Castle Manor Nursing: Infection Control Failure - CA
The inspection, conducted on March 26 and 27, 2025, documented a single lapse that four separate staff members, from the nurse himself up through the Director of Nursing, all agreed should not have happened.
The resident at the center of the finding, identified in the report as Resident 34, has a G-tube, a feeding tube inserted directly into the stomach through the abdominal wall. Touching that tube with contaminated gloves creates a direct pathway for bacteria to enter at the insertion site. Inspectors classified the violation as minimal harm or potential for actual harm.
LN 11, the nurse who performed the care, told inspectors during an interview on March 26 that he should have performed hand hygiene and changed his gloves after touching Resident 34's personal belongings and privacy curtain, and before touching the G-tube. He said he understood the reason: cross-contamination.
The next morning, three more staff members said the same thing.
The charge nurse told inspectors that LN 11 should have performed hand hygiene and put on a new pair of gloves while providing care and in between touching the resident's belongings and the privacy curtain. The facility's Infection Preventionist, whose job is specifically to track and prevent the spread of infection inside the building, acknowledged that LN 11 should have changed gloves and cleaned his hands after touching Resident 34's environment, and did not. The Director of Nursing stated the expectation was for LN 11 to perform hand hygiene and change his gloves in between touching the resident's environment and providing care.
Everyone in the chain of oversight gave the same answer. The nurse knew the standard. His supervisor knew it. The person hired to prevent infections knew it. The director responsible for all nursing care knew it. The step was skipped anyway.
Castle Manor's own hand hygiene policy, revised in October 2023, lists specific situations requiring hand cleaning. Among them: after touching a resident, and after touching a resident's environment. The privacy curtain around a bed, the personal items on a nightstand, the surface of a call button, all of it qualifies as the resident's environment under that language.
The gap between what a facility writes in its policies and what happens at the bedside is a recurring problem in nursing home inspections nationwide. A policy revised less than two years before this inspection did not prevent the lapse. Neither did the presence of an Infection Preventionist on staff.
For Resident 34, the specific risk is tied to the G-tube itself. A feeding tube site requires careful handling precisely because it bypasses the body's normal defenses. Skin is the first barrier against infection. The tube goes through it. Gloves touched to curtains and personal items, then pressed to that site without being changed, carry whatever was on those surfaces directly to the opening.
The inspection report does not describe any resulting infection in Resident 34. The violation was rated at the lower end of the harm scale. But the finding is not primarily about what happened to this one resident on this one morning. It is about what the facility's own leadership confirmed was a failure of basic infection control, performed by a nurse who understood exactly what he was supposed to do.
Four people said so. On the record. The day after it happened.
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.
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.
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Last verified: November 5, 2026 · Our methodology
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA was cited for violations during a health inspection on March 27, 2025.
Touching that tube with contaminated gloves creates a direct pathway for bacteria to enter at the insertion site.
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.