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Complaint Investigation

The Banyan At Montclair

January 29, 2026 · Omaha, NE · 2525 South 135th Avenue
Citations 2
Beds 175
Provider ID 285054
Healthcare Facility
The Banyan At Montclair
Omaha, NE  ·  View full profile →
Inspection Summary

The Banyan at Montclair in Omaha, NE — inspection on January 29, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0580
Resident Rights Deficiencies
Potential for More Than Minimal Harm

once per day for hypokalemia [low potassium]. A review of Nurses Note dated 12/11/25 revealed new order was received to start Resident 3 on Metformin [a medication used to treat high blood sugars] 500 mg twice per day for prediabetes. A review of Health Status Note dated 1/8/26 revealed new order to start Resident 3 on Mirtazapine [an antidepressant] 15 mg every night for dementia with depression and weight loss. A review of physician order for Resident 3 dated 1/8/26 revealed an order for prealbumin [a lab test used to assess nutritional status] lab test due to weight loss. A review of provider orders for Resident 3 dated 1/8/26 revealed orders for weekly weights and renal ultrasound due to history of mass to significant weight. A handwritten note on order sheet identified that family declined ultrasound. A review of 1/14/26 Social Service Note revealed email was sent to Resident 3's POA regarding Resident 3 refusing meals, not eating, significant weight loss and sleeping a lot.

The email suggested a discussion about hospice. A review of Resident 3's Progress Notes between 10/20/25 and 1/8/26 did not reveal any documentation of Resident 3's POA being notified of Resident 3's weight changes, orders for prealbumin lab, new orders for potassium chloride, metformin, and mirtazapine. A review of Medical Professional Progress Notes dated 10/15/25, 10/27/25, 11/18/25, 11/24/25, 12/12/25, 1/5/26, and 1/8/2026 did not reveal any documentation of Resident 3's POA being notified of Resident 3's weight changes, orders for prealbumin lab, new orders for potassium chloride, metformin, and mirtazapine. In an interview on 1/29/26 at 12:55 PM, Registered Dietitian A confirmed that Registered Dietitian A had not spoken with Resident 3's family regarding Resident 3's weight loss. In an interview on 1/29/26 at 3:09 PM and 4:18 PM, ADON B [Assistant Director of Nursing] confirmed that the nurses are to notify POA of changes in condition including weight loss and changes in medication.

ADON B confirmed ADON B contacted Resident 3's POA about weight loss and kidney ultrasound on 1/8/26 and family declined. ADON B confirmed that no additional information could be located regarding notification of Resident 3's POA.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

The Banyan at Montclair

2525 South 135th Avenue Omaha, NE 68144

SUMMARY STATEMENT OF DEFICIENCIES

lbs. which reflected a loss of 7 lbs. or 5.79% in one week. A review of Resident 3's prealbumin lab dated 1/14/26 revealed a level of 14 which could indicate malnutrition. A review of Social Service Note for Resident 3 dated 1/15/26 revealed Resident 3 was admitted to hospice. In interviews on 1/29/26 at 12:55 PM and 4:35 PM, Registered Dietitian A had confirmed that weekly weights were not started.

Registered Dietitian A reported Resident 3 was started on med pass supplement and reviewed at weekly risk meeting weight loss.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Omaha, NE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Banyan at Montclair or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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