Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Castle Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Four residents with intact cognition did not have Advanced Directives or documentation of discussions about them in their medical records. Staff interviews confirmed that required discussions were not consistently held or documented, and some residents expressed specific wishes about life-sustaining treatment that were not recorded. Facility policy required these discussions and documentation, but this was not followed.
The QAA Committee did not identify or include a trend of deficiencies related to Advance Directives in the QAPI plan, as found by surveyors during a recertification survey. The QAPI team had been focused on falls and skin care, overlooking issues with Advance Directives despite facility policies requiring comprehensive monitoring of care systems.
A nurse left a resident's bubble wrap medications, labeled with the resident's name and medication details, unattended on a medication cart, exposing confidential information. Staff interviews confirmed this action violated privacy and confidentiality policies.
A resident with a history of scabies and ongoing pruritis did not have an individualized care plan addressing persistent rashes and itching. Despite being cognitively intact and requiring personal care assistance, the resident's continued symptoms were not documented or managed through a care plan, as confirmed by both the Treatment Nurse and DON.
A resident with multiple sclerosis and dementia, assessed as high risk for pressure ulcers and fully dependent on staff, was not repositioned according to facility policy and did not receive timely pericare. Observations and staff interviews confirmed the resident remained in the same position for extended periods in bed and in a wheelchair, contrary to required care standards, increasing the risk for skin breakdown.
A resident with nicotine dependence and a need for personal care was allowed to keep cigarettes and a lighter in their room and to smoke unsupervised, contrary to facility policy. Staff only enforced supervised smoke breaks and confiscated smoking materials after the resident was found smoking inside their room. There was no smoking risk assessment completed on admission or readmission, and required documentation and IDT involvement were lacking.
Two residents did not receive medications as intended: one had a medication cup with residual medicine left at bedside after crushed medications were mixed with a supplement, and another had a capsule left on the bedside table after an LPN failed to confirm ingestion. Both incidents were acknowledged by nursing staff and the DON as not meeting expectations for safe medication administration.
Staff failed to follow infection control protocols when a physical therapist exited an isolation room for a Covid-19 positive resident while still wearing full PPE and handled items outside the room, contrary to facility policy. Additionally, a nurse did not perform hand hygiene or change gloves between tasks while administering medication and handling a resident's G-tube, despite the resident's diagnosis of acute osteomyelitis. These actions did not comply with the facility's infection prevention policies.
A resident experienced a sudden decrease in oxygen level and blood pressure, but the LN failed to perform a complete assessment or notify the physician, as required by facility policy. Despite monitoring and providing oxygen and fluids, the resident was found unresponsive and later pronounced dead. Interviews confirmed the LN's failure to communicate the change in condition, leading to the deficiency.
A resident was given an incorrect dosage of Carvedilol due to a transcription error by a licensed nurse. The hospital discharge order specified 3.125 mg twice daily, but the facility's order was incorrectly documented as 25 mg twice daily. The error was not reconciled upon admission, and the pharmacy dispensed the higher dosage, which was not flagged by the system.
Failure to Document and Discuss Advanced Directives with Residents
Penalty
Summary
The facility failed to ensure that four of twenty-one sampled residents had either completed Advanced Directives or documented discussions regarding Advanced Directives with the Social Services Director (SSD). For each of these residents, there was no evidence in either the electronic medical record or the paper chart of an Advanced Directive or a Physician Orders for Life-Sustaining Treatment (POLST) form. Interviews with staff confirmed that these documents were not present, and that the process for discussing and documenting Advanced Directives was inconsistently followed. Residents involved in the deficiency had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores, and were capable of making decisions regarding their care. Despite this, interviews revealed that these residents either did not recall any discussion about Advanced Directives or stated that such discussions had not occurred. Some residents expressed specific wishes regarding life-sustaining treatment, such as not wanting to be placed on life support or wanting to be resuscitated, but these preferences were not documented in their records. Staff interviews further revealed that the SSD only documented if a resident requested more information about Advanced Directives, but did not document if a resident refused information. Additionally, staff acknowledged that a physician’s order for full code was not equivalent to an Advanced Directive. The facility’s policy required that residents be provided with information about their rights to make decisions about their care, including the right to formulate Advanced Directives, and that this information be documented in the medical record. However, this policy was not followed for the four residents in question.
