Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradley Court during CMS and state inspections, most recent first.
The facility failed to ensure proper food storage and sanitation practices, as a cut onion was undated and stored improperly, and whipped topping was kept 11 days past its use-by date. Additionally, pipes were observed extending directly into a floor drain without the required air gap, violating the FDA Food Code.
A facility's medication error rate was found to be 7.69%, exceeding the acceptable threshold. Errors involved two residents: one received vitamin C without a specified dose, and another received vitamin D3 with a misinterpreted measurement unit. The errors highlight the importance of verifying medication details to ensure proper administration.
The facility failed to keep the medication storage room free of staff's personal belongings and food, risking contamination and oversight issues. A licensed nurse confirmed the presence of personal items and food in the room, which should not be stored there, especially with controlled drugs. The DON emphasized the importance of keeping the area free from personal items and food to prevent drug diversion and pest infestation.
A facility was found non-compliant with regulations limiting the number of residents per room, as room [ROOM NUMBER] in Building 2 housed six residents instead of the maximum allowed four. Despite this, no quality of care or life issues were identified, and a waiver continuance was recommended.
The facility did not meet the minimum room size requirements for six resident rooms across two buildings. In Building 1, four rooms with two residents each provided only 75 sq. ft. per resident. In Building 2, two rooms with four residents each provided 64.5 and 66.75 sq. ft. per resident. Despite these deficiencies, there was no adverse effect on residents' health, safety, or quality of life during the survey.
A resident with schizophrenia and psychosis eloped from an LTC facility by using a trash bin to climb over a fence. The resident's care plan noted a risk of elopement but failed to identify potential tools for elopement, such as the trash bin. Staff last saw the resident at 10:10 A.M., and the incident was discovered during a headcount at 10:45 A.M. Surveillance footage confirmed the resident's actions, and the DON acknowledged the high risk of elopement among residents.
The facility failed to ensure food was served in a sanitary manner, as the cook did not change gloves or wash hands after touching potentially contaminated surfaces, leading to potential food contamination.
The facility failed to accurately code the MDS for two residents, leading to potential inaccuracies in their individualized plans of care. Both residents were observed using bed rails without restriction, but their MDS were incorrectly coded as restraints. The MDSN admitted unfamiliarity with the RAI manual's definition of a restraint, and the DON confirmed the coding errors.
The facility failed to re-evaluate the PASRR for a resident with schizoaffective disorder after discontinuing isolation for COVID-19. Despite the resident hearing voices, a Level II mental health evaluation was not scheduled. The MDSN and DON acknowledged that a PASRR Level I should have been re-submitted due to the change in the resident's condition.
The facility failed to develop and implement a comprehensive care plan for a resident with severe right knee pain. Despite the resident's pain and discontinuation of a knee brace, the care plan was not updated to address these issues, contrary to the facility's policy.
The facility failed to provide Trauma Informed Care for a resident with PTSD, as staff were unaware of the resident's specific triggers and did not include them in the care plan. This oversight led to the inability to prevent re-traumatization, despite the facility's policy emphasizing the importance of understanding and responding to trauma.
A facility failed to accurately record a resident's discharge date, leading to incorrect transmission of the discharge information to the federal database. The MDS Nurse confirmed the error, and the Director of Nursing emphasized the need for accurate data according to the RAI-MDS manual.
The facility failed to ensure that a resident room in Building 2 accommodated no more than four residents, as required by regulations. During a survey, it was observed that the room housed six residents. The Administrator confirmed the over-occupancy and provided a waiver permitting the six-bed room. No quality of care or quality of life concerns were observed.
