Casa de las Campanas: Wrong Medication Route Given - CA
The incident at Casa de las Campanas, a senior living facility in San Diego, came to light through a complaint filed in November 2024. Federal inspectors arrived to investigate on August 14, 2025, and what they found was straightforward: a staff member gave medication to a resident through the wrong route entirely.
The resident, identified in inspection records only as R1, was on tube feeding. Her attending physician had ordered that she receive nothing by mouth. That order existed for a reason. Aspiration, the process by which food or liquid enters the airway instead of the stomach, is a serious and sometimes fatal risk for patients on tube-feeding regimens. The physician's order was a safeguard against exactly that kind of harm.
Someone bypassed it.
When inspectors interviewed R1's attending physician on July 30, 2025, the doctor did not minimize what had happened. The physician said the incident had the potential for a very bad outcome. The doctor added that R1 was seen the following day and was okay. The word "potential" did not soften the gravity. A physician describing a medication error as carrying potential for a very bad outcome is not using routine clinical language. It is a warning about how close things came to going wrong.
The facility's own written policy, last updated in April 2019, spelled out exactly what staff are required to do before giving any medication to any resident. The policy requires checking the resident's identity first, using an identification band, a photograph attached to the medical record, or confirmation from other staff if necessary. It then requires checking the medication label three times, verifying the right resident, the right medication, the right dosage, the right time, and the right method of administration before giving anything.
Three times. The policy says three times.
Inspectors cited the facility under federal tag F0760, which addresses medication errors and requires that residents are free from significant medication errors. The level of harm was recorded as minimal harm or potential for actual harm, and the citation noted that few residents were affected. In the language of federal nursing home inspections, that classification sits below the most serious tiers. It does not mean the error was minor. It means, in this case, that the resident survived without documented lasting injury.
What the inspection record does not contain is an explanation for how the error happened. There is no account of which staff member administered the medication, no description of what the medication was, and no detail about what specifically caused someone to give a tube-fed resident something by mouth. The record does not say whether the person who administered the medication checked the identification band. It does not say whether they checked the label once, let alone three times.
What the record does say is that the policy requiring those checks existed and that the checks, whatever form they took, did not prevent this from happening.
Facilities that care for residents on tube feeding carry a specific and well-understood responsibility. Those residents cannot protect themselves from what enters their mouths. They depend entirely on the people caring for them to read the orders, follow the orders, and catch mistakes before those mistakes reach the bedside.
R1's physician saw her the day after the incident and found her okay. That outcome was not guaranteed when the medication was given.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa De Las Campanas from 2025-08-14 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 4, 2026 · Our methodology
CASA DE LAS CAMPANAS in SAN DIEGO, CA was cited for violations during a health inspection on August 14, 2025.
The incident at Casa de las Campanas, a senior living facility in San Diego, came to light through a complaint filed in November 2024.
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.