Health inspection·October 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to wait for staff to answer their call light, CR 4 stated fifteen to twenty minutes or longer. When other confidential residents were asked if they too had to wait an extended period of time for staff to answer their call light, six out of nine residents raised their hand (indicating they had to wait). CR 9 stated that sometimes staff, never answered the call light. CR 9 stated sometimes she had seen a hand reach in (inside the door) and turn the call light off (without the staff member entering the room or asking what she needed). When asked how many other residents had experienced having their call light, never answered, but seeing a hand turn off the light (without staff entering the room or asking about needs), eight out of nine residents raised their hands (indicating they had the same experience). CR 4 stated she thought staff did not want to get in trouble for leaving the call light on. When asked how this experience made them feel, CR 5 stated, lousy, and CR 7 stated, angry. CR 11 stated this made her, mad and stated, They are here to help us. When asked if call light response time had improved in the past few months as the issue was documented on the Resident Council minutes (notes from an organized group of residents who meet regularly, with staff, to discuss/address concerns about their rights, quality of care and quality of life), CR 4 stated, No and stated staff have told her the reason was they were short on staff. CR 11 stated staff were inconsistent and have, no system they follow (when responding to call lights). During an interview on 10/20/23 at 10:16 a.m., Unlicensed Staff A stated, when a resident pressed their call light for assistance, his goal was to answer right away, or if he was already helping someone, to answer as soon as he was done. When queried, Unlicensed Staff A stated one hour was too long for a resident to have to wait for assistance. During an interview on 10/20/23 at 10:19 a.m., Licensed Staff B stated it was her expectation that staff answered call lights immediately. Licensed Staff B verified one hour was too long for a resident to wait for assistance. When queried, Licensed Staff B stated it was not acceptable for staff to turn off the call light without helping the resident. During an interview on 10/20/23 at 3:05 p.m., the Director of Staff Development (DSD) was asked about timeliness of staff answering resident call lights. The DSD stated she had educated staff about this in the past, and the facility was monitoring and tracking call light response times by visiting and interviewing residents (Guardian Angel Rounds) and discussing the issue in Stand UP (meeting where healthcare team members connect at the start of the day to share relevant and time-sensitive information). When asked if she was aware staff were turning off call lights without speaking to the resident, the DSD stated she had seen staff tell the resident they would be back in five minutes, if they were busy, and then return. The DSD stated she was not aware staff were turning off the light by reaching into the room (without entering the room or asking what was needed). When asked what her expectation was for staff, the DSD stated they were not supposed to do that (reach in and turn off the light); she stated they should either answer the light or communicate (with the resident) that they would be back (to help them). Review of facility policy titled, Call Light/Bell (revised 02/2022), indicated call lights, .provide the resident a means of communication with nursing staff . Under subtitle, Procedures:, the policy indicated, 1. Answer the light/bell within a reasonable time. 2. Turn off the call light/bell. 3. Listen to the resident's request/need. 4. Respond to the request. If . you are unable to assist, explain to the resident and notify the charge nurse for further instructions . 2) During an observation on 10/16/23 at 1:15 p.m., the lunch trays arrived to the 100 hall. Staff in the hallway were speaking Spanish to each other while at the cart removing trays to deliver to residents who eat lunch in their rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 2 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a confidential interview on 10/18/23 at 9:58 a.m., CR 13 stated staff spoke languages other than English, all the time. CR 13 stated staff almost always spoke Tagalog and Spanish. CR 11 stated, while staff changed her roommate, they talked another language. CR 11 stated, It's rude and made her feel angry. CR 9 stated staff talked (another language), right in front of you and it was insulting. She stated they could be talking behind your back. CR 9 stated two staff had provided care to her roommates and while doing so, spoke to each other in another language. CR 8 stated this was disrespectful. CR 4 stated staff, talk around you in Tagalog and Spanish and it was, very frustrating, insulting and it made her feel like she was not a whole person. During an observation and concurrent interview on 10/18/23 at 3:09 p.m., two staff were in a resident room speaking Spanish to each other as they distributed water pitchers to the residents. Licensed Nurse C, outside the door, stated none of the residents in the room spoke Spanish. During an interview on 10/20/23 at 3:05 p.m., the DSD stated she was not aware residents had issues with staff speaking languages other than English around them. The DSD stated if staff spoke another language in resident doorways of over residents (while providing care), residents may feel staff are talking about them. The DSD stated her expectation was to prevent staff speaking languages in resident rooms while providing care if the residents (in that room) did not understand (the spoken language). Review of facility policy titled, Official Language Designation (revised April, 2004), indicated, . English as the official spoken and written business language of the company. Under subtitle, Purpose, the policy indicated English was the official language of the company, to respect and protect the residents' dignity and rights to communicate and be communicated to in their own language; to increase and promote harmony on the units and between employees . and, to decrease the amount of tension and anxiety among residents and employee which can result when multiple languages are spoken in and around patient care areas. Under subtitle, Terms, the policy indicated, 1 . Residents have the right to be treated with dignity, which requires . that residents not be excluded from conversations where residents are present or are likely to be present, regardless of the subject matter . When employees who are on duty communicate, they must speak English, except: A. If a resident's primary language is a language other than English, and an employee speaks that language . B. Other languages may be spoken by employees in employee break rooms . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 3 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of one residents (Resident 28), was able to have her provider care, from outside of the facility, incorporated into Resident 28's overall plan of care. This resulted in Resident 28's provider's recommendations being left out of the medical record and plan of care; due to lack of follow up after Resident 28 attended the appointment. Residents Affected - Few Findings: During an interview on 10/16/23 at 9:42 a.m., Resident 28 stated, when she was first admitted to the facility she brought in her own medications. Resident 28 stated those medications were used and, once those medications had been used, an appointment was made with a provider to obtain prescriptions of the medication of choice. Resident 28 stated the appointment had already taken place, and Resident 28 was waiting for the medication prescription to be processed through the facility. Resident 28 stated there had been no communication regarding the medication prescription and was concerned. During the interview, Resident 28 was waving her hands and stated the hand waving was related to not being on the medication she discussed during her provider visit. Resident 28 stated the facility was aware of her appointment with her provider as the facility facilitated the appointment through a computer. Resident 28 stated the provider at the clinic appointment was aware Resident 28 was at the facility and was aware of the name of the facility. During a concurrent interview on 10/18/2023 at 8:23 a.m., with Unlicensed Staff D and Social Services Director (SSD), Unlicensed Staff D stated the follow-up after a clinic appointment usually occurred with the receptionist who would relay the information to the nursing staff for follow-up. Unlicensed Staff D stated nursing would also follow-up after clinic appointments, and then the receptionist would call the clinic office to see if there were any notes to be put in the medical record. Unlicensed Staff D stated here would be a combination of social services follow-up, the receptionist followed-up and nursing followed-up, and it just depended on what was needed to be done on who did the follow-up. Unlicensed Staff D stated in the progress notes there were notes from the facility provider regarding Resident 28's visit. Unlicensed Staff D was unaware Resident 28 was requesting a medication to be prescribed and was unaware of any follow-up regarding the appointment. The SSD stated she was unaware of the follow-up and was not sure if the provider notes had been submitted to the facility to be placed in Resident 28's medical record. The date of the appointment was confirmed with Unlicensed Staff D and SSD to be 10/9/23, and there usually would be follow-up within a day or two of the clinic appointment. The SSD stated sometimes the clinics did not send the progress notes to the facility timely but agreed that the coordination had not been followed-up prior to the surveyor requesting what was going on with the follow-up. SSD stated she would ask medical records personnel where the progress notes were between the clinic and the facility. During an interview on 10/18/23 at 9:30 a.m., with the Director of Nursing, (DON) stated the clinic would not release resident information without a signature from the resident giving permission to submit clinic information. The DON stated the clinic had been contacted with the signed release of information, but the clinic had indicated the progress notes were not ready to be sent to the facility. The DON stated the facility was unable to make changes to Resident 28's plan of care until the facility received the progress note from the provider. The DON stated the appointment took place 10/9/23, and follow-up had not taken place until surveyor asked to follow up questions about the notes from the clinic appointment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 4 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview on 10/19/23 at 2:29 PM., the Administrator and DON indicated the facility was unable to make medication adjustments to Resident 28's plan of care until this notes had been received by the clinic to the facility. The clinic appointment took place on 10/9/23, and there was no follow-up until interviews requesting the documentation and system of follow-up regarding residents and their clinic appointments. The DON stated, as of that date (10/19/23), the clinic had not submitted any paperwork. A policy was requested from the facility regarding the follow-up of progress notes and the like from residents who attended clinic appointment or appointments with other providers outside of the facility. The facility did not present such a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 5 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation and interview, the facility failed to ensure one (Resident 31) of two sampled residents had belonging's which did not have a resident identification. This failure resulted in a resident's article of clothing not being labeled appropriately and being placed in another resident's closet. Finding: During an interview on 10/17/23 at 2:41 p.m , with Resident 30's family member, Resident 30's family member stated clothes were always getting lost in the laundry. Resident 30's family member stated Resident 30 would be wearing clothes which she had not purchased and did not know where the clothes came from. Resident 30's family member stated another family member dropped off a new shirt for Resident 30 at the front desk in a bag labeled with the resident, but the shirt had not been added to the inventory sheet or labeled with the resident's name and was subsequently lost. Resident 30's family member stated it was very frustrating because the staff had informed her to place new articles in a bag labeled with resident's name, and the inventory sheet would be updated and the laundry department would label the article of clothing with the name of the resident. During a concurrent interview and observation on 10/19/23 at 8:10 a.m. with Resident 31, he was asked permission to observe his closet to see if all of his belongings had been labeled. Resident 31 stated it would okay. Two articles of clothing were to not have a resident's name, one was a long sleeve blue t-shirt and the other was a gray/black pair of plaid shorts. Resident 31 stated he was not aware of these two articles of clothing and did not remember if they were his nor not. Resident 31 observed both articles of clothing to see if his name was labeled and could not find his name nor any other resident's name on the shirt or shorts. Resident 31 stated sometimes his clothes did get lost in the laundry and thought that not all of his clothes had been labeled by the facility. During a concurrent observation and interview on 10/19/23 at 8:28 p.m., with Unlicensed Staff O, Unlicensed Staff O stated the laundry for the residents would be conducted at the facility and washer and driers were observed to be running. Unlicensed Staff O showed the surveyor the clean laundry area where the clothes were folded and then hung up on hangers by the resident's room number. Unlicensed Staff O stated the facility had to label each article of clothing, even if a pair of socks were brought in, each individual sock would be labeled with the resident's name. Unlicensed Staff O stated family members were encouraged to label the articles of clothing with black permanent marker, and the facility would then print out a label and press it into the clothing to further identify each resident's article of clothing. The machine and a staff member were printing out labels with resident names and pressing them into articles of clothing. Unlicensed Staff O stated, if laundry came into the department to be cleaned and has not been labeled, then it would be really hard to find out who owned the article of clothing. Unlicensed Staff O stated there was a section in the laundry department where articles of clothing were stored as lost and found with the hope someone would claim the article of clothing. Unlicensed Staff O stated, if no one claimed the clothes, then the facility kept them for resident's who were admitted with little to no clothes. Unlicensed Staff O stated there was a storage area for unclaimed or donated clothes, and if a staff member accessed the closet to obtain clothes, then they would label the clothes with the resident's name. During an interview on 10/19/23 at 8:47 a.m., Unlicensed Staff K stated she was taking care of Resident 31 that day and was shown the two articles of clothing (blue t-shirt and gray/black plaid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 6 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shorts) which did not have a resident's name attached. Unlicensed Staff O stated, if she came across articles of clothing not labeled, she would return them to the laundry to be labeled. Unlicensed Staff O stated the gray/black shorts were not Resident 31's and stated she would take them back to