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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055987 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 01/14/2026 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)