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Nursing HomeMedicaid Investigative

The Pines at Blue Hill

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

414 North Willson Street, Blue Hill, NE 6893062 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.0/5

based on 8 Google reviews

5
4
3
2
1
The Pines at Blue Hill Nursing Home in Blue Hill, NE — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (11 vs median 5)
  • High staff turnover (71%)

Bottom 25% in NE · Critically understaffed (RN) · Very high staff turnover · Worst in AVID HEALTHCARE GROUP chain · $23,394 in fines

Source: Medicare data

What this means for your family

We strongly advise caution regarding this facility due to recent reports of medication errors and unsanitary living conditions. If you are considering this location, you must conduct an unannounced visit to inspect cleanliness and ask management for their specific plan to address the staffing shortages cited by families.

Google Reviews

Google Reviews

8 reviews on Google
The Pines at Blue Hill has received extremely negative feedback regarding basic care standards and hygiene. Reviewers have specifically cited issues with medication administration and unsanitary bathroom conditions, with management attributing these failures to understaffing.

Quality Themes

Tap a score for details
FoodN/AStaff1.0Clean1.0ActivitiesN/AMeds1.0MemoryN/AComms2.0ValueN/A

Concerns

  • Severe understaffing leading to neglect (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02016(1)1.02020(1)3.72022(3)5.02023(2)1.02024(2)1.02026(1)

Distribution · 10 analyzed

5
5
4
0
3
0
2
0
1
5

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the recent focus on facility maintenance, could you walk me through your current daily cleaning schedule and how you ensure high standards of hygiene in resident rooms?
  • 2I noticed the facility has had some recent challenges with staffing levels; what specific steps are you taking to ensure consistent, attentive care for every resident throughout the day and night?
  • 3How do you currently manage the communication process with families to ensure we are kept fully informed about our loved one's health status and any changes in their care plan?
  • 4Can you explain the oversight process for medication management to ensure that residents receive the correct dosages on time, every time?
  • 5What protocols do you have in place for handling medical emergencies, and how quickly can a resident expect a response if they require urgent assistance?
  • 6With a capacity of 62 residents, how do you tailor your social and daily activities to ensure that everyone feels included and engaged?

Personalized based on this facility's data


Key Review Excerpts

A loved one was sent to this facility and was not taken care of properly. Extremely poor care. Medications not given. Bathroom was dirty and feces present.

Family member of a resident · 2024☆☆☆☆
Source: 8 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.39hrs
52%
Registered nurses for medical care
Total Nursing
3.63hrs
88%
All nurses + aides combined
Staff Turnover
73%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

12

measures

Worse Than Avg

3

measures

Mixed Results

2

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
NE
4.3%
Webster
5.8%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility10.1%
Better than Avg
Here
10.1%
US
15.5%
NE
20.8%
Webster
19.3%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility29.2%
Worse than Avg
Here
29.2%
US
19.4%
NE
26.3%
Webster
22.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility15.8%
Better than Avg
Here
15.8%
US
19.5%
NE
19.3%
Webster
22.8%
⚖️

Residents who lost too much weight

↓ Lower is better
This Facility11.0%
Worse than Avg
Here
11.0%
US
5.3%
NE
5.2%
Webster
4.5%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility14.2%
Better than Avg
Here
14.2%
US
15.3%
NE
19.1%
Webster
20.0%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility90.0%
Better than Avg
Here
90.0%
US
79.8%
NE
75.9%
Webster
72.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility89.8%
Better than Avg
Here
89.8%
US
81.8%
NE
80.5%
Webster
85.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
NE
2.3%
Webster
1.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

11deficiencies
1penalties
Well above state avg (6.7)
16 complaint-triggered
$23,394 in fines

The Pines at Blue Hill has persistent, recurring issues with families filing complaint reports triggering 18 of 64 total deficiencies. The facility shows ongoing problems with medication management (appearing across multiple surveys), safety and accident prevention, and infection control practices. While all deficiencies have correction dates, the repeated nature of issues in key care areas like medication errors and safety supervision indicates systemic challenges that warrant careful scrutiny during any visit.

Apr 17, 2025Routine
17
0867Potential for harm · WidespreadCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0032Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide primary/alternate means for communication.

0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0222Potential for harm · WidespreadCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0711Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0921Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0582Potential for harm · PatternCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

0700Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

0922Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use and maintenance of medical gas equipment.

0660Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Apr 17, 2025Complaint
6
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0584Potential for harm · PatternCorrected

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.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0923Potential for harm · IsolatedCorrected

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

May 23, 2024Routine
13
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0692Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

May 23, 2024Complaint
6
0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0582Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

0622Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Feb 13, 2024Complaint
2
0689Immediate jeopardy · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0867Potential for harm · PatternCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Dec 28, 2023Complaint
2
0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0675Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Honor each resident's preferences, choices, values and beliefs.

Federal Penalties

Fine

Feb 13, 2024

$13,644

Ownership & Operations

Who Operates This Facility

Owner / Operator

The Pines at Blue Hill

Organization Type

for profit

Chain Affiliation

Chain Name

Avid Healthcare Group

Chain Size

11 facilities nationwide

Chain avg rating: 1.5/5 · Rank 7 of 10 (Worst)

Ownership & Management

Owners

Douro Valley Investment, LLC

Owner · Organization

Ne 11 Holdings Opco LLC

Owner · Organization

Brass Ne Trust

Owner (parent company) · Organization

Bsd Beis Health Trust

Owner (parent company) · Organization

Copper Ne Trust

Owner (parent company) · Organization

Gold Ne Trust

Owner (parent company) · Organization

Ne Snf Holdings LLC

Owner (parent company) · Organization

Sf 4140 Olde Washington Boulevard Real Property LLC

Owner (parent company) · Organization

Silver Ne Trust

Owner (parent company) · Organization

Tulip Investments Ne LLC

Owner (parent company) · Organization

Key personnel

Jackson, DixieW-2 Managing EmployeeSilberstein, AriOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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