 7, who was taking Sertraline for depression and Ambien for insomnia. Resident 7's care plan indicated the use of psychoactive medications for anxiety, depression, and insomnia, with guidelines for gradual dose reduction being followed. Despite this, pharmacy notes revealed that the attending physician did not document a rationale for not attempting dose reductions for Sertraline and Ambien, as recommended by CMS guidelines. The guidelines suggested dose reduction attempts twice within the first year for newly admitted residents, but these were not followed, and no specific clinical rationale was provided for maintaining the current dosages. Interviews with the Director of Nursing confirmed the lack of documentation for clinical rationale and the absence of resident education regarding the risks and benefits of gradual dose reductions. The facility did not provide evidence of educating Resident 7 about the potential benefits of reducing the medication doses, nor did they document any resident-specific reasons for continuing the medications at their current dosages.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene during wound care for a resident with a chronic pressure wound. The resident required substantial assistance with dressing and personal hygiene and was dependent on toileting and transfers. Despite the presence of an isolation caddy with necessary protective equipment outside the resident's room, a medication aide entered the room without wearing a gown, performed wound care without changing gloves, and assisted the resident with toileting, all while failing to adhere to the EBP protocol. Additionally, the facility did not correctly use Personal Protective Equipment (PPE) to prevent the potential spread of COVID-19. A housekeeper was observed exiting a room of a resident on transmission-based precautions without removing potentially contaminated PPE and then entering another resident's room without changing the N95 mask. The housekeeper also wore a surgical mask underneath the N95 mask, which compromised the proper seal and fit of the N95 mask. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the lapses in protocol adherence. The staff acknowledged that gowns should have been worn during high-contact care activities, gloves should have been changed during wound care, and proper PPE procedures should have been followed to prevent cross-contamination between residents.
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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 Norfolk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Joseph's Rehabilitation And Care Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Community Pride Care Center | 9.7 mi | ★★★★★ | 7 | 0 |
| Accura Healthcare Of Pierce | 11.7 mi | ★★★★★ | 2 | 0 |
| Stanton Health Center | 12.1 mi | ★★★★★ | 2 | 0 |
| Arbor Care Centers-countryside Llc | 14.4 mi | ★★★★★ | 16 | 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.