The Banyan at Montclair

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews and interviews: the facility staff failed to utilize handwashing and gloving techniques for 4 (Residents 5, 15, 28, and 41), failed to implement Enhanced Barrier Precautions (EBP) on 2 residents (Residents 5 and 15), failed to store equipment to prevent potential cross contamination for 1 resident (Resident 5), failed to implement isolation procedures for 1 (Resident 102) and fails to provide personal care in a manor to prevent potential infection for 1 (Resident 28). The total sample size was 53 and the facility census was 111.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.5(G)Based on record review and interview the facility failed to ensure that a psychotropic medication had an adequate indication for use for Resident 5, and side effect monitoring was in place for residents 10 and 105 of 6 sampled residents. The facility identified a census of 111.

Inspectors wroteBased on record review and interview, the facility failed to investigate and report a fall with significant injury within the required time frame for 1(Resident 63) of 1. The facility reported a census of 111.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview, and record review, the facility failed to implement interventions to prevent the potential for pressure injuries on 1 (Resident 15) of 5 sampled residents. The facility census was 111.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(1)(i)Based on record review and interview, the facility failed to implement a new fall intervention for Resident 63 following a fall on 05/02/2026. The facility reported a census of 111.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.9(H)(iv) Based on record reviews and interviews the facility failed to ensure that a bowel protocol was followed for 1 resident (Resident 2) of 5 sampled residents. The facility identified a census at 111.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(4)Based on record review and interview, the facility failed to ensure a medication irregularity was reported to the attending physician and failed to ensure the report was acted on for 1 (Resident 5) of 5 sampled residents. The facility reported a census of 111.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on interview and record review, the facility failed to ensure that 2 (Resident 5 and 15) of 5 sampled residents were free of significant medication errors. The facility census was 111.

Inspectors wroteLicensure reference: 175 NAC 12-006.04(F)(i)(5) Based on interview and record review, the facility failed to notify resident representative of changes in treatment and significant weight loss for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 111 residents.

Inspectors wroteLicensure reference: 175 NAC 12-006.09(J)(i)(l) Based on record review and interview, the facility failed to monitor nutritional status after implementation of nutritional interventions for weight loss for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 111 residents.

Inspectors wroteThe facility failed to ensure all food stored in the facility's kitchen was labeled, sealed, and/or dated, ensure food was discarded that was past it's use-by date, and failed to ensure all kitchen equipment was clean and sanitized. This had the potential to affect all residents that consume food from the kitchen. A record review of the facility's Food Safety Requirements with a date reviewed/revised of 5/2025 revealed facility staff shall inspect all food, product, and beverages for proper storage to include labeling, dating, and monitoring food so it is used by its use by date. All equipment used shall be cleaned and sanitized. A.An observation on 12/10/2025 at 7:12 AM - 8:04 AM The True 2 door reach-in fridge contained a bag of a green leafy substance that was not labeled or dated. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.02(H) Based on observation, interview, and record review, the facility failed to ensure Adult Protective Services (APS) was notified within 2 hours of an allegation (a statement, made without giving proof, that someone has done something wrong) of potential abuse for 1 (Resident 51) of 3 sampled residents. The total facility census was 113.

Inspectors wroteLicensure Reference Number 12-006.09(H)(vi)(3)g Based on observation, interview and record review the facility failed to ensure oxygen and BiPap orders were obtained and followed for 1 (Resident 73) of 4 residents sampled. The facility census was 113.

Inspectors wroteBased on record review and interview, the facility failed to evaluate and identify situational triggers for post -traumatic stress disorder [PTSD, a psychological reaction occurring after experiencing a highly stressing event (such as wartime combat, physical violence, or a natural disaster) that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of reminders of the event] for 1 (Resident 12) of 2 residents reviewed. The facility census was 113.

Inspectors wroteLicensure Reference Number 175 NAC 12-006. 09(H)Based on record review and interview, the facility failed to hold blood pressure medications according to prescribed blood pressure parameters for 2 (residents 1 and 3) of 5 sampled residents. The facility census was 113.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications revealed 4 errors with a resulting error rate of 16%. The medication errors are related to 1 (Resident 100) of 4 sampled residents. The facility census was 113.

