Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Broadway Villa Post Acute during CMS and state inspections, most recent first.
Damaged Kitchen and Storage Room Flooring: Gouged, cracked, and broken floor tiles were observed in the kitchen and dry goods storage room during a tour with the DM. The DM confirmed the damaged flooring and stated there was a plan to make repairs. The facility policy stated residents are to be provided with a safe, clean, sanitary, and orderly environment.
Damaged Wall and Baseboard Behind Resident’s Bed: A resident with severe vascular dementia and limited ability to communicate was found with her bed pushed against a wall with damaged baseboard molding and dust and debris collected at the base. Her RP said he had noticed the issue and complained about it previously, but no action had been taken. The Maintenance Director said he was unaware of the problem, and the facility’s policy called for a clean, sanitary, orderly, and homelike environment.
Nursing staff failed to follow established fall-prevention care plan interventions for three residents after documented falls. One resident with a history of repeated falls and intact cognition had care plan orders for fall mats and a toileting schedule after sustaining multiple injuries from falls, yet no fall mats were present and there was no documentation of a toileting schedule. A second resident with prior falls and TIA had care plan directives for a bedside commode and non-skid footwear following a bathroom fall, but no commode was provided and the resident instead used worn, slippery household slippers. A third resident with osteoporosis and atherosclerosis had a care plan requiring the call light to be within reach and fall mats by the bed after a fall with skin tears and abrasions, but the call light was found hidden under bedding and no fall mats were in place. Staff reported that fall risk and interventions were communicated in shift report and on printed tools, while leadership acknowledged uncertainty about how often care plans were actually used.
A resident with a displaced, comminuted humerus fracture experienced ongoing severe pain because LNs did not adequately implement ordered pain management, failed to recognize and act on a pattern of recurring severe pain before the next PRN oxycodone dose, and did not promptly contact the MD to adjust ineffective orders. When ordered oxycodone was unavailable, an LN delayed accessing the narcotic E-kit for several hours despite repeated requests and persistent severe pain, offering only an ice pack and acetaminophen, which the resident declined due to perceived ineffectiveness. The DON, ADON, and MD were not notified of the unrelieved pain or pharmacy delays, contrary to facility pain management and E-kit policies.
A resident with impaired mobility, instability of the left knee, and dependence on staff for bed-to-chair transfers was assisted from bed to a shower chair without non-slip socks or shoes, despite a care plan and facility policy requiring nonskid footwear during transfers. During the transfer, the resident used a transfer pole, became dizzy, and as the bed was adjusted, his leg moved and his toe caught on the floor, with the resident later reporting his foot slipped on the linoleum and he slid down. The resident sustained a laceration and an open fracture of the left 5th toe. Facility staff, including the charge nurse, DSD, and DON, acknowledged that residents are expected to wear non-slip socks during transfers, and the written transfer policy required proper footwear with nonskid soles.
A resident was transported to the hospital with hand bruising and pain consistent with a grabbing injury, prompting an abuse allegation. Although EMS and police were involved, the ADON did not report the incident to State authorities within the required timeframe, contrary to facility policy requiring immediate reporting of such events.
A resident with dementia and psychosis physically assaulted another resident with Alzheimer's disease, causing two skin tears. The incident was acknowledged by the DON and ADON, and the facility's abuse prevention policy prohibits such abuse between residents.
Three residents with cognitive and physical impairments were left unsupervised while smoking in the designated area, despite care plans and facility policy requiring staff presence. Staff interviews confirmed that the residents did not sign out for unsupervised smoking, and the required supervision was not provided during the observed session.
The facility did not ensure that call light systems were accessible and functional for several residents, resulting in prolonged waits for assistance, including for basic care and pain management. Some call lights were found on the floor, out of reach, or missing, and staff did not consistently report or document these issues. Residents affected had a range of cognitive and physical impairments, and facility policy requiring call lights to be within reach was not consistently followed.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in documented care needs. One resident, a smoker, was inaccurately recorded as not using tobacco, while another receiving restorative nursing services was not documented as such. The DON and MDS Coordinator acknowledged these inaccuracies, which were attributed to non-billing for certain services.
