Skip to main content
Advertisement
Complaint Investigation

Broadway Villa Post Acute

Inspection Date: September 8, 2025
Total Violations 1
Facility ID 055987
Location SONOMA, CA
Advertisement

Inspection Findings

F-Tag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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 REDACTED] 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 REDACTED] 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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

BROADWAY VILLA POST ACUTE in SONOMA, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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.
« Back to Facility Page
Advertisement
Advertisement