Nebraska ›Omaha

The Banyan at Montclair

2525 South 135th Avenue, Omaha, NE 68144 · Douglas County · 175 certified beds · avg 109 residents/day · certified since Dec 1, 1978 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

SFF

Part of chain: AVID HEALTHCARE GROUP (11 facilities, chain avg rating 1.7★)

—/5
Health inspection rating (on-site)
4
Serious findings on record
$141,793
Fines, last 3 years
3.94
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: —/5 · CMS overall rating: —/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, facility-wide · Feb 24, 2025 · F-0584 · triggered by a complaint

The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.

Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.

Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.

Corrected: Apr 21, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Mar 4, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Apr 30, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 9, 2024 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 6, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Mar 26, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 30, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (61)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 12, 2026E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
May 12, 2026D · Potential for harm, one-offThe facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
May 12, 2026D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
May 12, 2026D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
May 12, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 12, 2026D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
May 12, 2026D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 12, 2026D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Jan 29, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jan 29, 2026D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Dec 16, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 16, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Dec 16, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 16, 2025D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Dec 16, 2025D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Dec 16, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Dec 16, 2025D · Potential for harm, one-offThe facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Dec 16, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 30, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jun 30, 2025E · Potential for harm, repeatedThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Jun 30, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Jun 30, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint
Jun 30, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint
Apr 2, 2025E · Potential for harm, repeatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Feb 24, 2025▲ L · Immediate jeopardy, facility-wideThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 24, 2025F · Potential for harm, facility-wideThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Dec 5, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Dec 5, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 5, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Nov 14, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Nov 14, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Sep 26, 2024D · Potential for harm, one-offThe facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint
Sep 26, 2024D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Aug 26, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Aug 26, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Jul 9, 2024▲ G · Actual harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Jul 9, 2024D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Jun 26, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Jun 3, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 26, 2024▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Mar 26, 2024F · Potential for harm, facility-wideThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Mar 26, 2024E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Mar 26, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Mar 4, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 4, 2024E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 8).

YearCitationsSerious (G–L)Worst severity that year
2024233J ▲
2025281L ▲
2026100E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

3 fines totaling $141,793, plus 2 Medicare payment denial periods.

DateTypeAmount / length
Feb 18, 2025Fine$33,862
Feb 18, 2025Payment Denial45 days from Mar 18, 2025
Jun 3, 2024Fine$55,795
Mar 4, 2024Fine$52,136
Mar 4, 2024Payment Denial31 days from Mar 30, 2024

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityNebraska avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.944.333.95bottom 38% in Nebraska; top 42% in the U.S.
Registered Nurse hours0.480.720.69bottom 21% in Nebraska; bottom 35% in the U.S.
Weekend total nurse staffing3.673.793.50bottom 49% in Nebraska; top 35% in the U.S.
Weekend RN hours (not acuity-adjusted)0.290.470.48bottom 25% in Nebraska; bottom 29% in the U.S.
Total nursing staff turnover (%)62.848.745.8bottom 25% in Nebraska; bottom 12% in the U.S.
RN turnover (%)61.944.142.9bottom 27% in Nebraska; bottom 19% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.16, RN 0.51, weekend 3.87. Staffing rating: —/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / managerTypeRoleStakeSince
Brass NE TrustOrganization5% or Greater Indirect Ownership Interest—03/01/2024
BSD Beis Health TrustOrganization5% or Greater Indirect Ownership Interest—03/01/2024
Douro Valley Investment, LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2024
Gold NE TrustOrganization5% or Greater Indirect Ownership Interest—03/01/2024
NE M2 Holdco Opco LLCOrganization5% or Greater Direct Ownership Interest100%03/01/2024
NE SNF Holdco LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2024
NE SNF Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2024
SF 4140 Olde Washington Boulevard Real Property LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2024
Silver NE TrustOrganization5% or Greater Indirect Ownership Interest—03/01/2024
Tulip Investments NE LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2024
Pihlgren, LindseyIndividualW-2 Managing EmployeeNOT APPLICABLE03/01/2024
Sharp, DavidIndividualContracted Managing EmployeeNOT APPLICABLE03/01/2024
Silberstein, AriIndividualCorporate OfficerNOT APPLICABLE03/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 285054.