Inspectors wroteLicensure reference: 175 NAC 006.11 Based on observation, interview and record review, the facility failed to ensure to physician's ordered diet was followed for 1 [Resident 122] of 1 sampled resident with orders for a renal diet. The facility had a total census of 113.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B)Licensure Reference Number 175 NAC 12.006.19(A)(i) Based on observation, interview, and record review, the facility failed to ensure staff transported clean linen in a manner to prevent potential cross contamination, ensure clean sheets were utilized for Resident 70, and failed to ensure Resident 1's nebulizer (neb)(a machine used to deliver aerosolized medications to the lungs) administration kit was cleaned after each use. The facility census was 113.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19 Based on observations and interviews, the facility failed to maintain the carpets in clean condition to prevent urine odors in 13 resident rooms (Rooms 103, 105, 106, 109, 203, 205, 207, 208, 311, 317, 407, 409) of 45 occupied resident rooms on the north side of the building and the carpets throughout the 100, 200, 300 and 400 hallways of the north side of the facility. This had the potential to affect 17 residents that resided in those rooms. The facility had a total of 81 occupied resident rooms in the facility. The facility census was 110.

Inspectors wroteD. Record review of Resident 16's admission Record revealed that Resident 16 was admitted to the facility on [DATE] with diagnoses that included secondary Parkinsonism, and Alzheimer's Disease early onset. Record review of Resident 16's Clinical Census revealed that Resident 16 was discharged to the hospital on [DATE]. Record review of Resident 16's quarterly MDS dated [DATE] revealed that Resident 16 had a BIMS score of 15. The MDS manual identified that a score of 13-15 indicated the resident was cognitively intact. The MDS identified that Resident 16 had verbal behaviors exhibited toward others and rejection of care 1-3 days per week. The MDS identified that Resident 16 used a wheelchair for ambulation and required supervision with activities of daily living. Record review of a Health Status Note for Resident 16, dated 12/10/24, revealed the following information: - Note Text: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Nebraska Food Code 2017 4-904.11(A) Based on observation, record review and interviews; the facility failed to handle dishware in a manner to prevent the potential for food borne illness while serving foods in the facility dining room. This had the potential to affect 7 (Residents 3, 44, 53, 72, 99, 105, and 250) residents that received foods during the meal service and failed to ensure a refrigerators were maintained below 41 degrees in 1 (Resident 75) of 15 resident refrigerators. The facility census was 110.

Inspectors wroteD. An observation on 6/23/2025 at 10:48 AM revealed a nebulizer machine (a machine that changes liquid medicine into fine droplets inhaled through a mouthpiece or a mask) and tubing and a room telephone placed directly on the carpeted floor beside the bed of Resident 64. An observation on 6/24/2025 at 5:00 PM revealed a nebulizer machine and tubing and room telephone on the floor beside the bed of Resident 64. An observation on 6/24/2025 at 7:10 AM revealed a nebulizer machine and tubing and room telephone on the floor beside the bed of Resident 64. An interview on 6/23/2025 at 10:50 AM with Resident 64 confirmed the nebulizer machine and tubing and the room telephone are always kept on the floor of the resident's room. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interview; the facility failed to notify the provider of unavailable medication for 1 (Resident 57) of 7 sampled residents. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.04 Based on record reviews and interviews, the facility failed to resolve an ongoing grievance (a complaint or protest) and provide a written decision regarding grievance to the resident's representative. This had the potential to affect 1 (Resident 40) out of 1 resident sampled. The facility census was 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(H) Based on interview and record review the facility failed to protect 1(Resident 3) of 2 resident's sampled from physical abuse. The facility census was 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to notify the required State Agency of a significant injury within the required time frame for 1 (Resident 70) of 1 sampled. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to complete the Quarterly Minimum Data Set (MDS, a federally mandated assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within the required time frames for 1 (Resident 72) of 29 sampled residents. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interview, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 04/25/25 reflected only medications received for 1 (Resident 49) of 6 sampled residents. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F) Based on record review and interview, the facility staff failed to ensure a Baseline Care Plan was completed for 1( Resident 255) of 1 residents within 48 hours of admission. The facility had a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record reviews and interviews, the facility failed to revise the comprehensive care plan for 1 (Resident 70) of 1 sampled. The facility census was 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (H) Based on record review and interview the facility failed to establish a restorative nursing program with frequency of modalities for 3 (Resident 3, 37 and 72) of 5 residents sampled. The facility census was 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to assess the ability to smoke safely, which resulted in physical injury for 1 (Resident 50) of 1 smoking residents sampled and failed to implement a fall mat for 1 (Resident 99) of 2 residents sampled. The facility census was 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(2) Based on observation, interview, and record review; the facility staff failed to evaluate and implement a toileting program for 1 (Resident 72) of 1 sampled resident. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observations, record reviews, and interviews; the facility failed to assess for bed assist bar (a bar affixed to the bed used to assist the resident in bed mobility and positioning) use for 1 (Resident 49) of 1 sampled resident. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview; the facility staff failed to ensure a medication error rate of less than 5 percent (%). Observation of 35 medications revealed 3 errors with a resulting error rate of 8.57%. The medication errors are related to 1 (Resident 91) of 6 sampled residents. The facility staff identified a census of 110.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2) Based on observation, interview and record review the facility failed to evaluate, monitor, implement interventions for pressure ulcer prevention and promote healing for 4 (Resident 1,2,3 and 4) of 5 residents sampled. The facility census was 108.

