Broadway Villa Post Acute
BROADWAY VILLA POST ACUTE in SONOMA, CA — inspection on February 27, 2026.
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
interventions should include a low bed and the placement of fall mats. LN 1 was not sure if any fall
Assistant Director of Nursing (ADON) and the Administrator (ADM) on 2/27/26 at 2:40 p.m., the
blank, the ADM stated Resident 1's fall risk score was 10, which placed Resident 1 at a moderate risk to fall prior to his fall on 2/13/26.
Neither the ADON nor the ADM were able to provide documentation of Resident 3 having been placed on a toileting schedule as per Resident 1's revised 2/13/26 care plan.
Furthermore, this surveyor notified the ADM and the ADON there were no fall mats in Resident 1's room as per revised 2/13/26 fall care plan.
The ADM and ADON reviewed Resident 2's interventions listed in her care plan regarding her fall risk.
The ADM and ADON were then shown a picture of Resident 2's slippers found at her bedside which had no grip on the soles which she stated she used.
The ADM and ADON were also notified that a bedside commode was not observed at bedside or in Resident 2's bathroom as indicated in her care plan.
The ADM and ADON reviewed Resident 3's interventions listed in her care plan regarding her fall risk.
The ADM and ADON were notified no fall mats were observed on either side of Resident 3's bed and Resident 3's call light was difficult to find.
The ADM stated nursing staff were encouraged to use resident care plans but added he cannot say how often they are used.A review of the facility's policy and procedure titled Falls and Accidents Prevention revised November 2022 indicated, Purpose.To investigate the circumstances surrounding each resident fall.and implement actions to reduce/prevent the incidence of additional falls.and minimize potential for injury.
055987 02/27/2026
Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476
administered the oxycodone at 7:16 a.m., resulting in Resident 4 experiencing unmanaged, severe pain
went away. Resident 4 stated her pain level was consistently elevated during her first two days at
experience pain like that again. Resident 4 stated she has never cared to take acetaminophen pain relief medication, as she felt it never worked for her. Resident 4 did accept the ice pack as ordered but stated it really did not have any effect on her pain level. Resident 4 stated, The experience was physically and mentally detrimental to my healing.
During an interview at the nursing station on 2/27/26 at 10:46 a.m., LN 2 stated if pain medication was ordered but not received at the facility, he would get a code from the pharmacy to open the E-kit. LN 2 further stated if he were unable to obtain the medication, he would notify the Director of Nursing (DON), the Assistant DON (ADON), or the Unit Manager. LN 2 stated the LN should notify the physician that the resident was unable to receive the ordered medication especially if the resident's pain could not be relieved.
During an interview on 2/27/26 at 10:55 a.m., LN 3 stated narcotics were kept in the electronic E-kit. LN 3 stated if ordered medications did not arrive with the next medication delivery, LN 3 would call the pharmacy to find out why medication was not delivered, notify the physician of the situation and obtain different orders.
During an interview with the DON, ADON, and the Administrator (ADM) on 2/27/26 at 2:40 p.m., the DON and the ADON confirmed they had not been notified that Resident 4 had been experiencing unrelieved pain on the evening of 2/4/26, nor the early morning of 2/5/26.
Both the DON and ADON acknowledged staff failed to escalate the clinical situation or seek assistance with pharmacy delays when Resident 4 continued to report severe pain.
The ADM stated he would have offered to send Resident 4 back to the hospital due to her uncontrolled pain.During a phone interview on 2/27/26 at 3:52 a.m., the physician (MD) stated he did not want any of his residents in pain. If staff are unable to obtain pain medication for a resident, I would want them to call me.
The MD stated it was not good physically or mentally for a resident to have unrelieved pain.A review of the facility's policy titled Recognition and Management of Pain, dated January 2020, indicated, It is the policy of this facility that pain management is provided to residents that require such services, consistent with professional standards of practice.and the resident's goals and preferences.If the pain management program is not effective, the licensed nurse will contact the resident's physician.Consult physician for additional interventions if pain is not relieved by current orders.A review of the facility's policy titled E-Kit, dated November 2023, indicated, It is the policy of this facility to maintain an Emergency Kit (E-KIT) containing essential medication and supplies to ensure timely and appropriate care for residents when medications are urgently needed and cannot be obtained from the pharmacy in a reasonable timeframe.
The E-KIT may be used for.Situations where a delay in medication therapy could cause harm to the resident.Purpose.To support timely intervention, reduce risk of complications and maintain continuity of care.