414 North Wilson Street, Blue Hill, NE 68930 · Webster County · (402) 756-2080
62 certified beds · For profit - Limited Liability company · Medicare and Medicaid since 1994
CMS Care Compare ratings, data as of September 1, 2026 · CCN 285144 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 17, 2025, inspectors cited 11 health deficiencies (the Nebraska average is 7.4, the national average 9.2).
Of 37 health citations since May 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $13,644 in the last three years; the largest was $13,644, and the latest is dated February 13, 2024.
68.9% of nursing staff left within the year CMS measured (Nebraska average 48.7%).
CMS links it to Avid Healthcare Group, an affiliated group of 11 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 37 health citations on file.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure that the facility dishwasher was operating, ensuring facility dishes and utensils were sanitized when washed with the facility dishwasher which had the potential to affect all residents utilizing dishware from the kitchen. The facility also failed to ensure that staff handled foods and assisted residents with meals in a sanitary manner to prevent the potential for cross contamination and foodborne illness. This affected 3 of 20 residents observed (Residents 1, 192, and 11). The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.07 Based on interview and record review the facility failed to implement Quality Assurance and Performance Improvement (QAPI) processes for identified concerns with ongoing evaluation. This had the potential to affect all of the residents residing in the facility. Facility census was 38.
Inspectors wroteBased on record review and interview the facility failed to ensure that the resident/resident representative was provided with the required Centers for Medicare and Medicaid Services (CMS) notifications of the ending of their Medicare Part A skilled services (a program that covers the cost of short-term skilled nursing facility (SNF) care for up to 100 days in a SNF). This prevented the resident/resident representative from making an informed decision regarding their choice for further care and financial options, and of the right to appeal the decision. This affected 3 of 3 residents reviewed (Residents 30, 91, and 90). The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.19(A) Licensure Reference Number 175 NAC 12-006.19(B) Based on observation, record review, and interview, the facility failed to ensure that rooms were clean and maintained for 5 of 16 residents observed (Residents 33, 10, 15, 2, and 29). The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review and interview; the facility failed to ensure a medication error rate of less than 5%. Observations of 27 medications administered revealed 13 errors for 3 (Residents 194, 13, and 17) of 3 sampled residents, resulting in an error rate of 48.15%. The facility census was 38.
Inspectors wroteBased on record review, interview, and observation; the facility failed to ensure that hand hygiene was performed between residents during medication administration to 3 (Residents 17, 31, and 26) of 3 sampled residents and during wound care for 1 (Resident 29) of 1 sampled resident to prevent the potential for cross contamination and infection. The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to ensure that interventions were put into place to prevent further potential abuse or self-harm for 1 (Resident 190) of 1 sampled residents. The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G) Based on interview and record review the facility failed to follow a resident's identified desired plans for discharge for 1 (Resident 30) of 5 sampled residents. The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(2) Based on observation, record review, and interview the facility failed to provide individualized 1 on 1 activities and engage residents in facility activities for 1 of 5 residents reviewed (Resident 10). The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on observation record review and interview, the facility failed to follow physician's orders to promote healing of a pressure related skin injury for 1 (Resident 29) of 1 sampled resident. The facility census was 38. Findings Are: A record review of a facility policy titled Wound Treatment Management dated 11/28/2023 revealed to promote wound healing it is the policy of the facility to provide treatments in accordance with physician orders and current standards of practice. [...]
Inspectors wroteLicensure Reference Number 175 NAC 12-007.04(D) Based on observation, record review, and interview the facility failed to ensure that bathroom exhaust vent fans were functioning for 2 of 16 residents observed (Residents 34 and 10). The facility census was 38.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, record review, and interview; the facility failed to maintain a sanitary environment for food storage and preparation. This had the potential to affect all residents receiving food from the facility kitchen. The facility stated census was 34. Findings Are: Review of a facility policy titled Kitchen Sanitization dated 10/2008 revealed Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. During an observation completed on 05/19/2024 at 8:50 AM the following was observed: -Three cupboards missing doors in the kitchen storage meal prep area of the kitchen exposing dishes stored in these cupboards to be exposed. [...]
Inspectors wroteLicensure Reference Number 175NAC 12-006.09D8b1 Licensure Reference Number 175NAC 12-006.09D8b Based on record review and interviews; the facility failed to evaluate, revise, and implement interventions for weight loss and the nutritional needs for 3 (Resident 1, 4, and 28) of 8 sampled residents. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.10D Based on observation, record review, and interviews; the facility failed to ensure a medication error rate of less than 5%. Observations of 32 medications administered revealed 4 errors resulting in an observed medication error rate of 12.5%. The errors affected 3 residents (Residents 19, 5, and 16) of 6 residents observed during medication administration. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.10D Based on observations, record review, and interviews; the facility failed to ensure that staff followed procedure for blood glucose (blood sugar) monitoring which had the potential for inaccurate blood glucose results, and failed to ensure that staff followed procedure for priming of insulin pens to ensure residents received the physician ordered dose of insulin to prevent significant medication errors. This affected 3 of 3 residents observed (Residents 19, 5, and 16). The facility census was 34.