The facility did not meet the minimum room size requirement of 80 square feet per resident in multiple resident rooms and 100 square feet for single resident rooms. In Building 1, Rooms 2, 3, 4, and 5, and in Building 2, certain rooms were below the required square footage per resident. Despite this, the variations in room size were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. The facility administrator confirmed the room sizes and presented a waiver from CMS for the affected rooms.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices in the kitchen, as observed during a survey. A cut onion was found undated and wrapped in clear plastic, stored in a bin with uncut onions, contrary to the facility's policy requiring all food items to be labeled and dated. The Food Service Director (FSD) was unable to confirm when the onion was cut or how long it had been stored, indicating a lapse in following the labeling policy. Additionally, whipped topping was found stored in the refrigerator 11 days past its use-by date, which the FSD acknowledged should have been discarded to prevent potential health issues such as diarrhea. Furthermore, the survey identified a sanitation issue with the floor sink drain under the dishwashing machine, where pipes were observed extending directly into the floor drain without the required air gap. This setup violates the 2022 Federal FDA Food Code, which prohibits direct connections between the sewage system and drains originating from food equipment. These deficiencies in food storage and sanitation practices exposed residents to potential risks of foodborne illness and unsanitary conditions.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 7.69%. During the medication administration process, two errors were identified involving two residents. Resident 52, who has diabetes mellitus and schizoaffective disorder, was administered vitamin C without a specified dose on the medication administration record (MAR). The licensed nurse (LN) responsible for the administration acknowledged the oversight and the importance of verifying the correct dose to prevent potential health decline and ensure compliance with doctor's orders. Resident 5, diagnosed with vitamin D deficiency and obesity, received vitamin D3 from a bottle labeled with the correct dosage. However, the LN misinterpreted the measurement unit on the MAR, assuming 'UT' was equivalent to 'units', which was incorrect. The facility's contracted pharmacist confirmed that vitamin D3 should be dosed in International Units, not 'UT'. The Director of Nursing emphasized the necessity of administering the correct dose to avoid side effects, aligning with the facility's medication administration policy that mandates verification of the right resident, medication, and dosage before administration.
Medication Storage Room Contamination
Penalty
Summary
The facility failed to ensure that the medication storage room was free of staff's personal belongings and food, which could lead to contamination and lack of oversight for medications stored there. During an observation and interview with a licensed nurse, it was noted that the medication storage room contained staff's personal items, including two large purses, a box of donuts, and a large carafe of coffee. The licensed nurse acknowledged that these items belonged to staff and not to any residents, and confirmed that personal belongings should not be stored in a medication storage room, especially one that contains controlled drugs. The Director of Nursing also confirmed that personal belongings and food should not be stored in the medication storage area to prevent drug diversion and pest infestation. The facility's policy on medication labeling and storage requires that medication storage areas be maintained in a clean, safe, and sanitary manner, and that medications be stored separately from food.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with regulations regarding the maximum number of residents per room. During an initial tour of Building 2, it was observed that room [ROOM NUMBER] contained six resident beds, exceeding the allowable limit of four residents per room. This observation was confirmed during a review of the facility's Analysis of Accommodations, which also indicated that six residents were housed in the room. Despite this non-compliance, no quality of care or quality of life issues were identified for the six residents residing in the room. Consequently, a continuance of a waiver allowing the six-bed room was recommended.
Room Size Deficiency in Resident Accommodations
Penalty
Summary
The facility failed to meet the minimum room size requirements for resident accommodations in Building 1 and Building 2. Specifically, six out of twenty-four resident rooms did not comply with the mandated space of at least 80 square feet per resident in multiple occupancy rooms. In Building 1, four rooms with two residents each provided only 75 square feet per resident, totaling 150 square feet per room. In Building 2, two rooms with four residents each provided 64.5 and 66.75 square feet per resident, totaling 258 and 267 square feet respectively. Despite these deficiencies, the variations in room size did not adversely affect the residents' health, safety, quality of care, or quality of life during the survey. A continuance of the room size waiver for all affected rooms was recommended.
Resident Elopes Using Trash Bin Due to Inadequate Supervision
Penalty
Summary
The facility failed to identify a trash bin as a potential means for a resident to elope, leading to an incident where a resident with schizophrenia and psychosis left the facility unnoticed. The resident, who was admitted for a Special Treatment Program and had a history of elopement, used the trash bin to climb over a fence. The resident's care plan noted the risk of elopement but did not include measures to identify and mitigate potential elopement tools like the trash bin. On the day of the incident, the resident was last seen by staff at around 10:10 A.M. and was not accounted for during a headcount at 10:45 A.M. Surveillance footage showed the resident moving the trash bin to the shed and using it to jump the fence. Interviews with staff revealed that the trash bin was left near the shed by kitchen staff, and the facility's policy on elopement did not prevent this incident. The Director of Nursing acknowledged that all residents were at high risk for elopement, but the trash bin's placement was not adequately controlled.
