Community Extended Care Hospital of Montclair: Medication Mix-Up - CA
The resident who needed the drug, identified in inspection records as Resident 1, missed twelve doses of Valproic Acid 250 mg before anyone caught the error. Valproic Acid is used to control seizures and certain psychiatric conditions. His medication was not initiated until December 21, 2025, five days after his admission on December 16.
During that same stretch, Resident 2, a woman who had no clinical reason to receive the drug, was given it six times.
The nurse who made the error, identified in the inspection report as RN 1, described what happened in a follow-up interview on December 30, 2025. "It was my mistake that caused Resident 1 did not receive his Valproic Acid to manage his clinical condition that made Resident 2 received Valproic Acid that was unnecessary for her, unfortunately," she said. She acknowledged she should have cross-checked the medication order against the hospital discharge records and confirmed with the physician before entering it into the system. She did not.
The facility's administrator confirmed the error in an interview on December 31, 2025, acknowledging that Resident 1 went without his prescribed medication and that Resident 2 received six unnecessary doses. The administrator described what the facility expects of its admission nurses: review hospital records, verify medication indications at admission, and have the Director of Nursing check the admission chart the next business day for accuracy.
None of that happened here. And the administrator acknowledged something else: the facility has no written policy governing the admission process, including how medication orders are handled when a new resident arrives.
The pharmacist who reviewed medications for the facility told inspectors on January 2, 2026, that the pharmacy typically reviews new admission medication orders within four to eight hours of admission, checking for correct dosage, frequency, drug interactions, and clinical indication. But the pharmacist was clear about one thing the pharmacy does not do: review hospital discharge records. That responsibility, the pharmacist said, belongs to the facility.
Which means the one check that might have caught the error before Resident 1 missed his first dose was the one nobody performed.
The inspection, conducted as a complaint investigation, found the level of harm to be minimal or potential for actual harm, and noted that some residents were affected. The finding does not describe what, if any, clinical consequences Resident 1 experienced during the five days he went without medication to manage his condition, or what effects Resident 2 experienced from six doses of a drug she had no reason to take.
What the record does show is that a nurse made an error that a basic verification step would have prevented, that the facility's own stated process was not followed, and that the facility had never written down what that process was supposed to be in the first place. The administrator confirmed all three of those things without dispute.
Resident 1's medication administration record, reviewed by inspectors, confirmed the twelve missed doses in black and white.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Community Extended Care Hospital of Montclair from 2026-01-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Community Extended Care Hospital Of Montclair in Montclair, CA was cited for violations during a health inspection on January 2, 2026.
The resident who needed the drug, identified in inspection records as Resident 1, missed twelve doses of Valproic Acid 250 mg before anyone caught the error.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.