Castle Manor Nursing: COVID Safety Violations - CA
The therapist emerged from the isolation room on March 26 at 9:23 a.m., holding a walker and face shield while still dressed in the gown, gloves, mask and face shield required for treating the infected resident. Federal inspectors observed the violation during their review of infection control practices at the 541 V Avenue facility.
"I shouldn't have left the room wearing PPE, especially in a Covid room," the therapist told inspectors when confronted about the breach.
The facility was experiencing an active COVID outbreak at the time of the inspection. Director of Nursing acknowledged the severity: "Proper precautions should've been taken. Staff needs to make sure they're taking PPE off inside the room to avoid spreading Covid since we're currently in an outbreak."
Facility policy explicitly requires that protective equipment for transmission-based precautions be removed inside the resident's room. The therapist's actions violated this protocol and put other residents and staff at risk of exposure.
The infection control failures extended beyond COVID protocols. Inspectors documented a licensed nurse providing unsafe care to a resident with acute osteomyelitis, a serious bone infection that develops rapidly.
The nurse, identified as LN 11, wore the same pair of gloves while taking the resident's blood pressure, touching a side table and radio, checking a gastrostomy tube, touching privacy curtains twice, and attempting to unclog the feeding tube. No hand hygiene was performed between any of these activities.
"He should have performed hand hygiene and changed his gloves after touching Resident 34's personal belongings and privacy curtains and before touching Resident 34's G-tube," the nurse admitted to inspectors. "Hand hygiene was important to prevent cross contamination."
The resident required specialized care due to the bone infection. The nurse's failure to follow basic hygiene protocols while manipulating the feeding tube created additional infection risks for an already vulnerable patient.
Multiple facility staff confirmed the violations. The charge nurse stated LN 11 "should have performed hand hygiene and put on a new pair of gloves while providing care and in between touching Resident 34's belongings and privacy curtain to prevent cross-contamination and the spread of infection."
The facility's infection preventionist acknowledged the nurse "should have performed hand hygiene and put on a new pair of gloves after touching Resident 34's environment but did not." The Director of Nursing confirmed the expectation was for proper hand hygiene "in between touching Resident 34's environment and providing care to prevent cross-contamination."
Facility policy requires hand hygiene "after touching a resident" and "after touching the residents' environment." The nurse's actions violated both requirements during a single care episode.
The inspection also revealed systemic problems with the facility's quality assurance program. Administrators admitted their monitoring system failed to identify a pattern of violations with advance directives that federal surveyors discovered during their review.
"The expectation was the QAA Committee should have identified the deficient trend with advanced directives that was identified by the surveyors," the administrator told inspectors. The deficient trend should have been included in the facility's quality improvement plan to "promote the highest standard of care for their residents."
The administrator stated the facility's Quality Assurance and Performance Improvement Committee was monitoring falls and skin care but had missed the advance directive problems entirely. This oversight violated the facility's own policies requiring the committee to "identify, evaluate, monitor, and improve facility systems" and "identify and help to resolve negative outcomes."
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs. The violations at Castle Manor demonstrate failures at multiple levels, from individual staff practices to facility-wide oversight systems.
The COVID protocol breach occurred during a period when the facility should have been especially vigilant about infection control. The therapist's admission that he knew better highlights the gap between policy and practice that put residents at risk.
For the resident with osteomyelitis, the nurse's contaminated gloves could have introduced additional pathogens through the feeding tube, potentially worsening an already serious infection. The resident's compromised condition made proper infection control even more critical.
The quality assurance failures suggest these problems may be more widespread than the specific incidents inspectors observed. A monitoring system that misses entire categories of violations raises questions about what other deficiencies remain undetected and uncorrected.
Castle Manor's infection control violations occurred at a time when nursing homes nationwide faced heightened scrutiny over COVID-19 protocols. The facility's inability to maintain basic safety practices during an active outbreak demonstrates the ongoing challenges in protecting vulnerable residents from preventable infections.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA was cited for violations during a health inspection on March 27, 2025.
Federal inspectors observed the violation during their review of infection control practices at the 541 V Avenue facility.
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.