Inspectors wroteBased on record review and interview; the facility staff failed to ensure the resident choice for advance directive (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate), and code status (an instruction from you to your medical team about what the medical team should do if you have a cardiac or respiratory arrest) was documented accurately throughout the resident medical record for 2 (Resident 27 and 23) of 16 residents reviewed. The facility staff identified a census of 34.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(1) Based on record review and interviews; the facility failed to provide 2 (Resident 88 and Resident 91) of 3 sampled residents with the cost of continuing to receive skilled Medicare Services, a choice of whether to appeal the facilities Medicare determination to discontinue services, or the reason for the discharge from skilled Medicare services. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.05(5)a Based on record review and interviews; the facility failed to notify the resident/resident representative of the facility decision to discharge the resident from the facility for 1 (Resident 89) of 3 sampled residents. This prevented the resident from returning to the facility. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.05(5) Based on record review and interviews; the facility failed to provide the resident/resident representative with written notice of transfer and discharge from the facility. This affected 1 (Resident 89) of 3 sampled residents. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-00-09B Based on record review and interviews; the facility failed to accurately complete resident assessments for 2 (Resident 23 and Resident 1) of 4 sampled residents. The facility stated census was 34.
Inspectors wroteBased on record review and interview; the facility failed to ensure a Preadmission Screening Resident Review (PASARR- federally mandated screening program to ensure Nursing Home residents with mental illness and/or developmental disabilities receive the care and services they need in the most appropriate settings) screen was accurately completed or a new PASSAR initiated to determine if a Level II PASARR review was warranted for 1 (Resident 42) of 2 sampled residents. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.09D2b Based on observation, record review, and interviews; the facility failed to perform wound care consistent with professional standards of practice to promote wound healing for 1 (Resident 1) of 4 sampled residents. The facility stated census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.09 Based on observation, record review, and interviews; the facility failed to assess and manage pain during wound care for 1 (Resident 1) of 4 sampled residents. The facility census was 34.
Inspectors wroteLicensure Reference Number 175NAC 12-006.017D Based on observation, record review, and interviewa; the facility failed to adhere to infection control practices to prevent the potential for cross contamination and infection prevention during wound care for 1 (Resident 1) of 4 sampled residents. The facility stated census was 34.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7 Based on observation, record review, and interview, the facility failed to ensure that staff were trained to check the function of individual resident elopement prevention equipment to prevent elopement (unsupervised wandering that leads to the resident leaving the facility without facility staff knowledge). This affected 4 (Residents 1, 2, 3, and 4) of 4 residents identified as at risk for elopement. The facility census was 33.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.07c Based on record review and interview, the facility failed to develop and implement a Quality Assurance Process Improvement Plan of action (a systematic data driven approach to improving the quality of care and services provided to residents, to correct a facility identified problem) related to elopements (unsupervised wandering that leads to the resident leaving the facility without notice). This has the potential to affect 4 (Residents 1, 2, 3, and 4) residents within the facility who were identified as elopement risks. The facility census was 33.
Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident to resident (Residents 2 and 3) sexual abuse investigation report was submitted to the state agency within the required 5 working days. The facility census was 30.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D3 Based on observation, record review, and interview, the facility failed to evaluate a residents need for continued laxative use when having diarrhea for 1 resident (Resident #5) of 4 sampled residents. The facility census was 30.
Inspectors wroteLicensure Reference Number 175NAC 12-006.17 Based on record review and interview the facility failed to ensure that Covid-19 testing was completed as required to prevent the potential for Covid-19 infection. This had the potential to affect all facility residents. The facility census was 40.
Inspectors wroteBased on record review and interview, the facility failed to ensure that a required written bed hold notification (written information outlining options for holding or reserving a resident's bed while the resident is absent from the facility for hospitalization) was provided to the resident/resident representative for 2 residents (Residents 27 and 10). This prevented the resident/resident representative from making an informed decision to either request a bed hold (a reservation that allows a resident to return to the facility) or release the resident bed. The facility census was 40.
Inspectors wroteLicensure Reference Number 175NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that a review of the baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was completed with the resident/resident representative and failed to ensure that the resident/resident representative was provided a written summary of the baseline care plan as required for 6 residents (Residents 27, 10, 37, 14, 141, and 142) of 7 residents reviewed. This prevented the resident/resident representative from identifying additional care concerns for inclusion in the care plan. The facility census was 40.
Inspectors wroteLicensure Reference Number 175NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure that facility staff did not reuse trays during meal service to prevent the potential for cross-contamination and foodborne illness for 14 residents observed (Residents 7, 10, 20, 141, 143, 29, 5, 3, 33, 9, 32, 12, 6, and 24); and the facility failed to ensure that staff handled foods in a manner to prevent the potential for cross-contamination and foodborne illness. The facility census was 40.