the laundry. Unlicensed Staff O stated, if a resident needed clothes and if they were obtained from the donation closet, then she would take them to the laundry to be labeled and then given to the resident. Unlicensed Staff O stated, if she needed clothes for a resident quickly, and if there was not a person to label the item in the laundry department then she would use black permanent marker to identify the resident. During an interview on 10/19/23 at 9 a.m., Unlicensed Staff P stated, if he found an article of clothing not labeled, then he would immediately take it to the laundry department to have it labeled. Unlicensed Staff P stated he had never found an article of clothing not labeled and re-stated all clothing had been labeled by the laundry department so there would not be an article of clothing not labeled. During an interview on 10/19/23 at 2:45 p.m., the Administrator stated there had been major improvements with the laundry and ensuring all residents' clothing had been labeled. The Administrator stated there was a label machine to make sure the resident names were identifiable and especially with each new admission there was a huge effort to make sure all articles of clothing are labeled. The Administrator stated he had made it a quality improvement project which the facility was working on a whole to be better about protecting resident belongings. The Administrator was surprised with surveyor observations of two articles of clothing which had not been labeled. During a review of the facility's policy and procedure titled, CONSENT TO LABEL CLOTHING WITH IRON-PRESSED LABELER, (not dated), it indicated residents/family would have to sign a consent to have their articles of clothing labeled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 7 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview and record review, the facility failed to put systems in place to safeguard one of one (Resident 30) sampled resident from misappropriation of resident funds. This failure had the potential of Resident 30's funds being used by someone else inappropriately, since Resident 30 was not able to safeguard his personal funds. Residents Affected - Few Findings: A review of Resident 30's, admission Record, dated 4/27/17, indicated Resident 30 had a diagnosis including vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), emphysema (one of the diseases that comprises chronic obstructive pulmonary disease) and nicotine dependence. A review of Resident 30's admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/25/23, indicated Resident 30 had a BIMS (Brief Interview of Mental Status) score of 8 (moderately cognitively impaired). A review of Resident 30's, Baseline Care Plan, dated 10/24/17, indicated he had, Cognitive Impairment Related to Disease Process: Dementia. An intervention indicated Resident 30 would need supervision and assistance with all decision making. During an interview on 10/17/23 at 2:21 p.m., with Resident 30's spouse, she indicated there was a Trust Fund where she deposited money into an account maintained by the facility for when Resident 30 needed anything like cigarettes. Resident 30's spouse stated she found money in Resident 30's pant pocket and asked Resident 30 why he had money in his pocket, and Resident 30 could not explain why. Resident 30's spouse stated she asked the Activities Director why Resident 30 had money in his pocket, since Activity Director indicated he was the person who purchased Resident 30's cigarettes routinely and would return any change back to Resident 30. Resident 30's spouse stated she had written a letter to Activity Director requesting all change from the purchase of cigarettes not be given back to Resident 30, but rather distributed back to Resident 30's account. During an interview on 10/18/23 at 2:52 p.m., Unlicensed Staff I stated Resident 30 had an account to which Resident 30's spouse replenished with money, when necessary, so Resident 30 may purchase cigarettes when needed. Unlicensed Staff I stated, when Resident 30 needed more cigarettes, the Activities Director accompanied Resident 30 to request money from Resident 30's account. Unlicensed Staff I showed the safe and then proceeded to unlock the safe and demonstrate a binder which had forms which residents filled out when they wished to use money from their account. Unlicensed Staff I showed the surveyor a form where Resident 30 signed, and the date was 10/18/23, the description was labeled cash, the amount was $110.00, and the disbursement was signed by Unlicensed Staff I and entered by Unlicensed Staff I. Unlicensed Staff I stated that money was disbursed to Resident 30 today (10/18/23). Unlicensed Staff I was asked what the money was for, and she replied, that is not their [staff] place to ask what the money was for, it is the resident's right to use the money for what they want. Unlicensed Staff I stated it would not be appropriate to ask a resident what they were using the money for, but for Resident 30, she thought it was for cigarettes. Unlicensed Staff I stated she came to this conclusion because the Activity Director was with Resident 30, as Resident 30 signed for the money but immediately gave the money to the Activity Director. Unlicensed Staff I stated she knew Resident 30 had memory issues but was not sure to what degree and thought it might not be a good idea (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 8 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if he was given money without the Activity Director, since Resident 30 could not go to the store and purchase those items by himself. Unlicensed Staff I re-affirmed that it was Resident 30's right to obtain money when he requested it, and it was not the okay to question what the money would be used for. During an interview on 10/18/23 at 3 p.m., the Activity Director confirmed he was with Resident 30 when Resident 30 visited the Admissions' Office to obtain money from his Trust account. The Activity Director indicated the money was obtained so he would be able to purchase cigarettes for Resident 30. The Activity Director indicated he would purchase a carton of cigarettes since it was more economical for Resident 30, and the cigarettes lasted for approximately a month. The Activity Director was asked if the amount of $110.00 covered the exact cost of the cigarettes or if there was any change left over at the end of the purchase. The Activity Director stated there would always be some loose change left over, like maybe $1.75 or so, and the change would be given back to Resident 30. The Activity Director stated, when he would give the money back to Resident 30, Resident 30 would put the money in his pant's pocket. The Activity Director stated he thought Resident 30 would then give the money to his wife, since she visited every week. The Activity Director stated Resident 30's spouse found some change in Resident 30's pockets and then wrote a letter requesting all change be given back to the business office since the money would be lost in the laundry. The Activity Director stated he was aware Resident 30 had problems with memory but did not think Resident 30 would forget to tell his wife about the change. The Activity Director stated he would not give Resident 30 anymore change, and any left-over change would be given back to the Business Office. During an interview and record review on 10/19/23 at 9:12 a.m., with the Admissions' Director, the, Resident Trust Fund Petty Cash Disbursement Voucher, for Resident 30, dated 10/18/23, was reviewed. The Admissions Director indicated Resident 30 had signed for his money and stated the Admissions' Office did not ask Resident 30 what the money was for as it was his right to request his money. The Admissions' Director stated it was understood Resident 30 did not have capacity but he came with activity personnel to secure the money so the activity staff may make the purchase. Once the form had been signed by the resident and the money had been disbursed, that would be the extent of our (Admissions' Department) involvement. The Activity Director stated, if Resident 30 came by himself to the obtain money that would be okay too since the admission Department would not ask Resident 30 what the money was for, and emphasized it was the residents' right to use their money how they wanted. The admission Director stated, if another resident had taken advantage of Resident 30, she would not know that since again she did not ask Resident 30 what his money would be used for. During a review of Resident 30's, Resident Trust Fund Petty Cash Disbursement Voucher(s), for year-to-date 2023, there were ten voucher forms reviewed, dated 4/3/23, 4/4/23, 4/27/23, 5/31/23, 6/17/23, 7/13/23, 8/10/23, 8/31/23, 9/21/23 and 10/18/23, which indicated Resident 30 had signed each voucher and admission staff signed the section which indicated who dispersed the money. There was one instance, dated 4/4/23, whereby Resident 30 had initialed the form without a full signature, and there was a signature indicating the witness, but the name was not printed, so it was unclear who the person was who witnessed the transaction. The remaining nine vouchers had Resident 30's signature and who dispersed the cash to him, but no witness signature or any indication there was oversight regarding the money being given to Resident 30. The dollar amounts of the nine distributions ranging from April to October 2023, were between $85.00 to $110.00, per each occurrence. During a concurrent interview on 10/19/23 at 2:45 p.m., with the Administrator and Director of Nursing (DON), the Administrator stated he was aware of Resident 30's Trust Account. The Administrator reviewed the form, Resident Trust Fund Petty Cash Disbursement, dated 10/18/23, where Resident 30 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 9 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Unlicensed Staff I had signed the form but there was no indication the Activity Director had been present to receive the money. The Administrator stated there was an arrangement between Resident 30's spouse and the facility, to have money for Resident 30 to access by himself. The Administrator stated Resident 30 would be able to maintain independence and dignity when he asked for his funds. The Administrator stated he thought Resident 30 had enough cognition to request funds on his own, independently. The DON stated activity personnel would always be with Resident 30 to obtain funds since he could not make purchases on his own nor remember he might be running out of cigarettes. The DON agreed the form indicated Resident 30 was by himself when requesting the money from his account, and there would be no way to indicate if another resident was taking advantage of Resident 30's trust account. During a review of the facility's policy and procedure titled, Accounts Receivable Policy and Procedure, revised 3/1/23, indicated, allows residents the appropriate access to their funds while ensuring protection of resident funds in accordance with state and federal regulatory requirements. 1. The facility will establish and maintain a system that ensures a complete and separate accounting, according to generally accepted accounting principle of each resident's personal funds entrusted to the facility on the resident's behalf. 3. Disbursements recorded will include a description of the use for the funds . RTF members should always be able to understand clearly the purpose or reason for the disbursement .2. If a resident is incapacitated or unable to make the request, then all transactions should be approved by the resident's legal responsible party on file or their representative payee. These witnesses can be any employee(s) except for the RTF petty check/cash handler, the Business office Manager, or the Data Entry Person .4. Goods Received Form- in the event that the resident requests or requires items to be purchased, either online or at a local store, a Goods received form will be required to be signed by the resident, or in cases when the facility is the representative payee, then it will be signed by the Executive Director. The Goods Received form should be completed by the employee who did the shopping for the resident. This cannot be the Check/Cash Handler, Trust Custodian, Data Entry Person . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 10 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change MDS (Minimum Data Set, an assessment tool) within 14 days of a change in condition for one of four residents, sampled for change of condition (Resident 76), when Resident 76 was hospitalized and came back to the facility with a G-tube (gastrostomy tube, a flexible tube surgically inserted through the abdominal wall to bring nutrition directly into the stomach). This failure could potentially lead to a lack information for staff to update Resident 76's care plan. Residents Affected - Few Findings: During an observation on 10/16/23 at 9:37 a.m., Resident 76 was lying in her bed. A tube feeding pump was attached to a pole next to her bed, and an empty bag of tube feeding formula, dated 10/15/23, was hanging from the pole. Review of Resident 76's medical record revealed she was re-admitted from the hospital on 9/6/23. Resident 76's medical diagnoses included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), gastrostomy, and dysphagia (swallowing difficulties), among others. Review of Resident 76's physician's orders revealed an order, dated 9/6/23, for NPO (non per os, Latin for nothing by mouth). During an interview on 10/20/23 at 10:19 a.m., Licensed Staff B verified Resident 76 had been to the hospital a couple of times in August. Licensed Staff B stated Resident 76 was alert and was eating, then stopped eating and was declining, so she was sent to hospital. During a record review and concurrent interview on 10/20/23 at 3:29 p.m., Resident 76's MDS, dated [DATE], was reviewed with MDS Nurse. When asked if Resident 76 was on tube feeding in the past, the MDS Nurse stated Resident 76 was sent to the hospital twice. On resident's first hospitalization, she came back with tube feeding orders. Resident 76's MDS history was reviewed with the MDS Nurse, and she verified there was no Significant Change of Status Assessment (SCSA) completed to reflect Resident 76 was changed to a tube feeding. The MDS Nurse stated there should be two changes in a resident's status to be able to complete an SCSA. When asked if a change in a resident's method of receiving nutrition from oral to G-tube and a change of her requirement of eating to total assistance did not meet the criteria for an SCSA, MDS Nurse stated, Yes. When asked what was the purpose of completing residents' MDS, the MDS Nurse stated, MDS paints a whole picture of the resident, and that MDS guides the facility in the development of residents' care plans. Review of facility policy, Resident Assessment, last updated 10/1/23, revealed, It is the policy of this facility to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity which are based on the State's specific Resident Assessment Instrument (RAI) and the facility's interdepartmental assessment forms. Review of the RAI 3.0, dated 10/2023, revealed, The SCSA is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 11 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 1. Will not normally resolve itself without intervention by staff or by implementing Level of Harm - Minimal harm or potential for actual harm standard disease-related clinical interventions, the decline is not considered selflimiting; 2. Impacts more than one area of the resident's health status; and Residents Affected - Few 3. Requires interdisciplinary review and/or revision of the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 12 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the MDS was accurately completed for three of 26 sampled residents (Residents 76, 56, and 38). This failure could potentially result in care planning for residents