Castle Manor Nursing: Repositioning Failures - CA
"She would get a bedsore if she stays up for a long time," the aide, identified in inspection records as CNA 11, told inspectors on March 27, 2025.
The resident, identified only as Resident 1, was already in her wheelchair when the aide arrived at 7:30 that morning. By the time inspectors conducted their interview, it was 9:08 a.m., nearly two hours into the shift. The aide had not repositioned the woman. She had not checked whether she was wet. She had not provided pericare.
"We should have checked her every 2 hours to see if she is wet," CNA 11 said.
The facility's own repositioning policy, last revised in May 2013, sets the standard even higher than that. Residents in bed are to be repositioned at least every two hours. Residents in a wheelchair are to be repositioned every single hour.
Nobody had done either.
The Director of Nursing, interviewed the same morning, did not dispute the standard. "The resident should be repositioned, even if she's in the wheelchair," she told inspectors. "We are trying to prevent the reopening of wounds. We also want to prevent any new wounds."
That phrase, "the reopening of wounds," carries weight. It suggests Resident 1 had existing wounds, injuries already in progress, that required active prevention to keep from getting worse. The inspection record does not describe those wounds in detail. But the Director of Nursing's own words make clear this was not a routine oversight involving a healthy resident. This was a woman with a documented wound history, left to sit without repositioning or hygiene care while the morning passed.
Bedsores, known clinically as pressure injuries, develop when sustained pressure cuts off blood flow to skin and underlying tissue. For residents already managing open wounds, the risk compounds. Tissue that is already compromised heals poorly and breaks down faster under pressure. Moisture from incontinence, left unaddressed, accelerates skin breakdown further.
CNA 11 understood this. She said so directly. The Director of Nursing understood this. She said so directly. The facility's written policy, unchanged since 2013, reflects this understanding in plain language.
The inspection was completed March 27, 2025, the same day inspectors observed and documented the lapse. CMS classified the harm level as minimal harm or potential for actual harm, with few residents affected.
Castle Manor Nursing & Rehabilitation Center operates at 541 V Avenue in National City. The facility did not respond to a request for comment prior to publication.
What the record does not answer is how long this had been the pattern. The inspection captured one morning, one aide, one resident. It documented what CNA 11 said and what the Director of Nursing confirmed. It does not say whether Resident 1's care plan had been followed on previous shifts, whether the wounds the director referenced were new or longstanding, or whether anyone had checked on her before inspectors arrived and asked.
Resident 1 sat in her wheelchair. The shift had been running for over ninety minutes. She had not been moved.
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 10, 2026 · Our methodology
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA was cited for violations during a health inspection on March 27, 2025.
"She would get a bedsore if she stays up for a long time," the aide, identified in inspection records as CNA 11, told inspectors on March 27, 2025.
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.