A resident with type 2 diabetes mellitus received insulin contrary to physician orders, which specified holding the medication if blood sugar was below 180 mg/dL. Despite this, the resident was administered insulin on several occasions when their blood sugar was below the threshold. Facility staff, including an LVN, ADON, and DON, confirmed the error, acknowledging the potential for adverse effects when medications are not administered according to prescribed parameters.
A resident with severe cognitive impairment was found with an unauthorized container of Citrucel on their nightstand, which was not identified or removed by staff. The facility's policy requires medications to be stored properly, and the staff acknowledged the oversight, noting that the resident's family likely brought the medication without informing the facility.
A resident with obstructive sleep apnea used a CPAP machine nightly without a physician's order, contrary to facility policy. The CPAP and nebulizer equipment were not properly cleaned or stored, as observed by surveyors. Staff were unaware of the correct procedures, and the equipment was not maintained according to policy.
The facility did not include the facility's name or actual hours worked by RNs, LVNs/LPNs, and CNAs in the daily staffing postings for a month. The Staffing Supervisor confirmed the omission, and the DON was unaware of the requirement. The Administrator expected the postings to include all necessary details.
A resident with a diagnosis of malignant neoplasm of the left breast felt uncomfortable and insulted after a CNA made an inappropriate comment about her breast size during care. The CNA admitted to the inappropriate comment, and the ADON confirmed the incident, emphasizing the expectation for staff to treat residents with dignity and respect.
The facility did not report allegations of abuse within the required timeframe for three residents. An altercation between two residents and an incident involving a staff member and a resident were reported late. The facility's policy requires reporting within two hours, but this was not followed, potentially delaying enforcement agencies' response.
Damaged Kitchen and Storage Room Flooring
Penalty
Summary
The facility failed to provide a safe and sanitary environment when gouged, cracked, and broken floor tiles were observed in the kitchen and dry goods storage room. During a concurrent observation and interview with the Dietary Manager, gouges were noted in the kitchen floor between the stove and the cook's tray line counter, and cracked and broken tiles were observed on the floor of the dry goods storage room. The Dietary Manager confirmed the damaged flooring and stated there was a plan to make repairs. A review of the facility policy titled, Quality of Life- Homelike Environment, indicated that residents are to be provided with a safe, clean, sanitary, and orderly environment.
Damaged Wall and Baseboard Behind Resident’s Bed
Penalty
Summary
The facility failed to provide a homelike environment for one resident when the wall and baseboard molding behind the resident’s bed required repair. Resident 47 had a BIMS dated January 2023 indicating she was rarely or never understood, and her face sheet documented severe vascular dementia and a responsible party who managed healthcare decisions for her. During an interview, the resident’s RP stated he had visited the resident and observed issues on the wall behind her bed, and he reported that he had complained to facility staff a long time ago without any action being taken. During a concurrent observation with the Maintenance Director and two maintenance staff, the resident’s bed was moved away from the wall and the baseboard molding was observed to be damaged. Four surveyor photos showed dust and debris collected on the floor at the base of the damaged molding. The Maintenance Director stated he was not aware of the issue and later stated he expected staff to write repair concerns on the maintenance log. The facility’s policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management shall maximize characteristics of a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Failure to Implement Post-Fall Care Plan Interventions for Three Residents
Penalty
Summary
The deficiency involves nursing staff failing to implement care plan fall-prevention interventions for three residents after falls occurred. For the first resident, admitted with muscle weakness, repeated falls, and diastolic heart failure, the fall risk assessment form was largely blank, making it unclear whether the resident was identified as a fall risk upon admission, despite a history of three or more falls in the prior three months and a recent hospitalization. The resident’s care plan dated 1/20/26 identified fall risk and required staff to place fall mats by the bed. After an unwitnessed fall on 1/22/26 during a transfer from a bedside commode to bed, and a subsequent fall on 2/13/26 while attempting to stand and use a urinal that resulted in a nasal fracture, orbital fractures, and a brain bleed, the care plan was revised on 2/13/26 to include fall mats by the bed and initiation of a toileting schedule. However, during observation on 2/27/26, no fall mats were present by this resident’s bed, and the Assistant Director of Nursing and Administrator could not