based on inaccurate information. Residents Affected - Some Findings: Resident 76 During an observation on 10/16/23 at 9:37 a.m., Resident 76 was lying in her bed. A tube feeding pump was attached to a pole next to her bed, and an empty bag of tube feeding formula, dated 10/15/23, was hanging from the pole. Review of Resident 76's medical record revealed she was re-admitted from the hospital on 9/6/23. Resident 76's medical diagnoses included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), gastrostomy, and dysphagia (swallowing difficulties), among others. Review of Resident 76's physician's orders revealed an order, dated 9/6/23, for NPO (non per os, Latin for nothing by mouth). During an interview on 10/20/23 at 10:19 a.m., Licensed Staff B verified Resident 76 had been to the hospital a couple of times in August. Licensed Staff B stated Resident 76 was alert and was eating, then stopped eating and was declining, so she was sent to hospital. During a record review and concurrent interview on 10/20/23 at 3:29 p.m., Resident 76's MDS, dated [DATE], was reviewed with the MDS Nurse. The MDS Nurse verified Section G110H under eating indicated activity did not occur. MDS Nurse stated this information was from the CNA's (Certified Nursing Assistants) documentation; however she verified Resident 76 was receiving tube feeding, and nurses were feeding her. The MDS Nurse stated the MDS was coded incorrectly and it should have been coded as total dependence. She stated she would modify the assessment. When asked what was the purpose of completing residents' MDS, the MDS Nurse stated, MDS paints a whole picture of the resident, and the MDS guides the facility in the development of residents' care plans. Resident 38 Review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE], with diagnoses including but not limited to Cerebral Infarction (also known as stroke); Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease); and Severe Protein Calorie Malnutrition (when a person is not consuming enough protein and calories). Review of the document titled, Order Summary Report, for October 2023, indicated a diet order written on 4/07/23, for Fortified diet Mechanical Soft texture Thin Liquids consistency. Review of Section K (Nutritional Approaches) of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) for Resident 38, dated 6/02/23, under Therapeutic diet, the MDS did not reveal a check mark indicating Resident 38 did not receive a therapeutic diet during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 13 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 the seven-day observation period from 5/25/23 to 6/02/23. Level of Harm - Minimal harm or potential for actual harm Review of Section K (Nutritional Approaches) of the MDS for Resident 38, dated 9/02/23, under the Therapeutic diet, the MDS did not reveal a check mark indicating Resident 38 did not receive therapeutic diet during the seven-day observation period from 8/25/23 to 9/02/23. Residents Affected - Some Resident 56 Review of the Face sheet indicated Resident 56 was admitted on [DATE], with diagnosis including but not limited to Adult Failure to Thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol) and Moderate Protein Calorie Malnutrition. Review of the document titled, Order Summary Report, for October 2023, indicated a diet order written on 6/11/23, for Fortified diet, Regular texture Thin Liquids consistency. Review of Section K (Nutritional Approaches) of the MDS for Resident 56, dated 8/15/23, under the Therapeutic diet, the MDS did not reveal a check mark indicating Resident 56 did not receive therapeutic diet during the seven-day observation period from 8/07/23 to 8/15/23. During a review of Resident 56's MDS, dated [DATE], and concurrent interview with the MDS Nurse on 10/20/23 at 3:45 p.m., the MDS Nurse verified that Section K under Therapeutic diet did not reveal a check mark. When the MDS Nurse was asked if fortified diet was considered therapeutic diet, she stated, Yes. The MDS Nurse concurred the assessment was incorrect and stated she would modify the assessment. When the MDS was asked about the importance of an accurate assessment, she stated, MDS paints a whole picture of the resident and that MDS guides the facility in the development of resident's care plan. Review of facility policy, Resident Assessment, last updated 10/1/23, revealed, It is the policy of this facility to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity which are based on the State's specific Resident Assessment Instrument (RAI) and the facility's interdepartmental assessment forms. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, effective October 2019, indicated, A therapeutic diet is a diet intervention prescribed by a physician or other authorized non-physician practitioner that provides food or nutrients via oral, enteral, and parenteral routes as part of treatment of disease or clinical condition, to modify, eliminate, decrease, or increase identified micro- and macro-nutrients in the diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 14 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to develop and implement person-centered care plans for 3 of 4 sampled residents (Resident 44, Resident 21, and Resident 110). These failures had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately. Findings: During a review of the Progress Notes titled, Change in Condition, dated 10/02/23 at 6:20 a.m., indicated Licensed Staff A found Resident 44 gasping for air with eyes rolling back at 3:30 a.m. on 10/02/23, and was sent to the hospital at 3:47 a.m. During a review of the hospital record titled, After Visit Summary, dated 10/02/23, indicated Resident 44 had a diagnosis of COVID-19 (Corona Virus Disease of 2019 - an infectious respiratory disease) virus infection. During an interview with the IP (Infection Preventionist) on 10/09/23 at 11:33 a.m., the IP stated Resident 44 shared a room with Resident 21 and Resident 110 prior to her hospitalization. He stated Resident 44 was moved to another room after returning from the hospital and was put on isolation (the state of one who is alone)/droplet precaution (used to prevent the spread of bacteria that are passed through respiratory secretions) through 10/12/23. The IP stated Resident 44, Resident 21 and Resident 110 were monitored for signs and symptoms of COVID, every shift. During an interview and concurrent record review with the DON on 10/09/23 at 12:48 p.m., the DON stated Resident 44 was sent to the hospital for a change of condition and returned to the facility on [DATE], with a diagnosis of COVID-19. After review of the Respiratory Care Plan for Resident 44 with the DON, the DON verified the Care Plan was created on 10/09/23, indicating Resident 44 tested positive for COVID. During a record review and concurrent interview with the DON on 10/09/23 at 12:51 p.m., the DON verified the Care Plan, created on 10/09/23, for Resident 110 indicated Resident 110 was exposed to a COVID-19 positive individual. After review of the Care Plan for Resident 21 with the DON, the DON stated Resident 21 did not have a care plan for COVID-19 exposure. When the DON was asked about the facility policy for care planning, the DON stated a care plan should be developed as soon as a resident's change of condition was identified. He stated he expected the IP to initiate the care plan immediately when Resident 44 tested positive for COVID and when Resident 21 and Resident 110 were exposed to COVID. Review of the Facility policy titled, Change of Condition Reporting, revised on January 2023, indicated, Document resident change of condition and response in nursing progress notes, and update resident Care Plan, as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 15 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility licensed staff failed to meet professional standards of nursing practice when: Residents Affected - Some 1. Nurses did not call to clarify the insulin order for one of two residents sampled for tube feeding (Resident 76); 2. Nurses did not call to clarify the decision-making capacity order for one of 10 residents sampled for accidents (Resident 269). These failures resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for vulnerable residents including: 1. uncontrolled blood sugars, or confusion about when to administer the insulin; 2. making decisions and signing consents for medical care without the mental capacity to understand the risks and benefits or the potential outcome of their decision. Findings: 1. During an observation on 10/16/23 at 9:37 a.m., Resident 76 was lying in her bed. A tube feeding pump was attached to a pole next to her bed, and an empty bag of tube feeding formula, dated 10/15/23, was hanging from the pole. Review of Resident 76's medical record revealed she was re-admitted from the hospital on 9/6/23. Resident 76's medical diagnoses included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), Type-2 Diabetes (a chronic condition that affects the way the body processes blood sugar), obesity, and dysphagia (swallowing difficulties), among others. Review of Resident 76's physician's orders revealed an order, dated 9/6/23, for NPO (non per os, Latin for nothing by mouth). A physician order, dated 10/13/23, indicated Diabetisource (a tube feeding formula) to be given via PEG-tube (percutaneous endoscopic gastrostomy; a flexible tube surgically inserted through the abdominal wall to bring nutrition directly into the stomach) at 76 mL (milliliters, a unit of measure) per hour from 12 p.m. until 8 a.m. (20 hours) for a total of 1440 mL every day. Resident 76's physician's orders also included an order, dated 9/7/23, for Humalog insulin to be injected subcutaneously (into the fatty tissue under the skin) per sliding scale (dose determined by blood sugar level) with meals. During an interview on 10/20/23 at 10:19 a.m., Licensed Staff B stated she was Resident 76's nurse. Licensed Staff B stated Humalog was a short-acting insulin that peaked about 15 minutes after injection. When queried, Licensed Staff B stated Humalog was given with meals so when it peaked, Resident 76's blood sugar did not bottom out. When asked about giving Humalog to a resident who was NPO, Licensed Staff B stated Resident 76 was constantly getting formula so her stomach was never empty. Licensed Staff B stated the order for Humalog probably rolled over from her hospital orders, and she did not question it because it was not uncommon for a resident to have insulin with a PEG tube. During an interview on 10/20/23 at 2:59 p.m., when asked about Resident 76's insulin order, the Director of Nursing (DON) stated it was his expectation staff should call the doctor to address that (the resident is NPO and the order indicates to give insulin with meals). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 16 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the package insert for Humalog insulin revealed, Administer the dose of HUMALOG U-100 or HUMALOG U-200 within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. HUMALOG administered by subcutaneous injection should generally be used in regimens with an intermediate- or long-acting insulin. 2. On 9/14/23, the Department received a report from the facility that Resident 269 eloped from the facility on 9/13/23. The report indicated Resident 269 had the capacity to make healthcare decisions. Review of Resident 269's medical record revealed he was admitted to the facility on [DATE], with multiple medical diagnoses including unspecified dementia, among others. Resident 269's physician history and physical exam note, dated 6/29/23, indicated, . not oriented to time, place and person (cannot correctly state the date, time, where he is, or who he is). Decision making capacity: without. Review of Resident 269's capacity statement, dated 6/30/23, revealed the same physician who had written the history and physical note checked the box indicating, Yes, Resident 269 had capacity to make medical decisions and was signed by the physician. At the bottom of the document, a nurse wrote, Noted 7/1/23, and signed their name. Review of Resident 269's physician orders revealed an order, dated 7/1/23, that indicated, Resident has the capacity to make health care decisions. Resident 269's MDS (Minimum Data Set, an assessment tool), with a reference date of 7/5/23, indicated his BIMS score was 5 (Brief Interview for Mental Status, a score of 5 indicates severe cognitive impairment). Resident 269's MoCA test (Montreal Cognitive Assessment; tool for early detection of mild cognitive impairment), dated 9/1/23, score was 17 out of 30 (a score greater than, or equal to, 26 is normal). During an interview on 10/20/23 at 2:59 p.m., when queried, the Director of Nursing (DON) stated it was his expectation staff should call the doctor to clarify if the BIMS score and the MoCA score did not correspond to the capacity order. When asked about the potential outcome to a resident whose order for capacity did not match their actual capacity, the DON repeated, We will reach out to the doctor to clarify. Review of facility job description, License [sic] Vocational Nurse/Licensed Practical Nurse, dated 12/17/21, indicated under section Essential Duties and Responsibilities: Confer with the Medical Director and the attending physician regarding specific residents assigned to you. Consult with the physician concerning resident evaluation and assist the Director of Nursing Services in planning and developing the nursing services to be performed for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 17 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an effective comprehensive system for monitoring parameters of nutritional status for three of ten sampled residents (Resident 38, Resident 19 and Resident 76), when: Residents Affected - Some 1. a. Resident 38's Desirable Body Weight Range (DBWR - general term for a person's optimal weight for a particular height) was not consistently established with the involvement of Resident 38 and/or Resident 38's RP (Responsible Party), to reflect Resident 38's and/or the RP's personal goals and preferences and was not coordinated with the IDT (Interdisciplinary Team) to include the physician responsible for Resident 38's care. b. The facility staff did not recognize insidious (proceeding in a gradual, subtle way, but with harmful effects) weight loss as a criteria to monitor, identify, and evaluate in order to recommend nutrition interventions, during which time Resident 38's weight loss continued to significant weight loss. c. The facility failed to ensure quantity of consumption of therapeutic (to cure or restore to health) nutritional supplement for Resident 38 was accurately documented and monitored, as ordered. This failure had the potential to ineffectively evaluate and delay timely revision of interventions needed to meet Resident 38's nutrition needs. d. Resident 38 did not receive a swallow screen (a test to determine if resident had swallowing problem) when facility staff were aware Resident 38 repeatedly expressed dislike of a mechanical soft diet (a texture-modified diet that restricts foods that are difficult to chew or swallow). In addition, Resident 38 informed Unlicensed Staff L that he almost choked on a cheese sandwich, in which Unlicensed Staff L failed to report to a Licensed Nurse for further evaluation and failed to communicate to dietary staff. These failures contributed to Resident 38's significant weight loss and had the potential for deterioration of general health status, choking and decreased quality of life. 2. The Facility failed to identify and address unplanned slow and progressive weight loss (insidious weight loss) in order to recommend nutrition interventions for Resident 19, in a timely manner, during which time unplanned weight loss continued. 