Inspectors wroteLicensure reference: 175 NAC 12-007.04C1 Based on observation, interview, and record review, the facility failed to ensure temperatures in 59 of 76 occupied resident rooms and common areas were maintained at a safe and comfortable level. This has the potential to affect all 119 residents of the facility. The facility was notified on 2/18/25 at 8:23 PM of an Immediate Jeopardy (IJ) which began on 2/18/25. The IJ was removed on 2/19/25, as confirmed by surveyor onsite verification.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.01 (C) Licensure Reference Number 175 NAC 12-006.02(A)(G) Based on observations, record review, and interviews; the facility administration staff failed to ensure effective management of facility resources to maintain the highest practical well being of residents and the facility environment as evidenced by failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice result. The facility staff identified a census was 119.

Inspectors wroteLicensure reference: 175 NAC 12-006.19 and 175 NAC 12-007.04(C) Based on observations, interviews, and record reviews, the facility failed to ensure temperatures were maintained on the 200 hallway which has the potential to affect 16 residents residing on the 100 hallway, the handrails on the 300/400 unit were in good repair which has the potential to affect 37 residents residing in the 300 and 400 hallway, the door to the smoking room was in good repair which has the potential to affect 16 residents who smoke at the facility, and a guard was in place on the baseboard heater in room [ROOM NUMBER] which has the potential to affect 2 resident residing in room [ROOM NUMBER]. The facility had a total census 117 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 Based on observation, interview and record review, the facility failed to ensure an order for daily weights was followed for 1 (Resident 34), failed to ensure a providers' order was clarified for 1 (Resident 12) and failed to ensure an order to discontinue medication was transcribed for 1 (Resident 7). The total sample size was 24. The facility had a census of 117.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18 Based on observation, record review and interview, the facility failed to ensure a nurse performed hand hygiene, changed gloves, and wore a gown when providing care to 1 resident (Resident 115) of 1 resident who was on Enhanced Barrier Precautions (EBP - a set of infection control practices that use gowns and gloves during high-contact care activities to reduce the spread of multidrug-resistant organisms (MDROs). The total sample was 24. The facility census was 117.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17(A)(v) Based on record reviews and interviews, the facility failed to maintain a complete and accurate medical record for 1(Resident 1) of 5 sampled residents. The facility census was 118.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(1) and 175 NAC 12-006.18(B) Based on record reviews, observations, and interviews, the facility failed to ensure that Resident 2's indwelling urinary catheter was cleaned in a manner to prevent potential urinary tract infection and failed to ensure that Enhanced Barrier Precautions were maintained for in order to prevent the potential for cross-contamination for 2 (Residents 2 and 5) of 4 sampled residents. The facility census was 118.