provide documentation that a toileting schedule had been implemented as ordered in the revised care plan. For the second resident, admitted with muscle weakness, a history of falling, and a transient cerebral ischemic attack, a progress note documented an unwitnessed fall in the bathroom, where the resident was found on her side next to the toilet with a cut to the left forehead. The resident’s fall risk care plan, initiated on 7/25/24 and revised on 2/10/26 following the fall, required staff to provide a bedside commode to assist with safe toileting. A subsequent care plan dated 2/9/26, addressing an actual fall, directed staff to ensure the resident wore non-skid footwear during all walking activities. During observation on 2/27/26, no bedside commode was present at the resident’s bedside or in the bathroom, and the resident confirmed that a commode had not been placed in the room. Instead, a pair of well-worn household slippers with very slippery soles and no grip was observed near the bed, and the resident stated she wore those slippers when getting out of bed and when walking, contrary to the care plan requirement for non-skid footwear. For the third resident, admitted with atherosclerosis of the aorta and age-related osteoporosis, progress notes dated 2/10/26 documented that the resident was found on the floor next to the bed with a skin tear to the right cheek and multiple abrasions to the upper back. The resident’s care plan dated 5/16/25 identified fall risk and required nursing staff to keep the call bell within reach to meet goals of being free from falls and avoiding serious injury. A revision on 2/12/26 added an intervention for staff to place fall mats on the left side of the bed. During observation on 2/27/26, the resident was in bed and the call light was not within reach; the resident could not locate it, and it was later found tucked under the blanket and pillow on the right side. Additionally, no fall mats were present on either side of the bed, despite the care plan directive. During interviews, staff reported that fall risk status and interventions were communicated in shift report and on printed reports, and that fall interventions should include low beds, call lights within reach, and fall mats, but the Administrator acknowledged he could not say how often care plans were actually used by staff. The facility’s written policy on falls and accident prevention required investigation of each fall and implementation of actions to reduce or prevent additional falls and minimize potential for injury, but the specified care plan interventions for these three residents were not carried out as written.
Failure to Provide Timely and Adequate Pain Management for Severe Fracture
Penalty
Summary
Licensed nurses failed to provide adequate pain management to a resident admitted with a displaced, comminuted fracture of the shaft of the left humerus. The resident was admitted with orders for acetaminophen as the first-line agent and oxycodone 5 mg PO every six hours PRN for severe pain rated 7–10/10, and a care plan directing staff to administer medications per orders, anticipate pain needs, respond immediately to complaints of pain, and follow the pain scale. On the evening of admission, the resident reported pain of 10/10 and received oxycodone at 7:50 p.m., with no further oxycodone doses given that day. On the following day, oxycodone was administered only three times despite documented recurring severe pain levels of 8–9/10, and staff did not recognize or act on the pattern of severe pain returning before the next allowable dose. The resident’s oxycodone administration and effectiveness record from 2/4 through 2/16 showed only temporary relief, with severe pain recurring prior to the next six-hour dosing window. Nursing staff allowed the medication to wear off completely before the next dose instead of contacting the physician to adjust the dosing schedule, resulting in ongoing severe pain. The facility’s pain management policy required that if the pain management program was not effective, the licensed nurse would contact the physician and consult for additional interventions if pain was not relieved by current orders, but this was not done while the resident continued to report severe pain. In addition, when the resident requested additional oxycodone late on the night of admission, the nurse informed the resident that the medication was unavailable and might arrive with later pharmacy deliveries. The nurse offered an ice pack and scheduled acetaminophen; the resident refused acetaminophen, stating it did not work for her, but accepted the ice pack, which did not relieve her pain. Despite the unavailability of the ordered oxycodone and the resident’s ongoing severe pain, the nurse did not immediately attempt to access the E-Kit as required by facility policy for urgent medication needs. The nurse delayed E-Kit access for approximately five hours, during which the resident repeatedly requested oxycodone and remained in unmanaged severe pain until the medication was finally obtained and administered at 7:16 a.m. Interviews with nursing staff and leadership confirmed that the DON, ADON, and physician were not notified of the resident’s unrelieved pain or the pharmacy delays, contrary to facility expectations and policies for pain management and E-Kit use.
