Castle Manor Nursing: Scabies Care Plan Failure - CA
The resident, identified in inspection records only as Resident 41, lifted his shirt for a state inspector on the morning of March 24. The bumps were visible across his upper body. He told the inspector the facility had given him scabies and that the mites were "hearty little suckers." He said he had been treated, but the intense itching had never stopped.
"These rashes overrun me," he said. "They're eating me up."
Resident 41 is cognitively intact, scoring a 15 out of 15 on the facility's cognitive assessment. He knew what had happened to him. He could describe it clearly. What he could not do was make the facility write down a plan to address it.
Two days after that observation, a Treatment Nurse sat down with the inspector for a joint interview and record review. The nurse confirmed he knew Resident 41 had been treated for scabies. He did not know the man was still itching. When the inspector checked the records, there was nothing there — no written care plan addressing the rash at all.
The Treatment Nurse did not dispute what that meant. "We also need to update it as needed," he told the inspector. "If the original plan isn't working, if he is still itching, we should have updated it to help the resident."
The Director of Nursing said the same thing the following morning, on March 27, the last day of the inspection. She told the inspector that Resident 41 should have had a care plan from the moment scabies was first diagnosed in January, and that the plan should have been updated as his condition changed — to track whether the treatment was working or not working. It was not a defense. It was a confirmation of what had not happened.
Scabies is caused by a microscopic mite that burrows into skin and lays eggs, producing an allergic reaction that causes relentless itching, often worse at night. Treatment can kill the mites, but the itching sometimes continues for weeks afterward as the body reacts to the dead mites and their waste. Without ongoing monitoring and a documented plan, there is no mechanism to determine whether a resident's symptoms are resolving, worsening, or requiring a different approach. The risk is not just discomfort. Persistent scratching can break the skin, opening the door to secondary infection.
Castle Manor's own care plan policy, last revised in March 2022, states that a comprehensive, person-centered care plan must be developed and implemented for each resident, and that assessments are ongoing, with care plans revised as a resident's condition changes. Resident 41 had been in the facility's care since his diagnosis. The condition had changed. Nobody revised anything, because nobody had started anything to revise.
The inspection was conducted on March 27, 2025. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. Castle Manor, located at 541 V Avenue in National City, was one of twenty-two residents sampled during the survey.
Resident 41 was still there when the inspectors left. Still itching. Still without a written plan.
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 29, 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 resident, identified in inspection records only as Resident 41, lifted his shirt for a state inspector on the morning of March 24.
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.