Complaint Investigation

Broadway Villa Post Acute

September 8, 2025 · Sonoma, CA · 1250 Broadway

Citations 1

CMS Rating 5/5

Beds 144

Provider ID 055987

Healthcare Facility

Broadway Villa Post Acute

Sonoma, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

BROADWAY VILLA POST ACUTE in SONOMA, CA — inspection on September 8, 2025.

Found 1 citation. 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

FF0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Potential for More Than Minimal Harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse for one resident (Resident 1) when Resident 2 pushed and hit Resident 1.This failure resulted in Resident 1 sustaining two skin tears.Findings:A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, and a need for assistance with personal care.A review of an admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis which included unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia, and muscle weakness.A review of Resident 1's progress note dated 8/17/25 at 7 a.m. indicated, .[Resident 1] stated, '[Resident 2] had pushed me and punched me as I was falling.' [Resident 1] noted with new skin tears to Left Elbow (2 cm [centimeters, a unit of measurement] x [by] 2 cm) and Right forearm (1 cm x 0.5 cm) .A review of Resident 2's progress note dated 8/17/25 at 7 a.m. indicated, .Resident [2] redirected and asked if she hit [Resident 1]. [Resident 2] stated, 'yes.'In an interview on 9/8/25 at 12:48 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) both the DON and ADON acknowledged Resident 2 did hit Resident 1.A review of the facility's policy and procedure titled Resident Rights .Abuse Prevention revised November 2023 indicated, It is the policy of this facility that each resident has the right to be free from abuse .Resident must not be subjected to abuse by anyone, including, but not limited to .other residents .Abuse is defined as the willful infliction of injury .This presumes that instances of abuse of all residents, even those in a coma, cause physical harm .

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.

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Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SONOMA, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BROADWAY VILLA POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.