3. The Facility failed to recognize, evaluate, and address unplanned weight gain, and slow and progressive weight loss, which continued to significant weight loss, for Resident 76. The Facility failed to ensure the desirable body weight range (DBWR) was established with the involvement of Resident 76's RP to reflect Resident 76's and/or RP's personal goals and preferences for resident-centered care, and in coordination with the IDT to include the physician responsible for Resident 76's care. The Facility's failure to ensure RD nutrition assessments evaluate, assess, implement interventions, re-[NAME] interventions and document reasons why a resident's identified weight goal could not be maintained, had the potential to negatively impact Resident 76's nutritional and medical status. In addition, the Facility failed to ensure the nutrition IDT Care plans listed specific and clear DBWR goals and updated and/or revised when the DBWR changed multiple times for Resident 76. The Facility failure to ensure the IDT recognized, evaluated and addressed slow, progressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 18 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unplanned weight loss which may be associated with an increased risk of mortality and other negative outcomes for the vulnerable elderly residents. Contradictory and unclear weight goal communication to IDT members had the potential to cause delays in assessing, planning and implementing nutrition interventions in a timely manner, and had the potential to promote loss of lean body mass (consists of your bones, ligaments, tendons, internal organs and muscles) that has multiple negative health implications. Findings: Resident 38 During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE], with diagnosis including but not limited to Cerebral Infarction (also known as stroke); Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease); and Severe Protein Calorie Malnutrition (when a person is not consuming enough protein and calories). 1 a. During a review of the document titled, IDT- Care Plan Review, dated 12/07/22 at 10:27 a.m., indicated the following: Resident 38, Resident Representative, DON (Director of Nursing), DOR (Director of Rehabilitation), CNA (Certified Nursing Assistant), Social Services, Activity Person, and Dietary Supervisor. The document indicated under the Dietary Plan of Care (Dental, Oral and Hydration and Nutritional Status), [Resident 38] is currently on a Regular Diet Mechanical soft texture with thin liquids. [Resident 38] receives health shakes once a day and snacks TID (three times a day). His current weight is 125 lbs. (a unit of measurement used for weight) weight stable for one year. During a review of the document titled, Nutrition Evaluation and RDN (Registered Dietitian Nutritionist) Review, dated 12/07/2022 at 10:44 a.m., indicated the following: Resident 38's Ideal Weight Range (IWR is a specific, ideal weight for each individual based on general criteria) was 139 lbs. to 169 lbs., usual weight was 128 lbs.; Desirable Body Weight Range (DBWR) was 125 lbs. -135 lbs. The document indicated Resident 38's weight on 12/01/22, was 125.6 lbs. During a review of Resident 38's weight history from December 2022 to April 2023, indicated Resident 38 weighed 129.8 lbs. on 01/02/23; 124.6 lbs. on 02/01/23; 120.2 lbs. on 03/02/23, and 116.2 lbs. on 04/03/2023. During an interview with the RD (Registered Dietician) on 10/18/23 at 11:14 a.m., when the RD was asked how Resident 38's Desirable Body Weight Range (DBWR) of 125 lbs. -135 lbs. was determined, the RD stated DBWR was specific to Resident 38 based on Resident 38's usual body weight. When the RD was asked if Resident 38 or his representative was involved in the determination of Resident 38's DBWR, she stated Resident 38 or his representative were not involved, she stated Resident 38's DBWR was determined based on Resident 38's weight history since Resident 38 had been at the facility since 2016. During an observation on 10/19/23 at 8:41 a.m., Resident 38 was in his room, in his bed, drinking his coffee. His meal tray had a slice of omelet barely touched, a bowl of cream of wheat, glass of water, cup of half-filled coffee and an empty glass. Resident 38 stated he was done eating. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 19 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he only had a bite of the omelet because he did not like cheese and did not like the cream of wheat; however, he stated he liked the orange juice, It was a treat. Resident 38 stated he would like to get back to his old weight which was around 130 lbs. During a review of the Facility Policy titled, Nutrition Care Management, revised on 4/20/23, indicated, It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight (UBW) or desirable body weight (DBW) and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible. Under purpose of the policy indicated, To provide care and services including: Assessing the resident's nutritional status and the factors that put the resident at nutrition/ hydration risk; Analyzing the assessment information to identify the medical conditions, risk factors, causes and/or concerns related to the resident's condition and needs; . During a review of the Facility policy and procedure titled, Food and Nutrition Services, revised on 4/20/23, indicated, Documentation shall reflect the nutritional assessment risks, goals, and interventions. These shall be incorporated into the plan of care with collaboration with the resident, responsible party, physician and other IDT consultation and collaboration. Nutritional care plans shall be reviewed, monitored, and updated based on resident response and progress toward measurable goals. 1 b. During a review of the Care Plan created on 5/09/16, the care plan indicated Resident 38 had the potential nutritional problem related to Cachexia (unintentional weight loss, progressive muscle wasting, and a loss of appetite) and Severe Protein Calorie Malnutrition. Care Plan interventions included but were not limited to: RD to evaluate and make diet change recommendations PRN (as needed), initiated on 10/19/17; Diet as ordered by the physician. Fortified diet (to add calories and/or protein), Mechanical Soft, initiated on 5/11/19; and Provide and serve supplements as ordered, initiated on 6/11/19. During a review of the document titled, Nutrition Evaluation and RDN (Registered Dietitian Nutritionist) Review, dated 12/07/22 at 10:44 a.m., indicated the following: Resident 38's Ideal Weight Range (IWR - is a specific, ideal weight for each individual based on general criteria) was 139 lbs. to 169 lbs., usual weight was 128 lbs.; Desirable Body Weight Range (DBWR) was 125 lbs. -135 lbs. The document indicated Resident 38's weight on 12/01/22, was 125.6 lbs. During a review of Resident 38's weight history from December 2022 to April 2023, indicated Resident 38 weighed 129.8 lbs. on 01/02/23; 124.6 lbs. on 02/01/23; 120.2 lbs. on 03/02/23, and 116.2 lbs. on 04/03/23. During an interview with the RD on 10/18/23 at 11:34 a.m., the RD verified Resident 38 lost weight to 120.2 lbs on 2/01/23, which was less than the facility's identified DBWR of 125 - 135 lbs. The RD reviewed Resident 38's EHR (electronic health record) and stated, the first weight committee since 12/07/22, was on 4/6/23, after Resident 38 lost 10.5% significant unplanned weight loss. The RD was asked if there had been significant weight loss prior to 4/6/23, and she calculated the weight loss from 12/22 to March 2023, and the RD stated, the Resident 38 had a 7.3% weight loss as of 3/02/23. The RD stated the 7.3% unplanned weight loss had not been evaluated and addressed because, it was close to triggering a weight committee meeting but it did not trigger one because it had not reached a 7.5% significant weight loss in three months which is the facility criteria. RD repeated, It was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 20 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm close, but it did not trigger. When the RD was asked if Resident 38 had a slow weight loss, and if he could have benefited from interventions prior to Resident 38's significant weight loss, the RD stated, It potentially could help but we don't know until we try. The RD verified the facility had not tried to prevent further weight loss, at that time. The RD stated slow, progressive weight loss was not addressed until, it triggers, the facility's criteria for significant weight loss of 5% in one month, 7.5% in 3 months and 10% in 6 months. Residents Affected - Some During an interview with the DON on 10/18/23 at 11:58 a.m., when asked if he would expect the facility to address an unplanned weight loss of 7.3%, the DON stated 7.3% unplanned weight loss in the elderly resident did not, trigger their facility system to convene a weight variance meeting to address the unplanned weight loss. The DON stated a significant weight loss of 5% in a month, 7.5% in 3 months and 10% in 6 months would trigger the facility to do a root cause analysis and put in interventions to prevent the resident from further weight loss. When the DON was asked if the facility system, that had not included the IDT identifying and addressing insidious weight loss, prior to continuing to a significant weight loss, allowed for the facility to do everything they could possibly do to help minimize or prevent significant weight loss in the elderly, which could be harmful, the DON repeated, identifying and addressing insidious weight loss was not currently in their system; however, he stated staff had been trained to report if a resident suddenly had a decline in oral intake using their, Stop and Watch Early Warning Tool. During an interview with the RD on 10/19/23 at 10:53 a.m., when the RD was asked about interventions put in place when the IDT determined Resident 38 had a 10% significant weight loss back in April 2023, the RD stated, in addition to Resident 38 receiving health shakes and Remeron (a medication used to treat depression), Resident 38 was also put on a fortified diet and added instruction on Resident 38's Medication Administration Record (MAR) for nurses to document percentage of health shakes consumed. The RD concurred Resident 38 had been receiving health shake once a day already, during which time Resident 38 lost weight. The RD verified the health shake was not increased to three times a day until June 2023, two months after the facility identified Resident 38 already experienced a 10% significant, unplanned, weight loss. The RD concurred Resident 38 had a doctor's order for Snacks TID (three times a day) since February 2022, and a health shake in the morning was part of the snacks. The RD also stated Remeron was not prescribed to address Resident 38's weight loss, however, she stated Resident 38 could benefit from the Remeron's appetite stimulant effect. During a review of the Facility Policy titled, Nutrition Care Management, revised on 4/20/23, indicated, Significant weight loss is a loss of (5% in one (I) month, 7.5% in three (3) months, or 10% in six (6) months or unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss (Insidious Weight Loss). Weight loss should be addressed in the care plan. Facility approaches to address weight loss may include root cause analysis and determination of desirable vs. undesirable and planned vs. unplanned. Under PURPOSE of the policy, indicated, To provide care and services including: . Defining and implementing interventions for maintaining or improving nutritional hydration status that are consistent with resident needs, goals, and recognized standards of practice; Assessing and documenting in the PCC medical record why the facility is unable to maintain or improve nutritional or hydration status; and Monitoring and evaluating the resident's response to the interventions, especially when there is no progress toward the nutritional goal. Revising or discontinuing approaches as appropriate or justifying the continuation of current approaches. 1 c. During a review of the document titled, Order Summary Report, for October 2023, indicated a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 21 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some doctor's order for Snacks three times a day for supplement, written on 2/02/22, and Health Shake three times a day for supplement, written on 6/10/23. During an observation on 10/16/23 at 1 p.m., Resident 38 was eating independently in the dining room. Resident 38 appeared very thin. Resident 38 ate all his meat serving and left the cut green beans on his plate. Resident 38 stated the food was average, and he did not care about cut green beans. During an interview with Unlicensed Staff K on 10/18/23 at 10:18 a.m., Unlicensed Staff K stated Resident 38 received a milk shake in the morning. When Unlicensed Staff K was asked where she documented how much of the milk shake Resident 38 had taken, Unlicensed Staff K stated it was documented in the POC (Point of Care - an electronic health care record for residents); however, when Unlicensed Staff K was asked if she could show where it was documented, she could not show the amount of milk shake Resident 28 had taken. She stated there was no place in the POC to document percentage of milk shake consumed; however, snacks were documented whether Resident 38 accepted or refused snacks. During an interview with the RD on 10/18/23 at 10:36 a.m., when the RD was asked about the reason why Resident 38 was given a milk shake, the RD stated, due to low body weight. The RD stated Resident 38's health shake consumption was not documented because Resident 38's weight was being monitored for further weight loss. She stated she would ask Resident 38 and the CNAs if Resident 38 was accepting the drink; however, the RD acknowledged that random speaking with Resident 38 and the staff did not provide a consistent mechanism of quantifying calorie and protein intake consumed in order to compare and assess daily nutritional needs for an accurate nutrition assessment which might warrant evaluation of further nutrition interventions, or to modify current interventions. The RD stated the facility system for requiring staff to document quantity consumed of an ordered nutrition intervention, such as health shake, was at her discretion. The RD stated she determined when it was necessary and when it was not, and stated sometimes she did not require staff to document quantity consumed of a nutrition intervention provided to address weight loss, as she would just monitor the weight. The RD acknowledged it was not effective monitoring to determine if an intervention was consumed sufficiently, by waiting to see if a resident lost further weight, when it was ordered to prevent further weight loss. During an interview with Unlicensed Staff L on 10/18/23 at 3:06 p.m., Unlicensed Staff L stated Resident 38 received, milk shake at 3 p.m., and peanut butter and jelly sandwich or cheese sandwich at bedtime. Unlicensed Staff L stated they did not document how much percentage of the snacks Resident 38 consumed. He stated they would only document on the POC if Resident 38 accepted or refused the snacks offered. When Unlicensed Staff L was asked how he would document if Resident 38 only had a bite of his sandwich or a sip of his milk shake in the POC, he stated he would document accepted since there was no place in the POC to document how much of the snacks was consumed. When Unlicensed Staff L was asked if he would report to the nurse how much of the milk shake Resident 38 drank, he stated, No; however, Unlicensed Staff L stated he would report if Resident 38 did not eat or did not drink fluids. During an interview with Unlicensed Staff K on 10/19/23 at 10:43 a.m., Unlicensed Staff K stated, [Resident 38] was not feeling well today. Unlicensed Staff K stated Resident 38 only ate a piece of toast, a bite of omelet and refused to drink his milk shake. During a review of Resident 38's Medication Administration Record it indicated Resident 38 consumed 100% of his morning health