Cycle 1
Health 2025-06-30 · Fire 2025-06-30
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Omaha, NE
The Banyan at Montclair
0-star overall rating with 0-star inspections with Special Focus status with $159,083 in total fines with 20 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2525 South 135th Avenue, Omaha, NE
(402) 333-2304
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
175
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avid Healthcare Group
Operator or chain grouping
Approved since
1978-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.93
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
5.00
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,728
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.77
Baseline 21.40% · Performance 19.22% · Measure score 4.77 · Achievement 4.77 · Improvement 4.49
Healthcare-associated infections
4.31
Baseline 9.42% · Performance 7.29% · Measure score 4.31 · Achievement 1.82 · Improvement 4.31
Total nurse turnover
0
Baseline 58.73% · Performance 74.14% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.87 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 12.26% · Lower 95% interval 8.08% |
| Discharge to community | 51.56% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 46.03% · Lower 95% interval 42.42% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 89.13% |
95.27%
6.1 pts worse
|
Numerator 82 · Denominator 92 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 92 |
| Discharge self-care score | 46.48% |
53.69%
7.2 pts worse
|
Numerator 33 · Denominator 71 |
| Discharge mobility score | 49.3% |
50.94%
1.6 pts worse
|
Numerator 35 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 0.91% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 8.85% |
42%
33.1 pts worse
|
Numerator 10 · Denominator 113 |
| Discharge function score | 47.89% |
56.45%
8.6 pts worse
|
Numerator 34 · Denominator 71 |
| Transfer of health information to provider | 86.36% |
95.95%
9.6 pts worse
|
Numerator 19 · Denominator 22 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 30 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 54.17% |
25.2%
29 pts better
|
Numerator 26 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
92.8%
4.6 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.1% · Q3 96.2% · Q4 95.0% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.2% |
96.1%
2.9 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
4.5%
0.9 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.5% · Q3 5.7% · Q4 7.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.4%
1.9 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 2.3% · Q4 5.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.3%
0.9 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 6.0% · Q3 6.0% · Q4 4.3% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
19.5%
3.4 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.8% · Q3 22.5% · Q4 28.1% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
21.6%
1.3 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 21.7% · Q3 23.9% · Q4 26.8% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.9% |
20.4%
6.5 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 17.4% · Q3 9.7% · Q4 12.1% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
19.9%
7.8 pts better
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 12.7% · Q3 10.9% · Q4 16.0% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.6%
0.6 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 2.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.9%
1.4 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
26.6%
2.9 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 30.1% · Q3 34.2% · Q4 32.9% · 4Q avg 29.5% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.3%
0.4 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.1% · Q3 4.6% · Q4 5.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
80.5%
2.2 pts better
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 87.1% · Q3 87.3% · Q4 56.5% · 4Q avg 82.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
11.6%
6.4 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 19.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.4%
1.8 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.8% |
75.9%
2.9 pts better
|
79.7%
0.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
20.9%
3.8 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 25.4% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-05 · Fire 2024-12-05
21 health deficiencies
Top issue: Resident Rights (6 deficiencies)
10 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2024-03-26 · Fire 2024-03-26
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-28
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Not marked corrected
F · Potential for more than minimal harm
2025-06-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-23
F · Potential for more than minimal harm
2025-02-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-02-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-02-18
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-01-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-07
F · Potential for more than minimal harm
2024-12-05
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-01-03
F · Potential for more than minimal harm
2024-12-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-05
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-05
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-03-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-01-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-16
F · Potential for more than minimal harm
2024-01-19
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-02-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Not marked corrected
E · Potential for more than minimal harm
2025-06-30
F584 · Resident Rights Deficiencies
Health
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 2025-08-23
E · Potential for more than minimal harm
2025-06-30
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F585 · Resident Rights Deficiencies
Health
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 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F688 · Quality of Life and Care Deficiencies
Health
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 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F690 · Quality of Life and Care Deficiencies
Health
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 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F700 · Quality of Life and Care Deficiencies
Health
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 2025-08-23
D · Potential for more than minimal harm
2025-06-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-04-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-02
L · Immediate jeopardy
2025-02-24
F584 · Resident Rights Deficiencies
Health
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 2025-04-21
F · Potential for more than minimal harm
2025-02-24
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-04-21
F · Potential for more than minimal harm
2024-12-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-05
F584 · Resident Rights Deficiencies
Health
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 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-09-26
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-26
F585 · Resident Rights Deficiencies
Health
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 2024-10-22
F · Potential for more than minimal harm
2024-08-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-09-26
G · Actual harm
2024-07-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-06-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-15
G · Actual harm
2024-03-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-03-26
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-03-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-03-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F700 · Quality of Life and Care Deficiencies
Health
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 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-26
F909 · Environmental Deficiencies
Health
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.
Corrected 2024-04-30
J · Immediate jeopardy
2024-03-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-04
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-30
E · Potential for more than minimal harm
2023-04-03
F584 · Resident Rights Deficiencies
Health
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 2023-04-21
E · Potential for more than minimal harm
2023-04-03
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-03
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
$33,862
2025-02-18
Fine
Fine · fine $33,862
Fine
$0
2025-02-18
Payment Denial
Payment Denial · denial start 2025-03-18 · 45 days
45 day denial
$55,795
2024-06-03
Fine
Fine · fine $55,795
Fine
$52,136
2024-03-04
Fine
Fine · fine $52,136
Fine
$0
2024-03-04
Payment Denial
Payment Denial · denial start 2024-03-30 · 31 days
31 day denial
$17,290
2023-04-03
Fine
Fine · fine $17,290
Fine
$0
2023-04-03
Payment Denial
Payment Denial · denial start 2023-04-28 · 14 days
14 day denial
Ownership
Ne M2 Holdco Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Brass Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Bsd Beis Health Trust
5% Or Greater Indirect Ownership Interest · Organization
Douro Valley Investment, LLC
5% Or Greater Indirect Ownership Interest · Organization
Gold Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Ne SNF Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ne SNF Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Pihlgren, Lindsey
W-2 Managing Employee · Individual
Sf 4140 Olde Washington Boulevard Real Property LLC
5% Or Greater Indirect Ownership Interest · Organization
Sharp, David
Contracted Managing Employee · Individual
Silberstein, Ari
Corporate Officer · Individual
Silver Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Tulip Investments Ne LLC
5% Or Greater Indirect Ownership Interest · Organization
Weisz, David
5% Or Greater Indirect Ownership Interest · Individual
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#3
Brookestone Village
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