Castle Manor Nursing Home: Advance Directive Failures - CA
The woman, identified in inspection records as Resident 17, was admitted to the facility with Type 2 diabetes and depression. She had intact cognition, according to a January 2025 assessment. When an inspector sat down with her on March 26, she said she had never been approached about an advance directive, the legal document that tells medical staff what to do if a patient can no longer speak for themselves. She said she wanted to start one. "I think I had something like that a long time ago," she told the inspector. "I have four granddaughters that could help me with that."
Her chart had nothing in it. No directive. No record of any conversation about one.
She was not alone. When the Director of Social Services sat down with the inspector later that same morning, she could not locate documentation of advance directive discussions for any of four residents whose records were pulled, including Residents 12, 231, and 233 in addition to Resident 17.
The Director of Social Services described how the process was supposed to work: staff meet with residents a few days before admission, the interdisciplinary team discusses the plan of care, and advance directives come up as part of that conversation. But she acknowledged a significant gap in how she recorded those conversations. She said she only documented when a resident wanted more information, not when a resident declined to pursue a directive. That meant a resident who said no, or a resident who was never asked, would leave no trace in the record either way.
She also told the inspector that a standing order for full treatment during a code blue, when a resident's heart and breathing have stopped, is not the same thing as an advance directive. The distinction matters. A code blue order tells staff to do everything. An advance directive tells staff what the resident actually wants, which may or may not be everything.
The Director of Nursing, interviewed the following morning, said it was important to discuss advance directives with residents on admission. She said it was important to honor residents' wishes. The inspection record does not indicate she offered an explanation for why that had not happened.
The facility's own policy, dated 2016, is specific on this point. It calls for the Social Services Director or a designee to provide written information to residents about their right to accept or refuse treatment and to formulate advance directives, either before or at the time of admission. It also requires staff to ask residents and their families whether any written directive already exists, and to make sure that information is prominently displayed in the medical record.
For at least four residents, none of that was documented.
Advance directives carry particular weight in a nursing home setting, where residents are often older, managing serious chronic conditions, and at greater statistical risk of a sudden medical crisis. Without a directive on file, medical staff making split-second decisions during an emergency have no recorded guidance about what the resident wanted. The Director of Social Services acknowledged this herself, telling the inspector that documenting those conversations existed precisely to protect the resident's right to decide what kind of treatment they receive.
Resident 17 said she wanted to make those decisions. She said her granddaughters could help her. As of the inspection date, she was still waiting for someone at the facility to start that conversation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Castle Manor Nursing & Rehabilitation Center from 2025-03-27 including all violations, facility responses, and corrective action plans.
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.
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Last verified: November 3, 2026 · Our methodology
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA was cited for violations during a health inspection on March 27, 2025.
The woman, identified in inspection records as Resident 17, was admitted to the facility with Type 2 diabetes and depression.
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.