Inspectors wroteD. Observation of Resident 14 on 5/02/23 at 11:22 AM revealed Resident 14 was sitting in their recliner in their room talking on the phone. Resident 14 had an indwelling urinary catheter (a tube inserted into and left in the bladder to drain urine) and the catheter urine collection bag was not in a cover and was hanging on the trash can that had visible garbage in it. E. Observation of Resident 18 on 5/1/23 at 10:11 AM revealed Resident 18 was sitting in their wheelchair in the hall. Resident 18 had an indwelling urinary catheter and the tubing connecting the catheter bag to the catheter was dragging on the floor. F. Observation of Resident 141 on 4/30/23 at 2:25 PM revealed Resident 141was sitting in the recliner in the living room. Resident 141 had an indwelling urinary catheter and the catheter urine collection bag was uncovered and laying on the floor. [...]
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation and interview, the facility failed to ensure resident dignity was maintained for Resident 14 by failing to place a visual barrier between the bathroom and the room door which placed Resident 14 at risk for exposure if a staff person or another resident opened the door while Resident 14 was using the bathroom. This affected 1 of 3 sampled residents. The facility identified a census of 40 at the time of survey.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (4) Based on interview and record review; the facility failed to honor bathing preference for 1 of 1 sampled residents, Resident 19. The facility identified a census of 40 at the time of survey.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observation, interview, and record review; the facility failed to assist residents with activities of daily living (ADLs) for 2 residents (Residents 19 and 25). This affected 2 of 3 sampled residents. The facility identified a census of 40 at the time of survey.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observation and interview, the facility failed to maintain toilet risers to prevent a potential accident hazard for Resident 141. This affected 1 of 3 sampled residents. The facility identified a census of 40 at the time of survey.
25 fire safety citations on file: 12 on April 17, 2025, 6 on May 23, 2024, 7 on May 3, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| February 13, 2024 | Fine | $13,644 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Nebraska | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 3.98 | 3.86 |
| Registered nurses | not reported | 0.67 | 0.69 |
| All nursing staff on weekends | not reported | 3.48 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | 68.9% | 48.7% | 45.8% |
| Registered nurse turnover | not reported | 44.1% | 42.9% |
| Administrators who left | 0 |
CMS note on this home's staffing data: The accuracy of the staffing data for this measure could not be validated by CMS.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.75 on weekdays and 3.31 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 31.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.41 in April to June 2025 to 3.62 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.62 | 0.43 | 3.75 | 3.31 | 31.4% | 1 of 90 | 34 |
| Oct to Dec 2025 | 3.63 | 0.39 | 3.77 | 3.27 | 35.7% | 0 of 92 | 34 |
| Jul to Sep 2025 | 3.63 | 0.36 | 3.78 | 3.26 | 42.3% | 0 of 92 | 34 |
| Apr to Jun 2025 | 3.41 | 0.38 | 3.56 | 3.05 | 41.0% | 0 of 91 | 37 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Nebraska, Jan to Mar 2026 | 4.01 | 0.66 | 4.21 | 3.53 | 7.1% | 1.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Nebraska, all employers | |||
| CNAs (nursing assistants) | $19.23 | $18.29 to $22.31 | 16,450 |
| LPNs and LVNs | $30.13 | $28.41 to $34.55 | 4,580 |
| Registered nurses | $40.74 | $38.09 to $47.90 | 24,720 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Nebraska | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 18.5 | 19.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.4 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.6 | 4.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 2.0 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 11.2 | 18.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.7 | 4.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.9 | 20.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 15.7 | 20.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.8 | 11.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 1.9 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Adept Nursing & Rehab of Blue Hill's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (37.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
37.4% this home
No different from the national rate
US median of homes 51.5% · Nebraska: 17 better, 24 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 34 eligible stays.
12.4% this home
No different from the national rate
US median of homes 10.7% · Nebraska: 2 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 47 eligible stays.
6.9% this home
No different from the national rate
US median of homes 7.1% · Nebraska: 2 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 35 eligible stays.
37.0% this home
Median of homes: Nebraska50.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 27 residents counted.
0.0% this home
Median of homes: Nebraska0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 37 residents counted.
2.4% this home
Median of homes: Nebraska2.2% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 37 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Nebraska100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 13 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: PINES AT BLUE HILL LLC. CMS links this home to Avid Healthcare Group, a group of 11 nursing homes averaging 1.6 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Douro Valley Investment, LLC | 5% or greater direct ownership interest | Organization | 08/02/2023 | |
| Ne 11 Holdings Opco LLC | 5% or greater direct ownership interest | Organization | 08/02/2023 | |
| Brass Ne Trust | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Bsd Beis Health Trust | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Copper Ne Trust | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Gold Ne Trust | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Ne SNF Holdings LLC | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Sf 4140 Olde Washington Boulevard Real Property LLC | 5% or greater indirect ownership interest | Organization | 08/01/2023 | |
| Silver Ne Trust | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Tulip Investments Ne LLC | 5% or greater indirect ownership interest | Organization | 08/02/2023 | |
| Jackson, Dixie | W-2 managing employee | Individual | 08/02/2023 | |
| Silberstein, Ari | Corporate officer | Individual | 08/02/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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