Failure to Ensure Use of Non-Slip Footwear During Transfer Resulting in Toe Injury
Penalty
Summary
The deficiency involves staff failure to ensure a resident wore required non-slip footwear during an assisted transfer, contrary to the resident’s care plan and facility policy. The resident had diagnoses including acute kidney failure, epilepsy, and instability of the left knee, and the MDS indicated he was dependent on staff for bed-to-chair transfers and required assistive devices for gait and balance. His care plan for impaired physical mobility directed staff to make sure he wore non-slip shoes or socks. During a transfer from bed to a shower chair, the CNA attempted the transfer while the resident was not wearing non-slip socks or shoes because he was going to the shower. During this transfer, the resident pulled himself up using the transfer pole, became dizzy, and as the CNA adjusted the bed, his leg moved and his toe caught on the floor. The resident later stated that as he was going down the transfer pole, his foot slipped on the linoleum, causing him to slide down, and noted he had no mobility in his left leg. Following the incident, nursing documentation and SBAR notes described a laceration to the plantar aspect of the left 5th toe with a “floppy” toe and no resistance to range of motion, and hospital discharge paperwork confirmed an open toe fracture. The charge nurse, DSD, and DON each stated that the expectation and policy were that residents wear non-slip socks during transfers, and the facility’s safe transfer policy required proper footwear with nonskid soles during transfers.
Failure to Timely Report Injury of Unknown Origin and Alleged Abuse
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframe for one resident. Emergency Medical Services (EMS) transported the resident to the hospital with bruising and pain to the hand, which was consistent with a grabbing injury. This incident was reported to Adult Protective Services (APS) by EMS, and the police visited the facility to investigate an allegation of abuse related to the injury. Despite being aware of the police investigation and the nature of the injury, the Assistant Director of Nursing (ADON) did not report the incident to the State agency, stating that she was conducting her own investigation first and believed that a report was unnecessary since another agency had already reported the allegation. A review of the facility's policy indicated that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—must be reported immediately, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury, and not later than 24 hours for other violations. The facility did not follow this policy, as the incident was not reported to the Department by the facility within the required timeframe.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when one resident physically assaulted another, resulting in injury. Specifically, a resident with a diagnosis of unspecified psychosis, dementia, and muscle weakness pushed and hit another resident who had Alzheimer's disease, muscle weakness, and required assistance with personal care. The incident led to the assaulted resident sustaining two skin tears: one on the left elbow measuring 2 cm by 2 cm, and another on the right forearm measuring 1 cm by 0.5 cm. The injured resident reported the assault, and the aggressor admitted to the action when questioned. Facility staff, including the DON and ADON, acknowledged that the assault took place. The facility's abuse prevention policy, revised in November 2023, states that all residents have the right to be free from abuse, including abuse by other residents, and defines abuse as the willful infliction of injury. The events described in the report indicate that the facility failed to prevent abuse between residents, resulting in physical harm.
