Cycle 1
Health 2025-01-23 · Fire 2025-01-23
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Sonoma, CA
Broadway Villa Post Acute
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1250 Broadway, Sonoma, CA
(707) 938-8406
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1974-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.47
Nurse aide staffing
Weekend hours
3.47
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
27%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
6.8%
0.3 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.2% |
4.1%
2.9 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
13.7%
0.8 pts worse
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
14.2%
7 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.2% |
11.0%
6.8 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.2% |
10.7%
8.5 pts better
|
14.9%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.0%
0.8 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
10.9%
4.6 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.7%
1.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
11.2%
1.5 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
93.2%
6.1 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
23.2%
1.6 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-23 · Fire 2023-10-23
17 health deficiencies
Top issue: Resident Rights (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-06-29 · Fire 2022-06-29
20 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-03
E · Potential for more than minimal harm
2023-10-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-10-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-16
D · Potential for more than minimal harm
2022-06-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-09-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-16
E · Potential for more than minimal harm
2025-04-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-04-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-01-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-29
C · Minimal harm
2025-01-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-29
F · Potential for more than minimal harm
2023-10-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-10-23
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-10-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-10-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-10-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-10-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-10-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-23
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-23
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-23
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-10-23
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-04-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-18
K · Immediate jeopardy
2022-06-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-29
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-07-18
F · Potential for more than minimal harm
2022-06-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-29
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-09
E · Potential for more than minimal harm
2022-06-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-29
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-07-27
E · Potential for more than minimal harm
2022-06-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-29
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-29
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-06-30
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare North LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Empey, Michael
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Serrano, Noel
Operational/Managerial Control · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Sonoma Post Acute
Sonoma, CA
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Valley Of The Moon Post Acute
Sonoma, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Meadows Of Napa Valley
Napa, CA
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out