shake on 10/19/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 22 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm During a review of the Facility policy and procedure titled, CNA Documentation, revised on 4/18/23, indicated, It is the policy of this facility to ensure that all care and services that CNAs provide are documented in the resident's medical record. Under, PROCEDURES, of the policy, it indicated what to document which included but not limited to, Meal consumption including nutritional supplements. Residents Affected - Some 1 d. During a review of the Care Plan, created on 5/09/16, it indicated Resident 38 had the potential nutritional problem related to Cachexia (unintentional weight loss, progressive muscle wasting, and a loss of appetite) and Severe Protein Calorie Malnutrition. The Care Plan interventions include, but not limited to: Monitor/document/report to MD PRN for signs and symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. During a review of the document titled, Nutrition Evaluation and RDN Review, dated 12/07/22 at 10:44 a.m., indicated Resident 38 was on a Regular, Mechanical Soft Diet. Resident 38 had Dysphagia and Chewing difficulty related to poor oral health, as evidenced by reports of poor dentition (arrangement or condition of the teeth). During a review of the document titled, Order Summary Report, for October 2023, indicated the following orders: Snacks three times a day for supplement, written on 2/02/22; Health Shake three times a day for supplement, written on 6/10/23; and Fortified diet Mechanical Soft texture Thin Liquids consistency, written on 4/07/23. During a review of the document titled, Nutrition Evaluation and RDN Review, dated 12/07/22, and concurrent interview with the RD on 10/18/23 at 11:14 a.m., the document indicated Resident 38 expressed dislike for the mechanical soft diet. When the RD was asked how she addressed Resident 38's statement of disliking the mechanical soft diet, she stated she could not upgrade Resident 38's diet. She did not make an action plan or address it because, it was up to the Speech Therapist (ST - person who specializes in the evaluation, diagnosis, treatment, and prevention of cognitive-communication disorders, voice disorders, swallowing disorder, etc.). The RD stated Resident 38 told her he had spoken with the ST a couple of times already, so she took no action on the matter and repeated it was up to the ST. During a review of the document titled, Nutrition Evaluation and RDN Review, dated 12/07/22, and concurrent interview with the ST on 10/18/23 at 12:13 p.m., the ST verified the document indicated Resident 38 expressed dislike for the mechanical soft diet, and he had spoken to the ST a few times about it; and the ST verified he continued to complain about his mechanical soft diet until this day. ST stated, however, she had never screened Resident 38 to determine if he could safely swallow an advanced texture diet. She stated there was no formal screen done for Resident 38's swallowing ability because she did not received a referral to do a swallow screen. She stated she did not need a doctor's order to screen Resident 38 for swallowing. The ST stated she only needed a request form, and any discipline could fill out the form for a swallow screen. The RD stated a swallow screen for Resident 38 should have been completed if there was a request to screen Resident 38. During an interview with Unlicensed Staff L on 10/18/23 at 3:06 p.m., Unlicensed Staff L stated Resident 38 received, milk shake at 3 p.m., and peanut butter and jelly sandwich or cheese sandwich at bedtime; however, Unlicensed Staff L stated Resident 38 did not like the cheese sandwich because he almost choked from it. When Unlicensed Staff L was asked if he reported this information to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 23 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 nurse or to the dietary manager, he stated, No. Level of Harm - Minimal harm or potential for actual harm During an observation on 10/19/23 at 8:41 a.m., Resident 38 was in his room, in his bed, drinking his coffee. Resident 38 stated he was done eating. He stated he only had a bite of the omelet because he did not like cheese and did not like the cream of wheat. When Resident 38 was asked what he got for snacks, he stated he would get a cheese sandwich; however, he stated he did not like the cheese sandwich because he would choke on it. Resident 38 stated he did not report this to his Nurse or to the Dietary Supervisor. Residents Affected - Some During a review of the document titled, Snacks Consumption, for Resident 38 from 9/20/23 to 10/18/23, indicated Resident 38 refused his bedtime snacks on 9/23/23; 10/04/23; 10/09/23; and 10/16/23. During a review of the facility's Diet Manual, under the Mechanical Soft Diet (MSD), the MSD indicated, The mechanical soft diet is designed for residents who experience chewing or swallowing limitations. The diet is modified by mechanically altering, chopped, or ground. Food that may need to be modified include proteins, raw vegetables, raw fruit, and all other fibrous foods. During a review of the facility's job description for, Speech-Language Pathologist Job Description (SLPJD), the SLPJD indicated, Duties and Responsibilities: .Effectively screens/evaluates patients and/with communication, cognitive or swallowing disorders and develops appropriate plan of care following all regulatory and clinical practice standards .Resident 19 2. During a review of Resident 19's, Weights and Vials Summary, dated 10/1/2022 through 10/2/2023, Resident 19's weight was documented as: 10/1/2022 - 136.0 Lbs (pounds) 11/1/2022 - 133.8 Lbs 12/1/2022 - 130.8 Lbs 1/2/2023 - 129.8 Lbs 2/1/2023 - 130.0 Lbs 3/1/2023 - 128.6 Lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 24 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 4/2/2023 - 128.2 Lbs Level of Harm - Minimal harm or potential for actual harm 5/1/2023 - 127.6 Lbs Residents Affected - Some 6/4/2023 - 125.0 Lbs 7/3/2023 - 129.0 Lbs 8/3/2023 - 127.0 Lbs 9/3/2023 - 125.0 Lbs 10/2/2023 - 125.2 Lbs During a concurrent interview and record review on 10/19/23, at 9:29 a.m., with the Registered Dietitian (RD) and Director of Nursing (DON), Resident 19's, Nutrition Evaluation and RDN Review (NE), dated 10/27/2022, was reviewed. The NE indicated, Resident 19's, most recent weight, was 136 lbs, usual weight, was 140 lbs, and Resident 19's weight had been stable for over one year. RD stated, Resident 19's desirable body weight range (DBWR) was 135-145 lbs. The RD stated she did not use the documented ideal weight range (IWR) of 86-105 pounds, noted on the NE, because it was generated from a chart and was not based upon the resident for resident-centered care, and was not recommended. The RD stated the assessed goal for Resident 19 was for weight maintenance at 136 lbs. During the same concurrent interview and record review on 10/19/23, with the RD and DON, Resident 19's, Nutrition- Quarterly Evaluation (NQE), dated 7/25/2023, was reviewed. The RD stated the quarterly evaluation was completed by the Dietary Manager (DM). The NQE indicated, Most recent weight: 129 lbs on 7/3/2023, usual weight 137 lbs .weight history stable x [for] 6 months, .had no changes this quarter . The RD verified Resident 19 had lost 7 lbs. from the time of the RD assessment, on 10/27/2022, in which the goal was for weight maintenance. The RD verified the weight loss was not a planned weight loss. Both the RD and DON stated the unplanned weight loss would not be recognized by the IDT (including the DON, RD or DM) because their facility system was to address unplanned weight change if the facility criteria was triggered, in which it was not in Resident 19's case. Both the RD and DON stated the IDT was to identify, evaluate and address unplanned weight change only if it reached their criteria as a, significant weight change (weight loss or weight gain) of 5% weight change in one month, 7.5% weight change in 3 months or 10% weight change in 6 months. The RD and DON both verified they would not have expected the DM to make a referral to the RD when Resident 19 had an unplanned weight loss of 7 lbs, despite the RD noting Resident 19 had a stable weight the year before. During the same concurrent interview and record review on 10/19/23, with the RD and DON, the RD stated Resident 19 weighed 125.2 lbs as of 10/2/2023. The RD verified Resident 19 had further 4 lb weight loss since the NQE was completed, on 7/3/2023. The DON and RD stated they did not recognize the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 25 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unplanned weight loss as a concern as it was not a, significant weight loss, meaning the weight loss had not fallen within 5% wt loss in one month, 7.5% wt loss in 3 months or 10% wt loss in 6 months. The RD reviewed Resident 19's, Active [physician] Orders as of: 10/18/2023, and noted Resident 19 had an order for, snacks three times a day for supplement, dated 7/01/2018. The RD reviewed Resident 19's EHR (electronic health record) and verified the facility had not evaluated and addressed the slow, progressive weight loss, in order to help prevent or minimize further unplanned weight loss. During a review of Resident 19's, Weights and Vials Summary, on 10/01/2022, Resident 19 weighed 136 lbs. On 10/02/2023, Resident 19 weighed 125.2 pounds, which was a -7.94 % (percent) body weight loss in one year. During a review of the facility's policy and procedure (P&P) titled, Nutrition Care Management, dated 4/20/23, the P&P indicated, Policy: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight (UBW) or desirable body weight (DBW) and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible .Weight loss: Significant weight loss is a loss of (5% in one (I) month, 7.5% in three (3) months, or 10% in six (6) months or unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss (Insidious Weight Loss). Weight loss should be addressed in the care plan. Facility approaches to address weight loss may include root cause analysis and determination of desirable vs undesirable and planned vs. unplanned. During a review of National Library of Medicine, an article titled, Weight Loss - Unintentional (WL), WL, dated 2/2/2023, indicated, When to Contact a Medical Professional; You have lost more than 10 pounds (4.5 kilograms) or 5% of your normal body weight over 6 to 12 months or less, and you do not know the reason. (https://medlineplus.gov/ency/article/003107.htm) During a review of National Library of Medicine, an article titled, An approach to the management of unintentional weight loss in elderly people, dated 3/15/2005, indicated, Weight loss of 4% to 5% or more of body weight within 1 year, or 10% or more over 5 to 10 years or longer, is associated with increased mortality or morbidity or both. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/) Resident 76 3. During an observation on 10/17/23, at 12:28 p.m., in Resident 76's room, Resident 76 was in her bed asleep with her tube feeding pump on (delivery of nutrients through a feeding tube directly into the stomach) with Diabetisource AC (a liquid formula providing nutrition) at 72 ml [milliliters]/hr [per hour], with 250 ml every 6 hours water flush via tube for hydration. During a concurrent interview and record review on 10/18/23, at 3:30 p.m., with the Registered Dietitian (RD) in the presence of the Director of Nursing (DON), Resident 76's, Nutrition-Quarterly Evaluation (NQE), dated 7/20/2022, signed as completed by the RD on 8/22/2022, was reviewed. The NQE indicated, Regular texture diet ., Most recent weight: 226 lbs [pounds] as of 7/03/2022, usual weight 200 lbs, desirable weight range 188-198 lbs, weight history: gradual weight gain, wt [weight] now above DBWR [desirable body weight range] ., unable to interview resident at this time - will follow up to discuss updated preferences and weight goal with resident ., weight has not been within DBWR for >[greater than] 1 year -DBWR should be updated to 206-216 [lbs] in order to better reflect goal weight. Meal intake is consistently 100%. The RD to visit [name of resident] to discuss her personal weight goals and will provide education regarding weight loss if she is agreeable. The RD stated she had previously determined Resident 76's daily calorie needs based on Resident 76's usual body (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 26 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm weight (UBW) of 198 lbs, and the RD used 22 kcal [kilocalories] - 25 kcal/kg [kilogram] of her UBW. The RD was asked how she determined to use 22 kcal/kg, and the RD stated, I reduced it because of her high BMI [body mass index; based on height and weight and a way to measure underweight, normal weight or overweight]. So, in this case it was because of recent weight gain, as her usual weight was 198 lbs, so the goal was to prevent unplanned further weight gain because she is diabetic. Residents Affected - Some During a review of Resident 76's, Significant Change in Status Asses[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 27 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not provide trauma-informed care, for behaviors, for 1 of 5 residents sampled, when Resident 92 was experiencing claustrophobia, anxiety, and panic attacks. Resident 92 lived at the facility for approximately one year and informed staff he suffered from claustrophobia (extreme or irrational fear of small, enclosed, or confined places) but the facility did not assess or attempt to treat his mental health needs as evidenced by: 1. Staff did not develop nursing care plans (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) that addressed Resident 92's claustrophobia and accompanying anxiety; 2. Staff did not notify Resident 92's Physician about his reports of claustrophobia and anxiety; 3. All care staff were not aware of Resident 92's claustrophobia and anxiety and did not attempt to minimize his triggers (a stressor; action/situation leading to an adverse emotional reaction); and, 4. Leadership team members (Administration, Nursing) did not ensure staff were educated and trained regarding provision of care for residents with claustrophobia. Residents Affected - Few This caused Resident 92: 1. To feel panicky and anxious, viscerally ill and angry; 2. Contributed to Resident 92 having verbal outbursts in response to known triggers of closing privacy curtains and closing doors; 3. Potentially prevented Resident 92's physician from being aware of his psychosocial needs, thereby preventing him the opportunity to diagnose and treat Resident 92's condition; and, 4) Potentially prevented Resident 92, and other residents, with a history of trauma or psychiatric needs, from attaining or maintaining their highest practicable mental and psychosocial well-being, thereby negatively impacting their quality of life. Findings: During an observation and concurrent Interview on 10/17/23 at 10:06 a.m., Resident 92 was lying in bed: the bed was elevated in a high position, and the window curtains were open. Resident 92 stated about a week ago, he had an issue with his roommate and it, got heated. He stated the Administrator, DON (Director of Nursing), and DOR (Director of Rehabilitation) were involved, and they called the police on him. Resident 92 stated there was also an incident in August (2023) regarding roommates, and the Social Services Manager (SSM) and her assistant (Staff D) were involved in that episode. He stated the SSM told him at the time (August) he could pay $500 a day if he did not want a third roommate in the room (he was in a three-bed room). During an observation on 10/18/23 at 9:13 a.m., Resident 92 was sitting up in bed quietly looking at his electronic device. His roommate was sitting quietly on his own bed. During an interview on 10/18/23 at 9:15 a.m., Unlicensed Staff E (Staff E) and Unlicensed Staff F (Staff F) were