Castle Manor Nursing: Medication Privacy Breach - CA
The incident happened on March 26, 2025, at Castle Manor Nursing & Rehabilitation Center, a skilled nursing facility on V Avenue in National City. An inspector conducting a medication administration observation watched Licensed Nurse 11 leave the bubble-wrap packets on the cart outside the resident's room at 10:32 a.m. and walk inside. The packets sat there, unattended and unlabeled with any warning, in a hallway accessible to other residents, visitors, and staff.
The resident, identified only as Resident 181, had been admitted to the facility with a fracture of the superior rim of the right pubic bone. The medications left exposed told a fuller story than that diagnosis alone. Lexapro 5 mg, taken once daily, is prescribed for depression. Losartan 25 mg, once daily, controls blood pressure. Namenda 10 mg, twice daily, is used to treat dementia. Each packet carried the resident's name alongside the drug name and dosage. Together, they disclosed a medical profile the resident had every right to keep private.
When inspectors interviewed LN 11 at 10:45 that morning, the nurse didn't dispute what had happened. He acknowledged he should not have left the packets exposed on the cart. He said he understood it was a privacy violation and a HIPAA issue.
The charge nurse, interviewed the following morning, said the medications should have been locked inside the medication cart before LN 11 entered the room. The Director of Nursing, interviewed that same afternoon, said the same thing. The expectation, the DON explained, was that LN 11 would secure the packets in the locked cart first, then go in to administer the medications. That step didn't happen.
Three separate staff members, the nurse who left the medications out, the charge nurse responsible for the unit, and the facility's top nursing official, all agreed on what should have occurred. All agreed it didn't.
The facility's own confidentiality policy, last revised in October 2017, states that the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Bubble-wrap medication packaging, which organizes individual doses into labeled units, functions as a medical record in miniature. It tells anyone who picks it up or glances at it what a person is being treated for, and how seriously.
Dementia is not a diagnosis most people choose to share openly. Depression carries its own weight. A resident living in a nursing facility has already surrendered a great deal of privacy simply by being there, sharing rooms and common spaces, receiving intimate care from strangers. The medications left on that cart represented what little remained confidential about Resident 181's inner life and medical history.
Federal inspectors cited the violation as causing minimal harm, the lowest level on CMS's harm scale. That classification reflects the absence of documented physical injury, not a judgment about the significance of what was exposed. Resident 181's name was on those packets. So was the fact of their dementia.
The inspection was completed March 27, 2025. Castle Manor has not publicly responded to the findings.
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: October 31, 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 incident happened on March 26, 2025, at Castle Manor Nursing & Rehabilitation Center, a skilled nursing facility on V Avenue in National City.
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.