Residents Left Unsupervised During Smoking Sessions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for three residents who were left unsupervised while smoking cigarettes in the designated smoking area. Resident 7, who had moderate cognitive impairment, muscle weakness, and mobility issues, was observed smoking without staff supervision. Resident 8, also with moderate cognitive impairment, hemiplegia, vascular dementia, and a history of falls, was similarly left unsupervised. Resident 9, who had intact cognition but significant physical disabilities including hemiplegia and speech disorders, was also present without the required 1:1 observation as indicated in their care plan. All three residents were observed smoking on the patio for at least 15 minutes without staff present, contrary to their care plans and facility policy. Interviews with staff confirmed that some residents do not comply with the smoking policy or their individual care plans, and that the three residents observed had not signed out of the facility as required for unsupervised smoking. The facility's policy specifies that smoking may only occur with staff present and during designated times, but these procedures were not followed. The lack of supervision during smoking sessions created a potential for burn injuries and fire hazards, as noted in the findings.
Failure to Ensure Accessible and Functional Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to residents in their bathrooms and bathing areas, resulting in six residents being unable to reliably summon assistance. Multiple residents experienced inoperable or inaccessible call lights, with some call buttons found on the floor, out of reach, or missing entirely. In one instance, a resident's call light was removed due to safety concerns, but no alternative means of communication was provided, and the replacement manual call bell was not within reach. Staff interviews confirmed that issues with call lights were not always reported or documented, and maintenance logs were incomplete. Residents affected by this deficiency had varying degrees of cognitive and physical impairment, including diagnoses such as monoplegia, muscle weakness, dementia, multiple sclerosis, and chronic obstructive pulmonary disease. Some residents had intact cognition, while others were severely cognitively impaired, increasing their vulnerability when call systems were not accessible. One resident was left in soiled clothing and bedding for extended periods due to unanswered call lights, and another waited over an hour for pain medication because the call system failed to alert staff. Observations and interviews revealed that staff were sometimes unaware of missing or inaccessible call lights, and there was a lack of consistent communication between nursing and maintenance regarding repairs. Facility policy required call devices to be within reach and prompt reporting of defective equipment, but these procedures were not consistently followed. Rounds were supposed to include checks for call light accessibility, but this was not reliably implemented, contributing to the deficiency.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their documented care needs and clinical status. Resident #64, who was admitted with a diagnosis of nicotine dependence, was observed smoking and confirmed their smoking habit during an interview. However, the MDS assessment inaccurately indicated that the resident did not use tobacco. The facility's Infection Prevention Nurse/MDS Coordinator and the Director of Nursing (DON) acknowledged that the resident's smoking status should have been captured in the MDS assessment. Resident #79, admitted with a history of hemiplegia and hemiparesis, was receiving restorative nursing services as per their care plan and active orders. Despite this, the MDS assessment failed to document the provision of these services. Interviews with the MDS Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) confirmed that the resident received restorative services, but these were not coded in the MDS. The ADON mentioned that the facility did not bill for restorative services, which was why it was not included in the MDS. The Director of Nursing and the Administrator both emphasized the importance of MDS accuracy for billing and reflecting the care provided. However, the oversight in coding for both residents' MDS assessments resulted in inaccuracies that did not align with the residents' actual care and clinical status. These discrepancies highlight a failure in the facility's processes to ensure accurate and comprehensive documentation in the MDS assessments.
Failure to Adhere to Insulin Administration Parameters
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of insulin for a resident with type 2 diabetes mellitus. The resident, who had moderate cognitive impairment, was prescribed insulin glargine with specific instructions to hold the medication if their blood sugar was below 180 mg/dL. Despite these orders, the resident received insulin on multiple occasions when their blood sugar levels were below the specified threshold, as documented in the Medication Administration Record (MAR) for December 2024 and January 2025. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the insulin was administered contrary to the physician's parameters. The LVN acknowledged administering the insulin when it should have been held, and both the ADON and DON recognized the potential for adverse effects when medications are not administered according to the prescribed parameters. The facility's policy required vital signs and blood sugar to be monitored and medications to be given based on results, which was not followed in this case.
