The Banyan at Montclair
2525 South 135th Avenue · Omaha, NE · 68144 · 4023332304
175 certified beds For profit - Limited Liability company Chain: Avid Healthcare Group
Why this verdict
- On the federal Special Focus list of the most persistently poor performers.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $33,862 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
Special Focus Facility
CMS has designated this facility one of the most persistently poor performers in the country — it is under increased inspection and enforcement.
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
64% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: not rated Inspections: not rated Staffing: not rated Quality measures: not rated
| Total nurse hours / resident-day | 4.01 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.52 | 0.55–0.75 |
| Weekend hours / resident-day | 3.63 | ≈ weekday level |
| Nursing turnover / year | 64% | median 45% |
| Fines (3-yr window) | 3 · $141,793 |
Inspection citations (57 in the current record)
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Potential for harm · D January 29, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected March 8, 2026 · Resident Rights
-
Potential for harm · D January 29, 2026 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected March 8, 2026 · Quality of Life and Care
-
Potential for harm · D December 16, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 31, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D December 16, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 31, 2026 · Quality of Life and Care
-
Potential for harm · D December 16, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected January 31, 2026 · Quality of Life and Care
-
Potential for harm · D December 16, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected January 31, 2026 · Pharmacy Service
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Potential for harm · D December 16, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected January 31, 2026 · Pharmacy Service
-
Potential for harm · D December 16, 2025
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected January 31, 2026 · Nutrition and Dietary
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Potential for harm · F December 16, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 31, 2026 · Nutrition and Dietary
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Potential for harm · D December 16, 2025
Provide and implement an infection prevention and control program.
Corrected January 31, 2026 · Infection Control
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Potential for harm · D June 30, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected August 23, 2025 · Resident Rights
-
Potential for harm · E June 30, 2025 · found via complaint
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.
Corrected August 23, 2025 · Resident Rights
-
Potential for harm · D June 30, 2025 · found via complaint
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.
Corrected August 23, 2025 · Resident Rights
-
Potential for harm · D June 30, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 23, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 30, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 23, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E June 30, 2025 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected August 23, 2025 · Resident Rights
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Potential for harm · D June 30, 2025 · found via complaint
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected August 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 30, 2025 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected August 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 30, 2025 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected August 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 30, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected August 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 30, 2025 · found via complaint
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.
Corrected August 23, 2025 · Quality of Life and Care
-
Potential for harm · D June 30, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 23, 2025 · Quality of Life and Care
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Potential for harm · D June 30, 2025 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected August 23, 2025 · Quality of Life and Care
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Potential for harm · D June 30, 2025 · found via complaint
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.
Corrected August 23, 2025 · Quality of Life and Care
-
Potential for harm · D June 30, 2025 · found via complaint
Ensure medication error rates are not 5 percent or greater.
Corrected August 23, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 18, 2025 | Fine | $33,862 |
| February 18, 2025 | Payment Denial | 45 days |
| June 3, 2024 | Fine | $55,795 |
| March 4, 2024 | Fine | $52,136 |
| March 4, 2024 | Payment Denial | 31 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 285054 · certified since December 1, 1978. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.