Castle Manor Nursing: Medication Left Unattended - CA
The resident, identified in the inspection report as Resident 41, is a man who was readmitted to Castle Manor Nursing & Rehabilitation Center with Type 2 diabetes and diabetic neuropathy. He was fully cognitively intact, scoring a perfect 15 on the facility's cognition assessment. He knew exactly what the pill was and where it came from.
"The nurse brought it here and put it on my table," he told an inspector on March 26, 2025. "I just forgot to take it earlier."
The nurse, identified as Licensed Nurse 5, had brought the capsule to his room at 1 p.m. She told inspectors she turned her back and did not watch him take it. By the time an inspector noticed the medicine cup sitting on his bedside table at 2:07 p.m., the medication had been sitting there for over an hour, unswallowed and unattended.
The nurse did not minimize what had happened. "I should have made sure that he swallowed it, to make sure that he took it, to make sure he got the proper dose of the medication," she told inspectors. She also noted the table was positioned close to the room's door. "We don't want anyone else to take it," she said. "It's not safe to leave a medication there."
She acknowledged the medication was now being given late.
The Director of Nursing, interviewed the following morning, was equally direct. Medications should never be left with a resident, she said, because there was no way to confirm the resident had actually taken them. She told inspectors it was important that nurses remain with residents until the medication was swallowed, specifically because another resident could walk in and take it.
That concern is not theoretical in a nursing facility. Residents move through shared spaces and into each other's rooms. A loose capsule in a medicine cup on a table near an open door is accessible to anyone who passes by, including residents who may not be cognitively intact, who may not know what the medication is, or who may be on drugs that would interact badly with whatever was in that cup.
The inspection report does not identify what medication was in the capsule.
Castle Manor's own written policy, in place since 2001, states that medications are to be administered in a safe and timely manner and as prescribed. Leaving a capsule on a table and walking away satisfies none of those three conditions. The medication was not confirmed administered. It was not timely, arriving late. And it was not given as prescribed, because it was not given at all.
The deficiency was cited at the level of minimal harm or potential for actual harm, affecting a small number of residents. Federal inspectors completed their review on March 27, 2025.
What the inspection report captures is a gap between what a facility's policies require and what happens in a resident's room when a nurse is busy and a table is right there and it seems easier to set the cup down and move on. The nurse knew it was wrong. The Director of Nursing knew it was wrong. The policy written in 2001 knew it was wrong.
The capsule sat on the table anyway, in a plastic medicine cup, next to an open door, for more than an hour, while Resident 41 waited and forgot and a federal inspector eventually walked in and found it still there.
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 2, 2026 · Our methodology
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA was cited for violations during a health inspection on March 27, 2025.
He was fully cognitively intact, scoring a perfect 15 on the facility's cognition assessment.
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.