Health inspection·January 14, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to implement measures to prevent a fall for one (Resident 1) of ten sampled residents when nursing staff did not ensure Resident 1 wore non-slip socks during an assisted transfer from his bed to a shower chair.This failure resulted in Resident 1 sustaining a laceration to the left foot and a 5th digit fracture.Findings:A review of Resident 1's admission record indicated he was admitted in August 2024 with diagnosis of acute kidney failure (a rapid loss of the kidney's ability to filter waste), epilepsy (a brain disorder causing recurring seizures) and instability of the left knee. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/9/25, indicated Resident 1 had no memory impairment. The MDS further indicated Resident 1 was dependent on staff for assisted bed to chair transfers.A review of Resident 1's Fall Risk Assessment, dated 1/9/26, indicated Resident 1 required the use of assistive devices for gait and balance.A review of Resident 1's care plan, related to Resident 1's impaired physical mobility related to decreased muscle strength, coordination or balance indicated staff were expected to make sure the resident wears non-slip shoes or socks.A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) note dated 12/27/25 at 1:34 p.m., indicated, laceration to bottom of left pinky toe with floppy left pinky toe. Non-resistive to ROM [range of motion]. 0.9 x 2.0 x 0.2 cm [centimeters, a unit of measurement], bleeding noted. MD [physician] notified; RP [Responsible Party] notified. A review of Resident 1's nursing note dated 12/27/25 at 4:08 p.m. indicated, CNA [Certified Nursing Assistant] reported to this nurse that resident injured toe during transfer. Upon assessment resident noted with laceration to plantar aspect [bottom surface of foot] of L [left] 5th toe. Measurements are 2.0 cm L [length] x 0.8 cm W [width] x 0.2 cm D [depth]. Toe also appears floppy, feels disconnected with no resistance. Patient denies pain. Laceration cleansed with NS [normal saline, a solution used to clean wounds], patted dry [thin cotton fabric used to clean and protect wounds], layered gauze applied to wound bed to help with bleeding, moderate amount. Wrapped with kerlix(R) and secured with tape. Patient charge nurse informed, also notified of possible need for x-ray. A review of Resident 1's hospital discharge paperwork dated 12/27/25 at 11:17 p.m. indicated Resident 1 sustained an Open Toe Fracture.During an interview on 1/14/26 at 10:06 a.m., CNA 1 stated she attempted the transfer with Resident 1 from his bed to the chair when he fell. CNA 1 stated Resident 1 had pulled himself up using the transfer pole and got dizzy. CNA 1 then put the bed down and to prevent his leg from not getting caught, he moved it and that's when his toe got caught on the floor. CNA 1 stated Resident 1 was not wearing any non-stick socks or shoes because he was going to the shower. During an interview on 1/14/26 at 1:05 p.m., Resident 1 stated, I was going down the [transfer] pole and my foot slipped on the linoleum, which made me slide down.My left leg is my bad leg and I have no mobility. During an interview on 1/14/26 at 1:34 p.m. the Charge Nurse stated, Because [Resident 1] is unstable, I would expect the Page 1 of 2 055987 055987 01/14/2026 Broadway Villa Post Acute 1250 Broadway Sonoma, CA 95476

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident to be wearing no- slip socks while transferring from bed to shower chair. During an interview on 1/14/26 at 2:09 p.m. the Director of Staff Development (DSD) stated, When teaching [staff] safe transfers, I always mention socks. Socks should be on at all times when a resident will have their feet on the ground.During an interview on 1/14/26 at 2:25 p.m. the Director of Nursing (DON) stated, The expectation is to wear the non-slip socks during transfers. We follow policy. During an interview on 1/14/26 at 3:16 p.m., Resident 1 stated, I wear them [the non-slip socks] when they tell me to. During a review of the facility's policy titled, Transfer of a Resident, Safe, revised January 2025, stipulated during transfer the resident wears proper footwear that fits well and has nonskid soles. 055987 Page 2 of 2