asked about their experience caring for Resident 92. Staff E and Staff F stated Resident 92 liked to stay in bed and he sometimes got up into the wheelchair, but his heels hurt so he did not like to stay up long. Staff E and Staff F stated Resident 92 was chatty, fun to talk to, very friendly and social, and easy to get along with. Staff E and Staff F stated Resident 92 used to work in customer service and was big on introductions and respect. They stated, if they communicated clearly and respected him, he was okay. If he became frustrated, staff could talk to him; he was reasonable if staff communicated with him. Staff F stated Resident 92 was a very pleasant gentleman, and she had never seen him be rude or raise his voice. Staff E and Staff F stated it was hard to get him upset. During the same interview on 10/18/23 at 9:15 a.m., Staff E and Staff F stated Resident 92 was very (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 28 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few independent, and when he used his bedside commode (BSC; portable toilet, containing no water, that can be easily moved around for convenience), he wanted it changed. If a new CNA (Certified Nursing Assistant) was late answering his call light, he wanted to be acknowledged. They said his requests made sense. Staff E and Staff F stated Resident 92 got grumpy if his curtain (privacy curtain between resident beds) was closed. They stated Resident 92 felt claustrophobic, so they gave him a heads-up before closing the curtain. Staff E and Staff F stated Resident 92's room was his private space, and if you bombarded (barged) in, that would upset him. During the same interview on 10/18/23 at 9:15 a.m., Staff E and Staff F were asked how Resident 92 acted if he was upset. Staff E and Staff F stated he would verbalize the issue in a calm tone. For example, he might say, Today is not a good day; I don't appreciate that. He was never agitated, and his language was always polite. Staff E stated she had never heard him yell; other residents yelled, and she could tell who they were because she knew them and heard them often. Staff E and Staff F stated Resident 92 was great to work with. Staff E stated he told her that day that they were like extended family, and he stood out to her as a kind, considerate person. During an interview on 10/18/23 at 11:20 a.m., the Volunteer Ombudsman (VM; resident advocate; handles complaints against facilities; works to resolve problems related to residents' health, safety, welfare, and rights) stated she met with Resident 92 on several occasions. The VM stated Resident 92 was unable to walk, was unable to get out of bed independently, and needed staff assistance transferring to the BSC. The VM stated Resident 92 could get emotional and worked up. She stated he was depressed and grieving his illness and the potential amputation of his leg. The VM stated she thought Resident 92 needed psychiatric intervention. During the same interview on 10/18/23 at 11:20 a.m., the VM stated the facility had a hard time getting Resident 92 a roommate. She stated he was claustrophobic and got embarrassed using the BSC with B Bed (middle roommate in a three-bed room) so close. She stated one of Resident 92's past roommates had gotten out of bed in the middle of the night and gone up to Resident 92 (while he was lying in bed). The VM stated, the prior week, staff brought in a new resident (as a roommate into Resident 92's room), and the facility reported to her Resident 92 was verbally aggressive with the new roommate. In response, the VM stated the Administrator or Social Service Manager (SSM) called the police. The VM stated Resident 92 was upset the police were called, was fearful he would have a police record, and was afraid he would be evicted from the facility. During an interview on 10/18/23 at 3:07 p.m., Resident 92 was lying in bed and described the incident that occurred on 10/6/23. Resident 92 stated his prior roommate had checked out and he had no roommates for a few days. Resident 92 stated, on the day of the incident, Unlicensed Staff D (Staff D, the SSM's assistant) notified him he was getting a roommate. He stated the new roommate was confused and called him a pervert right off the bat. Resident 92 stated he was given no notification of this confused resident as a potential roommate and staff did not run it by him; he stated staff did not give him information regarding the roommate's willingness to keep the curtains and the door open. During the same interview on 10/18/23 at 3:07 p.m., Resident 92 stated the DOR and a, CNA (actually not a CNA but a student the DOR was training) were present when the incident occurred on 10/6/23. Resident 92 stated he told the DOR and, CNA, as they were moving the new roommate into the room, that, this is not going to work. When asked what their response was, Resident 92 stated they ignored him and continued to move the person into the room. Resident 92 stated he began recording the interaction on his Ipad, and the DOR became, incensed about the recording and closed the privacy curtain, which made him feel, panicky and anxious. Resident 92 stated he tried to use reason and civility but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 29 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (when that did not work), he got angry, lost his temper, and shouted. He stated staff raised their voices in response and took the roommate out of the room. During the same interview on 10/18/23 at 3:07 p.m., Resident 92 stated he felt angry, his heart was beating fast, and he felt viscerally ill after the incident. He stated he put the (head of the) bed down and put a mask over his eyes (to try and calm down). Resident 92 stated the next two people into the room were the Administrator and the Director of Nursing (DON) who stated they needed to talk. Resident 92 stated he felt like he was being ambushed and told them he was not talking, he was angry and, I want to calm down. He stated they left the room and a few minutes later he felt a kick on the bed and the Administrator told him the police were on the way; the Administrator left the room. During the same interview on 10/18/23 at 3:07 p.m., Resident 92 stated in his entire life, he had never had the Police called on him, and he did not know if they were going to arrest him. He stated the Sheriff showed up (with the DOR) and told him he had received a complaint about him. The Sheriff asked the DOR if Resident 92 as able to get out of bed. Resident 92 stated he answered himself and told the Officer he could transfer to a wheelchair with help from a CNA. Resident 92 stated the Sheriff asked him if he could, keep it down, they talked, and he apologized for having him called out. Resident 92 stated his current roommate was later moved into the room, and he was a wonderful roommate. During the same interview on 10/18/23 at 3:07 p.m., Resident 92 stated he had been suffering from claustrophobia for thirty years. He stated it began after he had an experience where he was trapped in an elevator. He stated his claustrophobia lead to panic attacks, and it reminded him of PTSD (Post Traumatic Stress Disorder). Resident 92 stated, if someone shut the door or shut the curtains, he could, freak out. He stated, if the CNA's closed the door or curtains (to care for a roommate) and then reopened them, it was okay. When asked about potential triggers, Resident 92 stated loud noise or televisions could trigger a panic attack. Resident 92 stated he had spoken to the Social Worker (SSM) in the past (08/2023) about roommates in the B-Bed (immediately next to his bed) being in close proximity to his BSC. He stated the SSM told him, if he wanted to keep the B-Bed open (without a roommate), he could pay $500 per day to keep the bed open. Resident 92 stated he had no conversations with staff in the past regarding his claustrophobia, and stated they almost treated it as if it were not real or, it's a joke. Review of Resident 92's medical record revealed he had a BIMS (Brief Interview for Mental Status; cognitive assessment tool) of 15, indicating he was cognitively intact. Review of an MDS (Minimum Data Set; assessment tool), dated 7/19/23, indicated Resident 92 required the assistance of one person (staff) to transfer (bed to wheelchair or BSC), walk in the room, and move about the unit. Review Resident 92's medical record revealed a nursing note documented by the DON (and other IDT team members), dated 10/6/23 at 3:12 p.m., which indicated, .resident altercation that occurred today . Patient (roommate) was assisted back to his room when . Resident 92 made severe and excessive verbal comments to (the roommate) and also to the therapist (DOR) and his student (who were assisting the roommate to bed) . (Resident 92) proceeded to film this pt (patient; roommate) with his Ipad . the therapist closed the privacy curtain to which he (Resident 92) responded (cursing vocabulary quoted) . He also made sexually aggressive remarks . Resident (roommate) and student immediately removed . DON and DOR went to the room to address the situation but were told to leave . ED (Administrator) went to the room with the DON and DOR . Resident (92) was informed that his behavior is unacceptable . Resident (92) was in bed with an eye mask, pretending to be (sic) asleep throughout the whole thing . informed the local authorities will be called . reported to (county) Police Department . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 30 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Resident is currently on a three-bed unit and refuses to have a roommate citing that he has claustrophobia, he claims that he has extensive medical records that show his claustrophobia . A comprehensive review of his medical records was performed with no success at finding claustrophobia diagnosis . (Roommate) assessed for psychosocial distress . The note did not indicate Resident 92 was assessed for psychosocial distress. Residents Affected - Few Review Resident 92's medical record revealed a nursing note documented by the DON, dated 10/5/23 (the day prior to the incident) at 11:45 a.m., which indicated, . spoke to the resident today to discuss possible room transfer . Resident is aware that his current room is a three-person room but refuses to have roommates citing that he has claustrophobia .he is fixated on his roommates, claiming that it is difficult for them to be moved around so much (frequent room changes) . Explained to resident that facility has accommodated his needs to not wanting a third roommate but with growing census and the facility's responsibility to serve patients in the community, resident has to keep an open mind to moving . Review of Resident 92's medical record on 10/19/23 at 10:26 a.m., revealed he had no nursing care plans or documented COC's (change of condition) that addressed his claustrophobia, potential triggers (curtain/door closure), roommate challenges, anxiety, or behaviors associated with these issues. (COC: sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains). During an interview on 10/19/23 at 11:14 a.m., Unlicensed Staff G (Staff G) stated Resident 92 liked to talk and converse about television. Staff G stated he put on his call light to empty the urinal (plastic container for urine) and BSC. He stated he had claustrophobia and did not like the curtains closed but he (Staff G) sometimes had to shut the privacy curtains. Staff G stated he had never seen Resident 92 yell at staff or residents. During an interview on 10/19/23 at 11:22 a.m., Licensed Staff C (Staff C) stated he worked full-time (as a nurse) at the facility and was usually assigned to Resident 92's hall. Staff C stated Resident 92 was pleasant, cooperative and would engage in conversation. He stated, if there were any medication issues, Resident 92 would let them know. When asked if he observed Resident 92 exhibit (negative) behaviors, Staff C stated he had not seen him lash out. Staff C stated, if Resident 92 had an issue regarding his care, he would tell Staff C about it. Staff C stated Resident 92 was very rational; he stated he analyzed (the issue) first and then asked questions. Staff C stated he appreciated that Resident 92 was alert and oriented (cognitively intact, not confused). When asked if he had seen Resident 92 yell at staff, Staff C stated, Not that I recall. When asked if he yelled at other residents, Staff C stated, He doesn't yell. If he thinks his roommate is doing something wrong, he let staff know. Staff C stated Resident 92 usually got along with his roommates and was usually pleasant with roommates and staff. When asked about his claustrophobia and anxiety, Staff C stated he was not aware of his claustrophobia, and Resident 92 had not verbalized anxiety to him. During an interview on 10/19/23 at 11:37 a.m., Unlicensed Staff H (Staff H) stated she was a new nursing assistant, had been working at the facility for approximately two weeks, and had worked with Resident 92. She stated Resident 92 was straightforward, super easy, and a, super nice man. Staff H stated Resident 92 told her he was claustrophobic and stated, I ask before closing the door. When asked about the privacy curtains, Staff H stated she did not close the curtains. During an interview on 10/19/23 at 11:46 a.m., the Medical Director (MD, Resident 92's Physician) stated Resident 92 was intermittently agitated and frustrated. He stated he was a younger resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 31 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who had been dealing with infection issues and he did not want to be at the facility. The MD stated Resident 92 had kind of given up. He stated Resident 92 had the option to see a Psychiatrist but had not wanted to. When asked about Resident 92's claustrophobia, the MD stated he did not hear about that, and stated Resident 92 spoke to him about his infections. The MD stated if he had know about the claustrophobia, he would referred him to Psychiatric Services. The MD stated claustrophobia could indicate a history of something unpleasant. When asked about Resident 92's issue with closing the privacy curtains, the MD stated that was reasonable (given the claustrophobia). The MD stated Resident 92 was a, nice guy. When asked why administration called the police but did not call him (in response to the 10/6/23 incident), the MD stated he did not know why they called the police. He stated they could have called him and maybe he could have given (Resident 92) some medication. Review of facility policy titled, Behavioral Health Services, subtitled, Procedure (revised 3/2023), indicated, . 