F45

The Banyan at Montclair

Grade F 45/100 composite score

For profit - Limited Liability companySpecial Focus Facility

CMS Star Ratings

Overall
Not rated
Health Insp.
Not rated
Quality
Not rated
Staffing
Not rated
RN Staffing
Not rated

Certified Beds

175

Ownership

For profit - Limited Liability company

Total Fines

$159,083

Last Survey

N/A

2525 South 135th Avenue, Omaha, NE 68144
4023332304

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.70h
LPN
1.05h
CNA
3.26h
Total
5.00h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

NE M2 HOLDCO OPCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Mar 2024

100%

BRASS NE TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

BSD BEIS HEALTH TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

DOURO VALLEY INVESTMENT, LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

GOLD NE TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

NE SNF HOLDCO LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

NE SNF HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

SF 4140 OLDE WASHINGTON BLVD REAL PROPERTY LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

SILVER NE TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

TULIP INVESTMENTS NE LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

WEISZ, DAVID

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2024

SILBERSTEIN, ARI

IndividualCORPORATE OFFICERSince Mar 2024

SHARP, DAVID

IndividualCONTRACTED MANAGING EMPLOYEESince Mar 2024

PIHLGREN, LINDSEY

IndividualW-2 MANAGING EMPLOYEESince Mar 2024

Penalties & Fines (7)

$159,083total fines
DateTypeDescriptionAmount
Feb 18, 2025Fine$33,862
Feb 18, 2025Payment Denial
Jun 3, 2024Fine$55,795
Mar 4, 2024Fine$52,136
Mar 4, 2024Payment Denial
Apr 3, 2023Fine$17,290
Apr 3, 2023Payment Denial

Health Inspection Deficiencies (60)

June 30, 2025Health17 deficiencies
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Aug 23, 2025
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Aug 23, 2025
0585DMinimal harm, Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Aug 23, 2025
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 23, 2025
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 23, 2025
0628EMinimal harm, Pattern

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies

Corrected Aug 23, 2025
0638DMinimal harm, Isolated

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 23, 2025
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 23, 2025
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Aug 23, 2025
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 23, 2025
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Aug 23, 2025
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Aug 23, 2025
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Aug 23, 2025
0700DMinimal harm, Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Corrected Aug 23, 2025
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Aug 23, 2025
0812EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Aug 23, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 23, 2025
April 2, 2025Health1 deficiency
0686EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected May 2, 2025
February 24, 2025Health2 deficiencies1 severe
0584LImmediate jeopardy, Widespread

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.

Resident Rights Deficiencies

Corrected Apr 21, 2025
0835FMinimal harm, Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Apr 21, 2025
December 5, 2024Health7 deficiencies
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Jan 3, 2025
0623DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Jan 3, 2025
0686DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 3, 2025
0867FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Jan 3, 2025
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Jan 3, 2025
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 3, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 3, 2025
November 14, 2024Health2 deficiencies
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 9, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 9, 2024
September 26, 2024Health2 deficiencies
0563DMinimal harm, Isolated

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Resident Rights Deficiencies

Corrected Oct 22, 2024
0585DMinimal harm, Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Oct 22, 2024
August 26, 2024Health2 deficiencies
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Sep 26, 2024
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Sep 26, 2024
July 9, 2024Health2 deficiencies1 severe
0760GActual harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Aug 6, 2024
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Aug 6, 2024
June 26, 2024Health1 deficiency
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Aug 6, 2024
June 3, 2024Health1 deficiency
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 15, 2024
March 26, 2024Health15 deficiencies1 severe
0604DMinimal harm, Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 30, 2024
0697DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 30, 2024
0700DMinimal harm, Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Corrected Apr 30, 2024
0758DMinimal harm, Isolated

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Apr 30, 2024
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Apr 30, 2024
0867FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Apr 30, 2024
0909DMinimal harm, Isolated

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Environmental Deficiencies

Corrected Apr 30, 2024
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Apr 30, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 30, 2024
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Apr 30, 2024
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 30, 2024
0686GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 30, 2024
0726FMinimal harm, Widespread

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies

Corrected Apr 30, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 30, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 30, 2024
March 4, 2024Health2 deficiencies1 severe
0689JImmediate jeopardy, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 30, 2024
0730EMinimal harm, Pattern

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Apr 30, 2024
April 3, 2023Health4 deficiencies
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Apr 21, 2023
0661DMinimal harm, Isolated

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 21, 2023
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Apr 21, 2023
0923EMinimal harm, Pattern

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

Environmental Deficiencies

Corrected Apr 21, 2023
January 11, 2023Health2 deficiencies
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Feb 1, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 1, 2023

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Frequently Asked Questions

What is the CareGrader rating for The Banyan at Montclair?

The Banyan at Montclair in Omaha, Nebraska has a CareGrader grade of F (Poor), with a composite score of 45 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

How many health deficiencies does The Banyan at Montclair have?

The Banyan at Montclair has 60 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has The Banyan at Montclair been fined?

Yes. The Banyan at Montclair has $159,083 in total fines from CMS enforcement actions across 7 penalties. This facility is designated as a Special Focus Facility (SFF) by CMS due to a history of serious quality issues.

How many beds does The Banyan at Montclair have?

The Banyan at Montclair has 175 certified beds with approximately 107 current residents (61% occupancy). The facility is located at 2525 South 135th Avenue, Omaha, Nebraska 68144. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.