Inadequate Food Handling Practices
Penalty
Summary
The facility did not ensure food was served in a sanitary manner, as observed during a tray line inspection. The cook was seen handling meatloaf and garlic bread with gloved hands, but did not change gloves or wash hands after touching potentially contaminated surfaces such as the oven handle and a pizza slicer. Despite being instructed by the Dietary Supervisor (DS) to change gloves, the cook continued to use the same gloves, thereby risking contamination of the food being served. The Director of Nursing (DON) confirmed that this was an infection control issue and that the food was contaminated as a result. The facility's policy and procedure on food handling, dated 2023, requires that food be prepared and served in a safe and sanitary manner. The 2022 US FDA Food Code also mandates that hands must be washed after any activity that may result in contamination. The cook's failure to follow these guidelines led to the potential contamination of food, putting residents at risk for foodborne illness and bacterial contamination.
Inaccurate MDS Coding for Physical Restraints
Penalty
Summary
The facility failed to accurately code the MDS for two residents, leading to potential inaccuracies in their individualized plans of care. Resident 11, who was admitted with hemiplegia and hemiparesis following cerebrovascular disease, was observed using a 1/4 length bed rail to assist in getting in and out of bed independently. However, the MDS for Resident 11 incorrectly coded the bed rail as a physical restraint. The MDSN acknowledged the error during a joint record review and interview, stating that the MDS should not have been coded as a restraint since the resident was not restricted by the bed rail. The DON confirmed that the MDS should accurately reflect the resident's care and needs, and that the bed rail should not have been coded as a restraint. Similarly, Resident 5, who was admitted with a history of arthritis, was observed getting out of bed without restrictions and stated that the bed rails did not hinder his movement. Despite this, the MDS for Resident 5 was also incorrectly coded as a restraint. The MDSN admitted unfamiliarity with the RAI manual's definition of a restraint and acknowledged the coding error. The DON reiterated that the MDS should accurately reflect the resident's status and that the bed rails should not be coded as restraints if they do not restrict the resident's movement. The facility's policy on physical restraints and the CMS RAI manual were reviewed, both indicating that equipment restricting resident mobility should be considered restraints, which was not the case for these residents.
Failure to Re-Evaluate PASRR After Discontinuation of Isolation
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review Level I (PASRR) was re-evaluated after a resident's isolation was discontinued. Resident 9, who was admitted with schizoaffective disorder, was observed sitting alone and speaking in a low voice. A Certified Nursing Assistant (CNA) reported that Resident 9 heard voices, including those of razor blades inside her body and her family hurting her. Despite these symptoms, a Level II mental health evaluation was not scheduled because the resident was initially isolated for COVID-19. The Minimum Data Set Nurse (MDSN) acknowledged that another PASRR Level I should have been completed when the isolation was discontinued, as it constituted a change in the resident's condition. The Director of Nursing (DON) confirmed that a PASRR Level I should be re-submitted if there is a change in a resident's condition. The facility's policy and procedure, titled
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive patient-centered care plan for Resident 48, who was admitted with diagnoses including abnormalities of gait and mobility. On 5/14/24, Resident 48 reported severe right knee pain, which was not adequately addressed in her care plan. Despite the resident's pain level being ten out of ten, dropping to seven after medication, there was no individualized care plan for her knee pain. The licensed nurse (LN 1) confirmed that the care plan initiated on 12/1/23 did not include specific measures for the resident's knee pain, and the Director of Rehabilitation (DOR) was unaware of the resident's ongoing knee pain issues after her discharge from physical therapy in March 2023. The resident had also stopped using her knee brace due to increased pain, which was not documented or addressed in her care plan. Further interviews revealed that the care plan should have been updated to reflect the resident's current condition and needs. The Director of Nursing (DON) acknowledged that the care plan did not include the resident's refusal to use the knee brace or her right knee pain. The facility's policy and procedure for developing and implementing comprehensive care plans, revised in March 2018, mandates that care plans must be person-centered and address all medical, physical, mental, and psychosocial needs. The policy also requires documentation of any declined care or treatment and efforts by the interdisciplinary team to educate the resident and find alternative solutions. These requirements were not met in the case of Resident 48, leading to the identified deficiency.