Improper Medication Storage for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, leading to a deficiency in accident prevention. Resident #37, who was readmitted to the facility with a medical history of hemiplegia and hemiparesis following a cerebral infarction, was observed to have a container of Citrucel, an over-the-counter fiber laxative, on the nightstand in their room. The resident had a severe cognitive impairment, as indicated by a BIMS score of 3, and there was no order for Citrucel in the resident's active medication orders. Interviews with facility staff, including a CNA, LVN, ADON, DON, and the Administrator, revealed that the Citrucel should not have been left at the resident's bedside without an order for self-administration. The staff acknowledged that the resident's family likely brought the Citrucel into the room without informing the facility, and it was not identified or removed by the staff as required by facility policy. The oversight was recognized by the staff, who stated that the medication should have been identified and an order obtained if its use was appropriate.
Failure to Obtain Physician Order and Maintain Respiratory Equipment
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP machine for a resident with a diagnosis of obstructive sleep apnea. Despite the resident using the CPAP machine every night, there was no documented order for its use in the resident's Order Summary Report. Additionally, the facility's policy required that BiPAP/CPAP be administered as ordered by a physician, but this was not adhered to. The resident's care plan indicated the need for BiPAP at night, yet the necessary physician order was missing. Furthermore, the facility did not properly clean and store the CPAP and nebulizer equipment for the resident. Observations revealed that the CPAP nasal pillows and nebulizer equipment were not stored in a bag or container when not in use, and the nebulizer equipment was not rinsed after use. Staff interviews confirmed a lack of knowledge regarding the proper cleaning and storage procedures, and the equipment was not maintained according to the facility's policy. The Director of Nursing and other staff acknowledged the need for proper orders and maintenance of the respiratory equipment.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with California state and federal regulations regarding the posting of daily nurse staffing information. For the period from December 20, 2024, to January 20, 2025, the facility's daily staffing postings did not include the facility's name or the actual hours worked by registered nurses (RNs), licensed vocational nurses/licensed practical nurses (LVNs/LPNs), and certified nursing assistants (CNAs). This omission was confirmed during interviews with the Staffing Supervisor and the Director of Nursing (DON). The DON was unaware that the facility's name and actual worked hours needed to be included in the postings, and the Staffing Supervisor was responsible for ensuring the postings contained all required information. The Administrator expected the postings to include the necessary details.
Inappropriate Comment by CNA Violates Resident's Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an inappropriate comment made by a Certified Nursing Assistant (CNA) to a resident. The resident, who was admitted with a diagnosis of malignant neoplasm of the left breast, reported feeling uncomfortable and insulted after the CNA made a comment about the size of her breast during care. The CNA acknowledged the inappropriateness of the comment during a phone interview. The Assistant Director of Nursing (ADON) confirmed awareness of the incident and agreed that the comment was inappropriate, emphasizing the expectation that staff treat residents with dignity and respect. A review of the facility's Resident Rights document indicated that residents have the right to be treated with respect and dignity.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for three of four sampled residents. An altercation between two residents occurred, and a separate incident involving a staff member and another resident was reported late. The facility's policy mandates reporting allegations of abuse to the Department within two hours, but this was not adhered to. The Assistant Director of Nursing confirmed that the allegations were not reported within the required timeframe, which could potentially delay the response by enforcement agencies to ensure resident safety.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Sonoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sonoma Post Acute | 0.7 mi | ★★★★★ | 23 | 0 |
| Valley Of The Moon Post Acute | 0.9 mi | ★★★★★ | 1 | 0 |
| The Meadows Of Napa Valley | 8.7 mi | ★★★★★ | 0 | 0 |
| Piners Nursing Home | 9 mi | ★★★★★ | 40 | 0 |
| Vineyard Post Acute | 9.4 mi | ★★★★★ | 28 | 0 |
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