Castle Manor: Resident Found Smoking in Room - CA
That was the second time it had happened.
The first incident was documented on December 26, 2024. A social services assistant and a charge nurse went to Resident 41's room and found him still smoking when they arrived. He handed over his cigarette and his lighter when asked, and told staff he thought he was outside. The social services assistant explained that smoking was only allowed at the designated outdoor area and that he would need to ask the charge nurse to accompany him there. He said he understood. Staff took his cigarette and his lighter and left.
His cigarettes were not secured at the nursing station. No interdisciplinary team meeting was called.
By March 27, 2025, when a federal inspector walked through the facility, Resident 41 was smoking in his room again. This time, the nurse on duty, identified in inspection records as LN 14, called the social services assistant, who came and took his cigarettes. But when the inspector spoke with LN 14, the nurse acknowledged she had not removed the cigarettes from his room herself after the incident.
"I forgot to remove the cigarettes from his room," LN 14 told the inspector. "We all need to be on the same page on what is the action for him. We should have done an IDT. It wasn't safe. He can hurt himself and others."
An interdisciplinary team, or IDT, is the group of clinical and support staff responsible for coordinating a resident's care plan. No IDT note existed in Resident 41's electronic health record for either smoking incident.
A review of his records found something else missing. Castle Manor's own smoking policy requires that residents who smoke be evaluated upon admission, with the assessment covering whether they can smoke safely with or without supervision, and that smoking materials be stored at the nursing station. Resident 41 had a smoking risk assessment completed on January 15, 2025, but there was no assessment from when he was first admitted, and none from when he was readmitted.
The Director of Nursing, interviewed the morning of the inspection, did not dispute any of it.
"We should have addressed the smoking, make sure we documented what we did about it," the director told the inspector. "The IDT should have been notified to keep him and other patients safe."
The facility's own undated smoking policy states that smoking inside the building is not allowed "under any circumstances."
Between December and March, Resident 41 had been found smoking indoors twice, his cigarettes had not been consistently secured, no team meeting had been convened to address his behavior or update his care plan, and the safety assessments that should have been completed when he arrived at the facility had never been done. A nurse who responded to the second incident left his room without taking the cigarettes with her.
The inspector cited the deficiency at a level of minimal harm or potential for actual harm. The violation affected a small number of residents.
What it did not resolve was the question of what would happen the next time Resident 41 decided he thought he was outside.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA was cited for violations during a health inspection on March 27, 2025.
That was the second time it had happened.
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.