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Nursing HomeMedicaid

The Banyan at Montclair

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

2525 South 135th Avenue, West Omaha · Omaha, NE 68144175 bedsLicensed & Active
Google rating
3.2/5

based on 101 Google reviews

5
4
3
2
1
The Banyan at Montclair Nursing Home in Omaha, NE — Street View
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What this means for your family

While the facility has undergone recent physical renovations and has an active activity program, the recurring reports of neglect and communication failures are concerning. If you consider this facility, we strongly recommend unannounced visits and asking for a detailed plan on how they ensure call lights are answered promptly and how they manage personal belongings.

Google Reviews

Google Reviews

101 reviews on Google
The Banyan at Montclair (formerly Azria Health) receives highly polarized feedback, with many families reporting severe neglect, poor hygiene, and communication failures. While some visitors praise recent renovations and specific staff members, a significant number of reviews describe a facility struggling with understaffing, slow response times, and missing personal belongings.

Quality Themes

Tap a score for details
Food2.0Staff4.0Clean2.0Activities7.0Meds2.0MemoryN/AComms2.0ValueN/A

Strengths

  • Dedicated rehab therapy department
  • Recent facility renovations and modern upgrades
  • Select compassionate and attentive nursing staff
  • Active and engaging activity department

Concerns

  • Chronic understaffing leading to ignored call lights and delayed care (mentioned by 12 reviewers)
  • Poor hygiene, including reports of foul odors, stained linens, and lack of cleanliness (mentioned by 9 reviewers)
  • Theft or loss of resident personal belongings and clothing (mentioned by 5 reviewers)
  • Communication barriers, including unresponsive management and faulty phone systems (mentioned by 7 reviewers)
  • Poor quality, cold, or unappealing food service (mentioned by 4 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'17(3)'19(13)'21(10)'23(12)'25(8)

Distribution · 103 analyzed

5
46
4
7
3
6
2
4
1
40

How They Respond to Reviews

20%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1Given the recent renovations to the building, what specific protocols are in place to ensure that the facility maintains a high standard of daily cleanliness and odor control?
  • 2I noticed your activity department is very active; could you walk me through a typical weekly schedule and how you encourage residents to participate in these programs?
  • 3With the current size of the facility, what is your process for ensuring that call lights are answered promptly and that residents receive consistent attention throughout the day and night?
  • 4How do you manage the laundry and personal belongings of residents to ensure that clothing and items are tracked and returned properly?
  • 5What steps are being taken to improve the variety and quality of the dining experience to ensure meals are served at the appropriate temperature and meet residents' nutritional preferences?
  • 6I see that management has been engaging with feedback online; what is the best way for families to reach leadership if they have urgent questions or concerns regarding their loved one's care?

Personalized based on this facility's data


Key Review Excerpts

She’s left in her own mess for and hour or more. When staff finally does come in they are rude, treat her as an inconvenience and have even made personal calls while they’ve cleaned her up.

Daughter of resident · 2021☆☆☆☆

The nursing staff and CNA's are on the ball and do a good job. They're very responsive and friendly. The medications come on time and if I ever need my pain meds I get them within a reasonable amount of time.

Rehab patient · 2019★★★★

My mother was there from 9-19-23 to 9-24-23 before she had to go back to the hospital with a new UTI, excoriated peri area from a kinked/leaking catheter, and her wounds were infected. 5 DAYS is all she made it.

Daughter of resident · 2023☆☆☆☆
Source: 101 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.52hrs
69%
Registered nurses for medical care
Total Nursing
4.01hrs
98%
All nurses + aides combined
Staff Turnover
64%
Lower is better (< 30% = good)
RN Turnover
68%
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

Better Than Avg

5

measures

Worse Than Avg

7

measures

Mixed Results

5

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility30.0%
Worse than Avg
Here
30.0%
US
19.4%
NE
26.3%
Douglas
24.1%
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.2%
Better than Avg
Here
3.2%
US
12.1%
NE
4.3%
Douglas
9.6%

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 Facility22.1%
Worse than Avg
Here
22.1%
US
15.5%
NE
20.8%
Douglas
16.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility23.7%
Worse than Avg
Here
23.7%
US
19.5%
NE
19.3%
Douglas
18.1%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility18.6%
Mixed vs Avgs
Here
18.6%
US
14.4%
NE
19.5%
Douglas
15.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility15.6%
Mixed vs Avgs
Here
15.6%
US
15.3%
NE
19.1%
Douglas
18.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility70.7%
Worse than Avg
Here
70.7%
US
81.8%
NE
80.5%
Douglas
80.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility78.8%
Mixed vs Avgs
Here
78.8%
US
79.8%
NE
75.9%
Douglas
78.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.6%
Better than Avg
Here
0.6%
US
1.6%
NE
2.3%
Douglas
1.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

10deficiencies
5penalties
52 complaint-triggered
$141,793 in fines

Families should exercise significant caution before visiting this facility, as most deficiencies (56 of 89) stem from families filing complaints about serious care issues. The facility has recurring problems with medication management, maintaining safe and clean living conditions, and proper care planning and assessment. While most issues have been corrected, the pattern of repeated violations in these critical areas, especially those requiring family complaints to be identified, suggests ongoing systemic problems that warrant careful consideration.

Jan 29, 2026Complaint
2
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jan 28, 2026Complaint
1
0232Potential for harm · WidespreadCorrected

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Dec 16, 2025Routine
12
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.

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.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

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

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0808Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jun 30, 2025Complaint
17
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.

0628Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0585Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0638Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Jun 30, 2025Routine
7
0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0222Potential for harm · PatternCorrected

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.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

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

0351Potential for harm · PatternCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Apr 2, 2025Complaint
1
0686Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

Federal Penalties

Fine

Feb 18, 2025

$33,862

Payment Denial

Feb 18, 2025

45-day denial

Fine

Jun 3, 2024

$55,795

Fine

Mar 4, 2024

$52,136

Payment Denial

Mar 4, 2024

31-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

The Banyan at Montclair

Organization Type

for profit

Chain Affiliation

Chain Name

Avid Healthcare Group

Chain Size

11 facilities nationwide

Ownership & Management

Owners

Ne M2 Holdco Opco LLC

Owner · Organization

100%

Brass Ne Trust

Owner (parent company) · Organization

Bsd Beis Health Trust

Owner (parent company) · Organization

Douro Valley Investment, LLC

Owner (parent company) · Organization

Gold Ne Trust

Owner (parent company) · Organization

Ne Snf Holdco LLC

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

Sharp, DavidContracted Managing EmployeePihlgren, LindseyW-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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