QAA Committee Failed to Identify and Address Advance Directives Deficiency
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and include trends related to Advance Directives in the facility's Quality Assurance Performance Improvement (QAPI) plan. During a recertification survey, surveyors found deficiencies concerning Advance Directives that had not been recognized or addressed by the QAA Committee. Interviews with the Administrator (ADM) and Director of Nursing (DON) confirmed that the QAPI team was primarily focused on monitoring falls and skin care, and had not identified the deficient trend in Advance Directives prior to the survey. Facility policies reviewed indicated that the QAPI Committee is responsible for identifying, evaluating, monitoring, and improving all systems and processes that support care delivery, including those affecting resident autonomy and choice. Despite these policies, the QAA Committee did not detect or prioritize the deficiency in Advance Directives, and this issue was not incorporated into the QAPI plan as required by facility protocols.
Resident Privacy Breach Due to Unattended Medications
Penalty
Summary
A licensed nurse left three bubble wrap medications containing a resident's name, medication names, and dosages unattended on top of a medication cart outside the resident's room. These medications were visible and accessible to the general public, which resulted in the exposure of the resident's personal and medical information. The medications included Lexapro 5 mg, Losartan 25 mg, and Namenda 10 mg, and the packaging clearly displayed the resident's identifying information. Interviews with the licensed nurse, charge nurse, and director of nursing confirmed that the medications should have been secured inside the locked medication cart and that leaving them unattended constituted a violation of privacy and confidentiality. The facility's policy on confidentiality and personal privacy requires safeguarding all resident personal and medical records, which was not followed in this instance.
Failure to Implement Individualized Care Plan for Resident with Persistent Rash and Itching
Penalty
Summary
The facility failed to implement an individualized care plan for a resident who experienced pruritis and rashes following a diagnosis and treatment for scabies. According to the admission record and Minimum Data Set, the resident was cognitively intact and required assistance with personal care. During an interview and observation, the resident reported ongoing intense itching and displayed multiple red bumps on his shoulders, chest, and stomach, despite having been treated for scabies. A review of the resident's records and interviews with the Treatment Nurse and Director of Nursing revealed that there was no written care plan addressing the resident's ongoing rash and itching. The Treatment Nurse was unaware of the continued symptoms and confirmed that no care plan had been developed or updated to address the resident's needs. The Director of Nursing acknowledged that a care plan should have been initiated and revised as the resident's condition changed. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed in the resident's case.
Failure to Reposition and Provide Pericare for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide care consistent with professional standards to prevent pressure injuries for a resident with multiple sclerosis and dementia, who was assessed as high risk for pressure ulcers. The resident was dependent on staff for all activities of daily living and was observed multiple times over two days either lying supine in bed or sitting in a wheelchair for extended periods without evidence of repositioning. Facility policy required repositioning at least every two hours in bed and every hour in a chair, but observations showed the resident remained in the same position for several hours at a time. Interviews with nursing staff confirmed that the resident had not been repositioned as required and that pericare had not been provided during the observed periods. Staff acknowledged the resident's high risk for skin breakdown due to incontinence, immobility, and dependence on care. The facility's Director of Nursing also confirmed that repositioning should occur even when the resident is in a wheelchair to prevent wounds. The failure to follow established protocols for repositioning and pericare had the potential to result in a decline in the resident's skin integrity.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to follow its own smoking policy for a resident with nicotine dependence and a need for assistance with personal care. The resident, who was cognitively intact, had previously been allowed to keep cigarettes and a lighter in his room and to smoke outside unsupervised. Staff only began enforcing supervised smoke breaks and confiscating smoking materials after an incident where the resident was found smoking a lit cigarette inside his room. Multiple staff interviews confirmed that the resident had a history of noncompliance with the smoking policy, including unsupervised smoking and possession of smoking materials, and that staff were not consistent in enforcing the policy or documenting incidents. A review of the resident's records showed that a smoking risk assessment was not completed upon admission or readmission, and there was no documentation of an interdisciplinary team (IDT) meeting after the incident of smoking inside the facility. The facility's policy required that smoking status be evaluated upon admission, that smoking only occur in designated areas, and that smoking materials be secured by staff. Staff acknowledged lapses in communication and documentation, and that the required procedures were not consistently followed to ensure the safety of the resident and others.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered appropriately for two residents. For one resident with end stage renal disease, dysphagia, pneumonia, and congestive heart failure, surveyors observed a used medication cup with residual medicine mixed with a renal supplement left on the bedside table. Interviews with two licensed nurses and the Director of Nursing confirmed that the expectation was for the resident to receive the full dose of medication and for the medication cup to be disposed of after administration. However, the nurse left some medication in the cup, and the cup was not disposed of, which could result in the resident not receiving the full dose and posed a risk of another resident ingesting the leftover medication. For another resident with type 2 diabetes and diabetic neuropathy, a plastic medicine cup with a yellow capsule was found on the bedside table. The resident stated that the nurse brought the medication but they forgot to take it. The nurse admitted to leaving the medication on the table without confirming ingestion, and acknowledged that this was not safe as another resident could take the medication and the dose was now late. The Director of Nursing confirmed that medications should not be left with residents and that nurses must ensure medications are taken before leaving.
Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
A deficiency was identified when a staff member, specifically a physical therapist, failed to follow proper infection control protocols after providing care to a resident on contact/droplet precautions for Covid-19. The staff member was observed leaving the isolation room while still wearing full PPE, including gown, gloves, mask, and face shield, and handled items such as a sanitizer tub and a walker outside the resident's room without doffing PPE as required by facility policy. The facility's policy states that PPE for transmission-based precautions should be maintained inside the resident's room, but this was not followed, as confirmed by staff interviews and policy review. Another deficiency was observed during medication administration to a resident with acute osteomyelitis. A licensed nurse failed to perform hand hygiene and change gloves between tasks, including after touching the resident's personal belongings, privacy curtains, and the resident's G-tube. The nurse used the same gloves throughout these activities, contrary to the facility's hand hygiene policy, which requires hand hygiene after touching a resident or their environment. Staff interviews confirmed that proper hand hygiene and glove changes were not performed, increasing the risk of cross-contamination.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a licensed nurse (LN) performed a complete assessment and notified the physician when a resident experienced a sudden decrease in oxygen level and blood pressure. The resident, who had been admitted with a urinary tract infection, showed signs of distress with an oxygen saturation of 87% and low blood pressure. Despite these changes, the LN did not notify the physician, which is a requirement according to the facility's policy. Throughout the night, the LN and certified nursing assistants (CNAs) monitored the resident's vital signs, which fluctuated but remained concerning. The LN provided oxygen and fluids and made adjustments such as elevating the resident's head and feet. However, the LN did not perform a thorough assessment or communicate the resident's change in condition to the physician, as confirmed by interviews with the LN, the Director of Nursing (DON), and the resident's physician. The resident was found with cold, pale skin and no pulse approximately four hours after the initial decrease in vital signs was noted. Emergency services were called, and CPR was performed, but the resident was pronounced dead an hour later. The facility's policy mandates prompt notification of the physician in such cases, which was not adhered to, contributing to the deficiency identified in the report.
Medication Transcription Error Leads to Incorrect Dosage
Penalty
Summary
The facility failed to ensure accurate transcription of a medication order for a resident, leading to a medication error. The resident, who was admitted with a diagnosis including a urinary tract infection, had a hospital discharge order for Carvedilol 3.125 mg twice daily. However, the facility's order summary incorrectly documented the medication as Carvedilol 25 mg twice daily. This discrepancy was not identified or reconciled upon the resident's admission to the facility. The Director of Nursing confirmed that the licensed nurse responsible for transcribing the order did not ensure the hospital orders matched the facility's admission orders. The Pharmacy Consultant also noted that the transcription error was not flagged by the computer system, as the dosage was within the allowable range. Consequently, the pharmacy dispensed the higher dosage as per the incorrect order, resulting in the resident receiving a higher dose than prescribed by the physician.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near National City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradise Valley Health Care | 0.6 mi | ★★★★★ | 2 | 0 |
| Friendship Manor Nursing & Rehab Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Hillcrest Manor Sanitarium | 1.4 mi | ★★★★★ | 20 | 0 |
| National City Post Acute | 1.6 mi | ★★★★★ | 25 | 0 |
| Reo Vista Healthcare Center | 2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.