Inspectors wroteLicensure Reference 175 NAC 12-006.05(S) Based on interview and record review, the facility failed to ensure that 1 (Resident 5) of 3 sampled residents was able to have a visitor of their choice. The facility had a census of 123.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S) Based on interview and record review, the facility failed to resolve grievances in a timely manner for 1 resident (Resident 5) of 3 residents sampled. The facility had a census of 123.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11(E) Based on observation, interviews and record review, the facility kitchen staff failed to ensure food was thawed in a manor to prevent the potential for food borne illness, failed to ensure that foods were labeled and dated and failed to discard food that was out of date This has the potential to effect all residents who ate food from the kitchen. The facility claimed a census of 123 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.04(G) Based on observation and interviews, the facility failed to ensure sufficient staff were available to answered calls for assistance in a timely manner for 6 (Residents 4,11,12,13,14 and 15) of 37 residents observed on the 500-600 hall. The facility census was 123.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on interview and record review the facility failed to ensure 1 (Resident 4) of 4 was free from significant medication errors. The facility staff identified a census of 131.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12.(D)(iii) Licensure Reference Number 175 NAC 12-006.12.(D)(vi) Based on observation, interview and record review the facility staff failed to ensure that an insulin injector pen was labeled correctly for 1 resident (Resident 6), failed to ensure that an expired insulin injector pen for 1 resident (Resident 5) was discarded and failed to ensure that an insulin injector pen was identified and dated before it was placed in the medication cart. The facility staff identified there were 26 residents in the facility who receive insulin via insulin injector pens. The facility staff identified a census of 131.

Inspectors wroteLicensure reference: 175 NAC 12-006.10 Based on record review and interview, the facility failed to ensure 1 [Resident 2] of 5 sampled residents was free from a significant medication error. The facility had a total census of 130 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to monitor 2 (Resident 1 and 3) of 3 residents post procedural appointments. The facility identified a census of 132.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2a Based on observation, record reviews and interview; the facility staff failed to implement interventions to prevent and treat pressure ulcer for 1 (Resident 87 ) of 5 sampled residents. The facility staff identified a census of 126.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04B2 Based on record review and interview, the facility failed to complete competencies for 7 (staff members C, T, U, V, W, X and Y) of 34 Licensed Practical Nurse [LPN] employees files, 2 (staff members Z, and AA) of 36 Registered Nurse [RN] employee files and 6 (staff members J, K, L, BB, CC and DD) of 122 Nurse Aide [NA] employee files. The files reviewed included both facility and agency staff. This had the potential to affect 126 residents that resided in the facility. The facility census was 126.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D1c Based on record review, interview, and observation, the facility failed to provide bathing per resident preference for 2 (Resident 78 and 384) of 13 sampled residents. The facility identified a census of 126.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.17B Based on observations, record review and interview; the facility staff failed to implement infection control precaution to prevent the spread of infectious disease for 1 (Resident 100) and failed to utilized handwashing and gloving techniques during the provision of care and treatments for 3 (Resident 120, 41 and 80). The total sample size was 12. The facility staff identified a census of 126.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to ensure the responsible party was notified of a change of condition for 1 [Resident 32] of 4 sampled residents. The facility had a total census of 126.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.02(8) Based on observation, record review, and interview; the facility failed to report an allegation of staff to resident abuse within the required timeframe to the Department of Health and Human Services [DHHS] for 1( Residents 233) of 4 facility self report investigations reviewed. The facility census was 126.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure monitoring was completed for change of resident condition for 1 [Resident 32] of 4 sampled residents. The facility has a total census of 126 residents.

Inspectors wroteLicensure Reference Number 175 12-006.10D Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident 137) of 8 sampled residents. The facility census was 126.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7 Based on observation, record review, and interview, the facility failed to ensure that staff were trained to check the function of individual resident elopement prevention equipment to prevent an elopement (unsupervised wandering that leads to the resident leaving the facility without facility staff knowledge). The facility staff identified a total of 13 residents at risk for elopement. The facility had a census of 135.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04 Based on record review and interview, the facility staff failed to ensure 5 Nursing Assistants (NA) (NA-G, NA-H, NA-I, NA-J and NA-K) of 33 Nursing Assistants sampled received and completed 12 hours of continuing education. The facility staff identified a census of 135.