6. The physician, in collaboration with the IDT team, will determine the appropriate psychiatric or psychological treatment or rehabilitative services needed. Treatment will be provided as ordered by the physician . During an interview on 10/19/23 at 2:32 p.m., Unlicensed Staff D (Staff D) stated she worked with Resident 92 in the past and her current job involved assisting with room changes. Staff D stated, in August (2023), she had to put someone in the B-Bed (third resident in the room) of Resident 92's room because there were no other room for that person. She stated Resident 92 said he did not want anyone in the B-Bed because he was claustrophobic. Staff D stated Resident 92 became aggressive with staff (not the roommate), played his radio loudly, and threw something on the ground. When asked why she thought he got so upset, Staff D stated, I'm not sure and stated she thought Resident 92 did not like anyone in the middle bed because it made him nervous. Staff D stated Resident 92 always got nervous with room changes. During the same interview on 10/19/23 at 2:32 p.m., Staff D stated, on 10/6/23, they had to move a roommate into Resident 92's room. Staff D stated the new roommate was confused but very sweet. She stated they (IDT team: Interdisciplinary Team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff) thought it would be a good match, and the IDT informed Resident 92 a new resident would be moving in. Staff D stated, about ten minutes before the move, Resident 92 began to get agitated, anxious, and was worried about who was coming. When asked what was done in response to Resident 92's anxiety, she stated they tried to talk to him but moved the new resident into the room because, We didn't have an (another) option. Staff D stated Resident 92 was upset and verbalized to her about the new roommate and, vented (expression or release of strong emotions) on her. She stated she let things calm down and then left the room. During an interview on 10/19/23 at 3:02 p.m., the Social Service Manager (SSM) stated she had taken over as manager of the Social Services Department at the facility in June, 2023 (approximately four months earlier), and she had had pleasant interactions with Resident 92 at that time. The SSM stated things started shifting, and he began to have, attitude with her personally. When asked to describe the attitude, the SSM stated he had, temper tantrum(s), turned the volume of his music and television up, and yelled at them (staff). The SSM stated Resident 92 had always had roommates during his stay at the facility, and she, a nurse and the Ombudsman (professional patient advocate) would coordinate about roommates. In August, 2023, they put a Hospice patient into Resident 92's room, and he was upset because the roommate walked around the room, slept in the B-Bed, and looked out the window. She stated it was difficult to find him a roommate. When asked about the 10/6/23, incident, the SSM stated it was the same type of situation (as August), and she thought the new roommate was a good fit for Resident 92. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 32 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During the same interview on 10/19/23 at 3:02 p.m., the SSM stated Resident 92 had verbally expressed his claustrophobia to her and told her about leaving the curtains open. She stated they kept the B-Bed open (no roommate in the middle bed) but, We can only do so much. The SSM indicated she had not received specific training on working with a resident with claustrophobia. During an interview on 10/19/23 at 3:35 p.m., the DOR stated Resident 92 was a nice guy during 90% of their interactions, and he seemed like a pleasant guy, but he had an explosive temper. The DOR stated Resident 92 did not like the privacy curtains closed and cursed at an Occupational Therapist (OT; healthcare professional who assists residents with everyday life activities to promote health, well-being, and independence) in the spring of that year when they closed the curtains. The DOR was present during the 10/6/23, incident. He stated he and a student were bringing Resident 92's roommate back into the room when Resident 92 took out his Ipad (to tape them). He stated Resident 92 was not upset until they closed the privacy curtain, at which point he cursed at the student. When asked if the curtain triggered his anger, the DOR stated, Yes. The DOR stated he sent the student and roommate out of the room to diffuse the situation and got the Administrator and DON. The DOR stated, when he went into the room with the sheriff, Resident 92 was calm. The DOR stated Resident 92 told the officer that he had overreacted. The DOR stated Resident 92 had total control of the room. When asked what he knew about Resident 92's claustrophobia, the DOR stated he did not know a lot about that. When asked how the facility accommodated his claustrophobia, the DOR stated they do not put a person in the middle (B-Bed) bed. The DOR indicated he had not received specific training on working with a resident with claustrophobia. Review of facility policy titled, Behavioral Health Services, subtitled, Procedure (revised 3/2023), indicated, .10. The facility will provide appropriate training to staff, to ensure skills and competencies that include but not be limited to the following: a. Caring for residents with mental and psychosocial disorders . c. Trauma-Informed Care. During an interview on 10/20/23 at 11:23 a.m., the DON stated Resident 92 was pleasant 95% of the time and was a smart guy who thought highly of himself. He stated they had been friendly in the past until leadership called the Police. The DON stated in August, they had an incident with Resident 92 that involved a roommate transfer; Resident 92 had berated and blown up at staff, but no residents were involved. The DON stated the type of verbal abuse (that occurred 10/6/23) was over the top. He stated Resident 92 knew not to do that stuff. The DON confirmed the facility called the Police, but did not call a Physician, in response to Resident 92's outburst on 10/6/23. During the same interview on 10/20/23 at 11:23 a.m., the DON was asked what might be the Root Cause (causes of problems) of Resident 92's outbursts, and he stated Resident 92 liked a sense of control. The DON stated Resident 92 stated he had claustrophobia but it was not documented (in his medical record). The DON stated Resident 92 was able to take a shower (in a small space), and stated they could not verify that he was claustrophobic. When asked why he (the DON) had not reached out to a Physician to obtain a diagnosis and determine if he was claustrophobic, the DON stated they were focused on roommates and getting someone Resident 92 was happy with. When asked if leadership staff should have reached out to a Physician, the DON stated they, could have been more specific. When asked about Resident 92's anxiety, the DON stated he was not aware of Resident 92 experiencing anxiety or panic attacks. During the same interview on 10/20/23 at 11:23 a.m., the DON was asked why Resident 92 had no nursing care plans, IDT meeting documentation, or Change of Condition addressing Resident 92's behaviors around claustrophobia and anxiety. The DON stated, We dropped the ball. The DON stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 33 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator followed up with Resident 92 after the October incident, but did not document the interaction in his medical record. The DON stated he had many conversations with Resident 92 about roommates but did not document them. The DON stated the facility had an in-house Psychiatrist available who could have seen Resident 92, regardless of insurance constraints. Review of facility policy titled, Comprehensive Person-Centered Care Planning, subtitled, Policy (dated 4/2023) indicated, . the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's . mental and psychosocial need that are identified in the comprehensive assessment . Review of facility policy titled, Behavioral Health Services, subtitled, Policy (revised 3/2023) indicated, . this facility to provide residents with necessary behavioral health care and services to attain and maintain the highest practicable . mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes . those with history of trauma and/or post-traumatic stress disorder. Trauma survivors will receive . trauma-informed care in accordance with professional standards of practice and according for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 34 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement an order for a sippy cup for all beverages to ensure one of one sampled resident (Resident 18) could use the assistive device when drinking. Residents Affected - Few Failure to provide appropriate assistive devices to residents who need them could impede their ability to drink independently and may result in decreased fluid intake. Findings: During a concurrent observation and interview on 10/16/23, at 12:32 p.m., with Unlicensed Staff R, in the presence of Registered Dietitian (RD), in the dining room, Resident 18 had a sippy cup with brown liquid, a cup of water, and a cup of milk in front of her on the table. Resident 18 was drinking her beverage from the sippy cup. Resident 18 was pointing to the cup with milk and looking at staff while pointing. Unlicensed Staff R spoke to Resident 18 in Spanish and asked Resident 18 how she preferred to drink her fluids. Unlicensed Staff R stated, Resident 18 stated she preferred to drink from a sippy cup. Unlicensed Staff R stated the brown liquid in the sippy cup was coffee. During a review of Resident 18's, Meal Tray Card (MTC), located on Resident 18's meal tray, the, MTC indicated, Adap.[adaptive] Equip [equipment]: Sippy cup .Standing Orders: 6 fl [fluid] oz [ounce] Decaf Coffee, 8 fl oz Milk Whole, 8 fl oz Water . During an interview on 10/16/23, at 12:50 p.m., with Therapy Staff N, in the presence of the RD, Therapy Staff N stated she did not know why only one beverage was put in a sippy cup and did not know why all beverages could not be put in a sippy cup to help Resident 18 drink independently. Therapy Staff N and the RD stated the OT (Occupational Therapist) specialized in adaptive equipment, and it was the OT who ordered adaptive equipment. During a review of Resident 18's Physician Order (PO), dated 9/1/23, the, PO indicated, Order Summary: Sippy cup on meal trays, Confirmed By: [name of] SLP . During a review of Resident 18's Nutrition Interdisciplinary Care Plan (NIDTCP), date initiated, 9/15/23, the NIDTCP indicated, Sippy cup on meal trays. During a review of Resident 18's IDT (Interdisciplinary Team) care plan, created on 10/16/23, the IDT care plan indicated, Focus: [name of resident] prefers to have sippy cup during meals for easier handle of liquids and improve drinking skills, Goal: Will maximize independence during meals, Intervention: Encourage fluid intake . During a concurrent interview and record review on 10/17/23, at 11:54 a.m., with Occupational Therapist Therapy Staff S, Resident 18's order for a sippy cup, dated 9/1/23, was reviewed. Therapy Staff S stated it was a telephone order written by the SLP. Therapy Staff S stated it would help Resident 18 reach her highest practicable well-being if all liquids were provided in a sippy cup when a sippy cup was ordered. Therapy Staff S stated she did not know why that could not happen, or why that did not happen. During an interview on 10/17/23, at 2:32 p.m., with Therapy Staff N , Therapy Staff N stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 35 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete had not completed an evaluation for Resident 18, as an ST (Speech Therapist) evaluation had not been ordered, but she observed Resident 18 spilling her drink during a dining observation. Therapy Staff N verified she obtained the order for a sippy cup on 9/1/23. During a review of the facility's policy and procedure (P&P) titled, Self-Feeding Devices, dated 2023, the P&P indicated, Policy: Residents will receive self-feeding devices to maintain or improve their ability to eat or drink independently. Procedures: The PT [physical therapist], OT, or ST, and/or designated person will evaluate residents for the need of a self-feeding device. 2. Devices commonly used, such as divider plates and feeding cups, will be kept in stock. A physician's order is recommended. 3. The Food & Nutrition Services Department will store self-feeding devices. Residents needing devices will receive them with each meal or snack, on their meal trays. Tray cards and diet profile will record which device is needed . Event ID: Facility ID: 055987 If continuation sheet Page 36 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe food handling and sanitary practices, when: Residents Affected - Many 1. Dietary Aide (DA) 2 failed to perform hand hygiene after touching a dirty utility cart, before touching a clean utility cart and clean dishes. 2. The Maintenance Supervisor (MS) failed to ensure one of one facility ice-machines was sanitized in accordance with the ice-machine's manufacturer's guidelines. These failures had the potential to result in cross contamination and foodborne illness in a highly susceptible resident population of 111 residents who were on oral diets. Findings: 1. During an observation on 10/16/23, at 10:21 a.m., in the kitchen at the dirty side of the room in front of the dirty side of the dish machine, Dietary Aide (DA) 1, was using a high- pressure water sprayer to spray food debris off a black utility cart that had just held dirty dishes from residents' breakfast. During an observation on 10/16/23, at 10:22 a.m., in the kitchen, Dietary Aide (DA) 2 was entering the dirty side of the room, located in front of the dish machine, and pushed the same black utility cart that was, dirty with her hands. DA 2 went to go to another utility cart that was clean and had clean pots and pans on top, and DA 2 pushed the cart into the food preparation area, without washing her hands. Next, DA 2 went to the clean side of the dish machine and touched clean plates, without washing her hands. During an interview on 10/16/23, at 10:24 a.m., in the kitchen, DA 2 was handling clean dishes at the clean side of the dish machine. The DM (Dietary Manager) spoke in Spanish to DA 2 to inform DA 2 that she was observed pushing the dirty utility cart and then proceeded to handle clean dishes, without washing her hands. DA 2 verified she should have washed her hands after handling a dirty task prior to handling a clean task and had not. The DM then directed DA 2 to go wash her hands. During a review of the facility's policy and procedure (P&P) titled, Hand Washing Procedure, dated 2020, the P&P indicated, Hand washing is important to prevent the spread of infection .When hands need to be washed: .2. After handling soiled dishes and utensils . 2. During a concurrent observation and interview on 10/16/23, at 11 a.m., with the Maintenance Supervisor (MS), inside the kitchen, the inside of the ice-machine bin and ice-making apparatus (top portion) was viewed. The MS stated he was responsible for cleaning the ice-machine for the past year. The MS verified there was no outside service company that cleaned the ice-machine in the past year. The MS was asked to show all products he used to clean the ice-machine, and he showed a bottle labeled by the manufacturer as, Manitowoc Ice Machine Cleaner/De-Scaler. The MS stated he ran the cleaner through the ice-making apparatus on a monthly basis. The MS was asked if there were any further products or steps he did after he was done with the ice machine cleaner/de-scaler product, and the MS added he removed the parts located inside the ice-making apparatus and cleaned them individually with the de-scaler. The MS was asked multiple times, in the presence of the Dietary Manager (DM) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 37 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Registered Dietitian (RD), if there were any other steps and/or products he used for the ice-machine, whether it was on a quarterly, semi-annual or annual basis, and the MS stated, No. The MS pointed to the bottle of Manitowoc ice machine cleaner/de-scaler and stated that was the only product used. During a concurrent interview and record review on 10/16/23, at 11:04 a.m., with the MS, in the presence of the DM and RD, the ice-machine manufacturer's guidelines (MG's) that were located on the inside panel of the ice-machine were reviewed. The, MG's indicated there was a sanitizing step after the cleaning step. The MS verified he had not done the sanitizing step for the ice-machine, and stated, I will going forward. Both the MS and RD were asked if the sanitizer step specified what sanitizer to use, and both the MS and RD reviewed the MG's, and stated they did not know but would look further into it. During further review of the ice-machine's, MG's, the MG's indicated to only use Manitowoc approved ice-machine cleaner and Manitowoc sanitizer. During a concurrent observation and interview on 10/16/23, at 11:21 a.m., with the RD and MS, in the conference room, the RD showed a bottle of Manitowoc ice-machine sanitizer, and stated, I think there was confusion because we do have ice-machine sanitizer. Concurrently, the MS verified the Manitowoc ice-machine sanitizer was in the building, but it was not part of his practice to use the sanitizer after he cleaned the ice-machine with the cleaner/de-scaler, and the MS stated, I will use it from now on. During an observation on 10/18/23, at 12:05 p.m., at the nursing station in front of the conference room, there were pitchers of water with ice in them to be filled with water by a Certified Nursing Assistant to be delivered to residents. During a review of the ice-machine's MG's, provided by the facility, the, MG's indicated, Clean and sanitize the ice machine every six months for efficient operation .Ice machine descaler is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated 2023, the P&P indicated, Policy: The ice machine needs to be cleaned and sanitized monthly 3. Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. Add instructions to your policies or use manufacturer's procedures to clean and sanitize the machine . During further review of the purpose of the products, the, Manitowoc Sanitizer and De-scaler Cleaner/De-scaler removes lime scale and mineral deposits from machine components. Sanitizer is used at least once every six months to remove algae, biofilm growth and to disinfect the machine. Meets EPA (Environmental Protection Agency) criteria for use against SARS-CoV-2 (cause of COVID-19). (https://www.manitowocice.com/Sanitation#:~:text=Manitowoc%20Sanitizer%20and%20De%2Dscaler,and%20to%20disinf FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 38 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure its Social Service Manager (SSM) was qualified for her position, when the SSM was leading the Social Services Department since approximately June, 2023 (approximately four months), but did not hold a Bachelors Degree (four-year college degree covering standard general education requirements and a specialized area of interest) in a human services field ([NAME] including, but not limited to, sociology, special education, rehabilitation counseling, and psychology); the SSM had an Associates Degree (two to three-year college degree; academic qualifications below a bachelor's degree) in business. In addition, the SSM did not have prior Social Service work experience in a Skilled Nursing Facility (like the facility) prior to her employment, which began in April, 2023 (approximately six months earlier). Residents Affected - Many This failure potentially prevented 114 residents, in a census of 114 residents, from attaining or maintaining their highest practicable mental and psychosocial well-being, consistent with the resident's plan of care, when the SSM did not have the required education to run the Social Services department and perform her job duties (planning, organizing, developing, and directing the overall operations of the Social Service Department). Findings: Review of facility license titled, State of California Department of Public Health (effective date 5/16/2023 5/15/2024), indicated, .Licensed Capacity: 144 . Bed Classifications/Services/Stations 144 Skilled Nursing (beds) . During a confidential interview on 10/18/23 at 11:20 a.m., Confidential Volunteer stated the SSM was, overloaded (with her job duties) and spent a lot of her time working on room changes (moving residents to new rooms when necessary). During an interview on 10/19/23 at 3:02 p.m., the SSM was asked how long she had been the facility's Social Services Manager, and she stated she had, just started. The SSM stated she had a BA in business (Bachelor of Arts). The SSM stated, in the past, she had worked as a banker, a realtor, and a CNA (Certified Nursing Assistant) when she was younger. The SSM stated she started (at the facility) in April (2023), was trained by Corporate Consultant M, and took over (the department) in June (2023). Review of the SSM's signed job description titled, Social Services Manager, indicated she was hired on 4/17/23, as the Social Service Manager. Under subtitle, Position Summary, the document indicated the manager's primary purpose was to, plan, organize, develop, and direct the overall operation of the Social Service Department . to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis . During an interview on 10/20/23 at 3:46 p.m., the Administrator was asked about the SSM's qualifications to manage the facility's Social Service Department. The Administrator stated the SSM had a college degree in business with an emphasis in communications, had previously worked in child care, and stated he would provide a copy of her qualifications, including her educational degree and work experiences (Evidence of the SSM having a Bachelor's Degree was not provided). During an interview and concurrent review of the SSM's employment application on 10/20/23 at 4:05 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 39 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0850 Level of Harm - Minimal harm or potential for actual harm p.m., the Administrator stated the SSM had an AA (Associate's Degree), not a Bachelor's Degree. Review of the SSM's job application titled, (Facility Name) Application For Employment - SNF California, subtitled, Please List Education Relevant To The Position For Which You Are Applying (revised 3/2022), indicated she graduated from (School Name) College Community (two-year college) with a major in, business/communications. Residents Affected - Many Review of facility job description titled, Social Services Manager, subtitled, Qualifications, further subtitled, Education and/or Experience (dated 11/2021), indicated, Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology. The document did not contain requirements for one year of supervised social work experience in a health care setting working directly with individuals (federally-mandated requirement). During an interview on 10/23/23 at 9:05 a.m., the Administrator stated the facility had suspended the SSM and contracted (hired) an individual with a PhD (Doctor of Philosophy; highest academic level in a given field of study) for their Social Service Department. During an interview on 10/23/23 at 11:47 a.m., the Administrator was asked how the SSM's AA degree was not noticed when she was hired. The Administrator stated it, got missed, and the facility needed a better process. He stated, if they had a better process, they (the hiring committee, which included the Administrator) could have caught it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 40 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies once identified, as evidenced by: 1. Facility leadership did not identify that the Social Service's Manager (SSM) was not qualified to run the Social Services Department (Cross reference F850); 2. Clinical staff failed to recognize, evaluate, and address unplanned weight gain, and slow and progressive weight loss (Cross reference F692); and, 3. Facility leadership did not ensure residents were treated with dignity and respect when effective interventions were not implemented to address staff failure to answer call lights (dome light typically located outside a resident's room providing a visual/audio indication of calls for help originating from the bedside and bathroom) or answer call lights timely and did not identify that staff communicated with each other, in front of residents, using languages residents did not understand (Cross reference F550). These failures prevented the facility from gaining insight into potential system failures (social services, nursing, dietary, certified nursing staff competency, etc.), thereby impairing facility leadership from implementing changes that would ensure residents attain and/or maintain their highest practicable physical, mental, and social well-being. Findings: During an interview on 10/20/23 at 3:46 p.m., the Administrator reviewed the facility's QAPI program and described the Quality Improvement projects implemented over the past year. The Administrator stated the facility QAPI committee had not identified staff were speaking languages around residents they did not understand and this was negatively impacting residents. He stated the QAPI committee identified Call light response times as an ongoing issue (but the issue persisted). During the same interview on 10/20/23 at 3:46 p.m., the Administrator was asked about the SSM's qualifications to manage the facility's Social Service Department. The Administrator stated he would provide a copy of her qualifications including her educational degree and work experiences. (These were not provided). During an interview and concurrent review of the SSM's employment application on 10/20/23 at 4:05 p.m., the Administrator stated the SSM had an AA (Associate's Degree), not a Bachelor's Degree (indicating she was unqualified to run the Social Services Department). Review of document titled, (Facility Name) Application For Employment - SNF California, subtitled, Please List Education Relevant To The Position For Which You Are Applying (revised 3/2022), indicated she graduated from (School Name) College Community (two-year college) with a major in, business/communications. Review of facility job description titled, Social Services Manager, subtitled, Qualifications, further subtitled, Education and/or Experience (dated 11/2021), indicated, Must have, as a minimum, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 41 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology. The document did not contain requirements for one year of supervised social work experience in a health care setting working directly with individuals (federally-mandated requirement). During an interview on 10/23/23 at 9:05 a.m., the Administrator stated the facility suspended the SSM and contracted (hired) an individual with a PhD (Doctor of Philosophy; highest academic level in a given field of study) for their Social Service Department. Review of facility policy titled, Quality Assessment and Performance Improvement, subtitled, Purpose (revised 7/5/2022), indicated, The purpose of the QAPI Plan and processes is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable physical, mental, and social well-being. Under subtitle, Framework/Procedures:, the policy indicated, . 4. Committee functions include: QAPI plan, identifying and prioritizing PIPs (performance improvement plans), implementing actions to correct quality issues, and monitoring to ensure the corrective action implemented is being sustained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 42 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and records review, the facility failed to maintain an effective infection control program, when nursing staff did not assess and monitor for signs of COVID-19 (Corona Virus Disease of 2019 - an infectious respiratory disease) for three of four sampled residents (Resident 44, 21 and 110), when Resident 44 tested positive for COVID-19 and Residents 21 and 110 were exposed to a COVID positive resident. This failure had the potential risk for exposing health care workers to undetected COVID-19 positive residents thereby exposing other residents, staff, and visitors of the infectious disease. Residents Affected - Some Findings: During a review of the Face Sheet (A one-page summary of important information about a resident) indicated Resident 44 was admitted on [DATE], with diagnoses including but not limited to Alzheimer's Disease (type of dementia that causes problems with memory, thinking and behavior); and Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). During a review of the Progress Notes titled, Change in Condition, dated 10/02/23 at 6:20 a.m., indicated Licensed Staff A found Resident 44 gasping for air with eyes rolling back at 3:30 a.m., on 10/02/23, and was sent to the hospital at 3:47 a.m. During a review of the hospital record titled, After Visit Summary, dated 10/02/23, indicated Resident 44 had a diagnosis of COVID-19 virus infection. During a review of the Respiratory Status Care Plan, created on 10/09/23, for Resident 44, indicated interventions to include but not limited to, Monitor/document/report abnormal breathing patterns to MD (Medical Doctor): increased rate, decreased rate, periods of apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts); prolonged inhalation (breathing in), prolonged exhalation (breathing out), prolonged shallow breathing, prolonged deep breathing, pursed-lip breathing (exercise that help slow breathing and inhale and exhale more air), nasal flaring (occurs when the nostrils widen while breathing). During an interview and concurrent record review with the IP (Infection Preventionist) on 10/09/23 at 11:33 a.m., the IP stated Resident 44 shared a room with Resident 21 and Resident 110 prior to her hospitalization. He stated Resident 44 was moved to another room after returning from the hospital and was put on isolation (the state of one who is alone)/droplet precaution (used to prevent the spread of bacteria that are passed through respiratory secretions) through 10/12/23. The IP stated Resident 44, Resident 21 and Resident 110 were monitored for signs and symptoms of COVID, every shift. When the IP was asked where the nurses documented their resident assessment, he stated they were expected to document in Residents' Progress Notes or on the Medication Administration Record (MAR); however, after review of the Progress Notes and MAR for Resident 44, Resident 21 and Resident 110 with the IP, the IP stated there was no documentation to indicate Resident 44, Resident 21 and Resident 110 were monitored every shift for signs of COVID. During an interview with Licensed Staff Q on 10/09/23 at 12:07 p.m., when asked about the facility policy for COVID positive residents, and residents exposed to COVID positive individuals, Licensed Staff Q stated residents were isolated for ten days and were monitored for signs of COVID, every shift. Licensed Staff Q stated resident assessment was documented in the MAR and in the vital signs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 43 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 section. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with the DON on 10/09/23 at 12:40 p.m., when asked about the facility policy when a resident tested positive for COVID, the DON stated the resident would be put on isolation/droplet precaution and would be monitored every shift for signs of respiratory changes and increased temperature. The DON stated nurses were expected to document their resident assessment/observation in resident's Progress Notes/medical records. After review of Resident 44's Progress Notes from 10/2/23 to 10/09/23, with the DON, the DON stated there was no documentation in Resident 44's record to indicate she was monitored for signs of COVID. Residents Affected - Some During an interview and concurrent record review with the DON on 10/09/23 at 12:48 p.m., when asked about their policy for residents who were exposed to COVID positive individuals, the DON stated residents exposed were tested for COVID within 24 hours and would be monitored every shift for signs of COVID. After review of Resident 21's and Resident 110's Progress Notes from 10/02/23 to 10/09/23, the DON stated there was no documentation in Resident 21's and Resident 110's record to indicate they were monitored for signs of COVID. Review of the Facility policy titled, Infection Prevention - Surveillance of Infections and Reporting, (no date) indicated, The charge nurse reports any residents displaying any signs/symptoms and the nature of the symptoms on the 24 Hour Report. All potential/actual infections must be treated as a change of condition. Review of the Facility policy titled, Change of Condition Reporting, revised on January 2023, indicated, Document resident change of condition and response in nursing progress notes, and update resident Care Plan, as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055987 If continuation sheet Page 44 of 44