Federal inspectors found that between October 2025 and January 2026, Resident 3 received multiple new prescriptions and medical orders due to declining health, yet staff failed to notify the resident's power of attorney about any of these changes.
The resident's weight loss became severe enough that doctors ordered specialized blood work to assess nutritional status. By January 8, physicians had prescribed three new medications: potassium chloride for low potassium levels, Metformin for prediabetes, and Mirtazapine for dementia with depression and weight loss.
Doctors also ordered weekly weight monitoring and a kidney ultrasound due to the resident's history of kidney masses and significant weight loss. The family declined the ultrasound when finally contacted.
The situation reached a crisis point on January 14 when social services emailed the power of attorney about the resident "refusing meals, not eating, significant weight loss and sleeping a lot." The email suggested discussing hospice care.
That was the first communication the family received about their loved one's deteriorating condition.
Inspectors reviewed medical records spanning from October 20, 2025, through January 8, 2026. Progress notes contained no documentation that the resident's power of attorney had been notified about the weight changes or any of the new medical orders.
Medical professional notes from seven different dates between October 15 and January 8 similarly showed no evidence that family members were informed about the resident's declining health or new treatments.
When questioned by inspectors on January 29, the facility's registered dietitian confirmed never speaking with the resident's family about the weight loss. This occurred despite the resident's condition warranting nutritional blood work and multiple medication changes.
Assistant Director of Nursing B acknowledged that nurses are required to notify powers of attorney about changes in condition, including weight loss and medication changes. The administrator confirmed contacting the resident's power of attorney about weight loss and the kidney ultrasound on January 8, when the family declined the procedure.
However, the administrator could not locate any documentation of additional family notifications despite months of concerning health changes.
The resident had been prescribed potassium chloride once daily by December 11 for low potassium levels. That same date brought the Metformin prescription for prediabetes. Three weeks later came the antidepressant Mirtazapine for dementia with depression and weight loss.
Each prescription represented a response to the resident's declining condition. Each went unreported to family members who had legal authority to make healthcare decisions.
The facility's own policies require staff notification of powers of attorney when residents experience significant changes in condition. Federal regulations mandate that nursing homes keep families informed about their loved ones' health status and treatment changes.
Yet for nearly four months, the resident's power of attorney remained unaware that their family member was losing weight, developing diabetes complications, experiencing depression, and requiring multiple new medications to address these problems.
The violation affected few residents but represented minimal harm or potential for actual harm, according to federal inspectors. The inspection occurred following a complaint about the facility's practices.
By the time family members learned about the resident's condition, the situation had progressed to the point where social services was recommending hospice discussions. The resident was refusing meals, sleeping excessively, and continuing to lose weight despite medical interventions.
The power of attorney's first substantial communication about their loved one's health came only when the resident's condition had deteriorated enough to warrant end-of-life care discussions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Banyan At Montclair from 2026-01-29 including all violations, facility responses, and corrective action plans.