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that Resident 48 received Trauma Informed Care (TIC), which is crucial for individuals with a history of trauma such as post-traumatic stress disorder (PTSD). Resident 48, who was admitted with a diagnosis of PTSD, was observed sitting in her room with a flat affect. Interviews with various staff members, including a CNA, LN, and SSD, revealed that they were either unaware of the resident's PTSD diagnosis or did not know the specific triggers that could lead to re-traumatization. The resident herself mentioned experiencing multiple traumatic events, including the death of her husband in a fire, and indicated a preference for keeping the light on at night without explaining why. This lack of awareness and understanding among the staff about the resident's triggers and needs indicates a failure to provide appropriate TIC. The Director of Nursing (DON) confirmed that it was the facility's policy to identify PTSD triggers and include them in the resident's care plan to prevent re-traumatization. However, a review of the facility's policy and procedure on Trauma-Informed and Culturally Competent Care showed that the staff did not follow these guidelines. The policy emphasized the importance of understanding and responding to the effects of trauma, including the identification of triggers, but this was not implemented in the care of Resident 48. This oversight resulted in the facility's inability to provide the necessary care to prevent re-traumatization for the resident.
Inaccurate Recording of Resident Discharge Date
Penalty
Summary
The facility failed to accurately record the discharge date of a resident, leading to an incorrect transmission of the discharge date to the federal database. Specifically, Resident 47, who had a history of bipolar disorder, was discharged on 5/8/24, but the MDS (Minimum Data Set) indicated a different discharge date. This discrepancy was identified during a record review on 5/15/24, where it was noted that the progress note correctly documented the discharge on 5/8/24, but the MDS dated 5/7/24 incorrectly reflected the discharge date. The MDS Nurse (MDSN) confirmed the error and acknowledged the importance of accurate MDS data to avoid confusion regarding the resident's discharge status. During an interview, the Director of Nursing (DON) emphasized the expectation for the MDSN to provide accurate information according to the Resident Assessment Instrument (RAI-MDS manual). The facility's policy and procedures, dated November 2017, also indicated that the MDS Nurse is responsible for ensuring appropriate edits are made before transmitting MDS data. The incorrect discharge date in the MDS was a clear deviation from these guidelines, resulting in the inaccurate transmission of Resident 47's discharge information to the federal database.
Room Occupancy Exceeds Regulation
Penalty
Summary
The facility failed to ensure that one of the resident rooms in Building 2, room five, accommodated no more than four residents as required by regulations. During a survey conducted from 5/14/24 to 5/17/24, it was observed that room five in Building 2 housed six residents. An interview with the Administrator (ADM) confirmed that the room had two more residents than allowed by regulation. The ADM provided a copy of a waiver that permitted the six-bed room, and the continuance of this waiver was recommended. There were no observed quality of care or quality of life concerns negatively impacting the residents in this room.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility did not meet the minimum room size requirement of 80 square feet per resident in multiple resident rooms and 100 square feet for single resident rooms. Specifically, in Building 1, Rooms 2, 3, 4, and 5, and in Building 2, certain rooms were found to be below the required square footage per resident. The Client Analysis of Accommodations indicated that six out of 24 resident rooms did not meet the minimum room size requirement. Despite this, the variations in room size were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. The facility administrator confirmed the room sizes and presented a waiver from CMS for the affected rooms.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 598 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Cajon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottonwood Canyon Healthcare Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Granite Hills Healthcare & Wellness Centre, Llc | 1.7 mi | ★★★★★ | 3 | 0 |
| The Royal Home | 1.8 mi | ★★★★★ | 35 | 0 |
| Somerset Subacute And Care | 1.8 mi | ★★★★★ | 2 | 0 |
| Country Hills Post Acute | 1.9 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.