NATIONAL CITY, CA - Federal inspectors found Castle Manor Convalescent Center failed to properly discuss and document advance directives with residents, left medications unattended, and did not follow established care protocols during a March 2025 inspection.
Advance Directive Discussions Not Conducted or Documented
The most significant violation involved the facility's failure to discuss advance directives with four cognitively intact residents upon admission. Advance directives are critical legal documents that allow residents to specify their preferences for end-of-life medical care, including whether they want to be resuscitated if their heart stops or if they want life-sustaining treatments.
Inspectors found that Resident 12, who was admitted with acute respiratory failure, asthma, congestive heart failure, and pneumonia, had no advance directive or POLST (Physician Orders for Life-Sustaining Treatment) form in either her electronic or paper medical records. When interviewed, the resident stated she "could not remember a conversation with a physician or other staff about Advanced Directives" and expressed that she "would not like to be put on machines to keep her alive in an emergency or be fed thru a tube."
The facility's Director of Social Services admitted she could not find documentation of advance directive discussions for any of the four sampled residents. She revealed a concerning practice where a particular physician "only writes an order for full code for all his residents and does not fill out Advance Directives for his residents."
Resident 17, who has Type 2 diabetes and depression, told inspectors she "did not have an Advanced Directive, and that she wanted to initiate one" and that "staff had not discussed an Advanced Directive with her." Similarly, Resident 233 stated she "was not offered an Advanced Directive or a POLST when she was admitted to the facility."
This violation represents a fundamental failure to respect residents' autonomy and self-determination. Advance directives serve as a resident's voice when they cannot speak for themselves during medical emergencies. Without these documents, healthcare providers may default to aggressive life-sustaining treatments that the resident would not have wanted, or conversely, may withhold treatments the resident would have preferred.
The medical significance of this violation cannot be overstated. In emergency situations, seconds matter, and healthcare teams rely on advance directives to make rapid decisions about resuscitation efforts, intubation, and other life-sustaining interventions. The absence of these documents places residents at risk of receiving care that conflicts with their personal values and wishes.
Medication Security Breach Compromises Patient Privacy
A licensed nurse violated federal privacy laws by leaving a resident's medications exposed and unattended in a hallway. The inspection revealed bubble wrap medications containing Resident 181's name, medication names, and dosages were left on top of a medication cart outside the resident's room. The visible medications included Lexapro for depression, Losartan for blood pressure control, and Namenda for dementia.
This breach violates both facility policy and federal HIPAA regulations, which require strict protection of patient health information. Medication labels contain sensitive medical information that can reveal a resident's health conditions to unauthorized individuals.
Licensed Nurse 11 acknowledged the violation, stating "he should have not left resident 181's bubble wrap medications over the cart, exposed to the general public, unattended" and recognized it as "a privacy and HIPAA issue." The facility's charge nurse confirmed that medications should have been secured inside the locked medication cart.
Beyond privacy concerns, leaving medications unattended creates safety risks. Other residents could potentially access and consume medications not prescribed for them, leading to dangerous drug interactions, overdoses, or adverse reactions. Each medication is specifically prescribed based on an individual's medical conditions, allergies, and other medications, making unauthorized consumption particularly hazardous.
Improper Medication Administration Creates Safety Risks
Inspectors documented unsafe medication practices affecting two residents. In one case, a licensed nurse left crushed medication mixed with supplement in a medication cup at Resident 133's bedside, failing to ensure the resident received the complete prescribed dose. The nurse acknowledged that "the importance of giving as much of the medication in the cup was to make sure R133 received the full dose of medication ordered."
A second incident involved Resident 41, whose prescribed medication was left unattended on his bedside table for over an hour. The licensed nurse admitted she "turned her back and did not see Resident 41 take the medication" and acknowledged "it's not safe to leave a medication there."
These medication errors violate fundamental safety principles. Proper medication administration requires the "five rights": right patient, right medication, right dose, right route, and right time. Leaving medications unattended compromises multiple safety checks and creates opportunities for medication errors.
For residents with complex medical conditions like end-stage renal disease or diabetes, missing doses or receiving incomplete doses can have serious health consequences. Kidney patients require precise medication timing and dosing to maintain their condition, while diabetic residents need consistent medication schedules to manage blood sugar levels.
Care Plan Failures and Positioning Protocol Violations
The facility failed to develop and implement proper care plans for residents with identified health issues. Resident 41, who was treated for scabies but continued experiencing intense itching and visible red bumps, had no written care plan addressing his ongoing skin condition. The resident described his symptoms by saying the rashes "overrun me... they're eating me up."
The treatment nurse admitted there was no care plan for the ongoing rash and acknowledged "We should have started a care plan when [the scabies] was first diagnosed and updated [the care plan] as it progressed to see if the interventions were working or not working."
Additionally, inspectors observed Resident 1, who has multiple sclerosis and dementia and was rated at high risk for pressure injuries, remained in the same position for extended periods. The resident was observed lying on her back for over six hours on one day and sitting in a wheelchair for over five hours without repositioning on another day.
A nursing assistant acknowledged the violation, stating "We should have checked her every 2 hours to see if she is wet... she would get a bedsore if she stays up for a long time." The facility's own policy requires repositioning bed-bound residents every two hours and wheelchair-bound residents every hour.
Additional Issues Identified
Inspectors also cited the facility for smoking policy violations, where a cognitively intact resident was allowed to keep cigarettes and a lighter in his room despite facility rules requiring staff supervision and secure storage of smoking materials. The resident was found smoking inside his room, creating fire safety risks for all residents and staff.
The facility's quality assurance committee failed to identify trends in advance directive compliance issues, indicating systemic problems with the facility's internal monitoring and improvement processes.
These violations collectively demonstrate gaps in fundamental nursing home operations, from admission procedures and medication management to care planning and safety protocols. Federal regulations require nursing homes to maintain these standards to ensure resident safety, dignity, and quality of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Castle Manor Convalescent Center from 2025-03-27 including all violations, facility responses, and corrective action plans.
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