Castle Manor Nursing & Rehabilitation Center
CASTLE MANOR NURSING & REHABILITATION CENTER in NATIONAL CITY, CA — inspection on March 27, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the recertification survey, deficient trends in Advanced Directives were identified by surveyors.
The ADM stated that this trend had not been identified by the QAA Committee and/or included in the QAPI plan.
On 3/27/25 at 2:30 P.M., an interview with the ADM was conducted.
The ADM stated that the expectation was the QAA Committee should have identified the deficient trend with advanced directives that was identified by the surveyors during recertification survey. In addition, the ADM stated the deficient trend should have been included in the QAPI plan.
The ADM stated the importance of QAA Committee identifying deficient trends and including them in the QAPI plan was to promote the highest standard of care for their residents.
Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership dated March 2020, indicated .4.
The responsibilities of the QAPI committee are to: .b.
Identify, evaluate, monitor, and improve facility systems and processes that support delivery of care and services; c.
Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process .
Review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, indicated .Implementation .The QAPI plan describes the process for identifying and correcting quality deficiencies.
Key components include .c.
Identifying and prioritizing quality deficiencies .
Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action, dated March 2020, indicated .1.
The QAPI program, overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level .
555263
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555263 B.
Wing 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950
Review of Resident 12's (R12) Admission Record dated 3/26/25 indicated R12 was admitted for diagnoses which included: Acute Respiratory Failure(a life-threatening condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Asthma(a chronic lung disease), Congestive Heart Failure(a chronic condition where the heart muscle is weakened and cannot pump blood effectively), Myocardial Infarction( another term for heart attack)and Pneumonia(an infection of the lungs).
Review of R12's physician orders dated 3/26/25 indicated .Resident is (Capable) Of Understanding Rights, And Informed Consent.
Review of R12's Minimum Data Set (MDS-standardized assessment tool used in Medicare and Medicaid certified nursing homes) Section C, dated 3/2/25, indicated that R12's Brief Interview for Mental Status (BIMs-a screening tool used to assess memory and orientation in nursing homes) was scored 15 which indicated intact cognition (thinking processes).
Review of R12's Care Plan Report dated 3/26/25 indicated, .Resident has the right to .formulate an advance directive .Offer the opportunity for resident .to review/complete POLST (Physician Orders for Life-Sustaining Treatment-It is a medical document that outlines a patient's wishes regarding end-of-life care) form with Physician/Nurse Practitioner as needed .
On 3/24/25 at 8:30 A.M., a record review of the electronic medical record (EMR-computer based charting) was conducted for R12. No advanced directive or POLST were in the EMR.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555263
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555263 B.
Wing 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950