Health inspection·February 25, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide quality care to one of two sampled residents (Resident 1) when:The facility failed to create specific and measurable care plan interventions for Resident 1's risk for elopement.The facility staff failed to follow physician orders for monitoring elopement attempts.These failures had the potential for Resident 1 to have an increased risk for elopement, had the potential for staff caring for Resident 1 to be unaware of his elopement attempt on 2/19/26 and had the potential to contribute to Resident 1's elopement attempt on 2/19/26.1.During a review of Resident 1's Facesheet dated 2/25/26, facesheet indicated, Resident 1 was admitted to the facility 29 days ago. Resident 1 had diagnoses including Respiratory failure, Falls, and Alzheimer's Disease (disease characterized by memory loss and cognition decline).During a review of Resident 1's Elopement Risk assessment dated [DATE], Assessment indicated, Resident was scored a 7 indicating he was a moderate elopement risk.During a review of Grievance Form dated 2/19/26, form indicated, [Resident 1's family member] states [Resident 2] called her & informed her that [Resident 1] left the building.During an interview on 2/25/26, at 11:05 a.m., with Resident 2, Resident 2 stated, he saw Resident 1 open the door and walk outside the conference room area.During a review of Resident 2's Brief Interview for Mental Status (BIMSscore is a 0-15-point assessment used in long-term care to measure cognitive function in orientation, memory, and attention. Scores indicate cognitive impairment levels: 13-15 Intact) dated 1/25/26, indicated, Resident 2 scored 15 indicating Resident 2 was cognitively intact.During an interview on 2/25/26, at 12:15 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she saw Resident 1 open the door to the conference room and walk out the door.During a concurrent interview and record review on 2/25/26, at 1:01 p.m., with Director of Nursing (DON), Resident 1's Care plan was reviewed. Resident 1's Care plan indicated, At risk for: elopement and wandering out of facility. Due to: Hx [history of] Elopement/Wandering and impaired Cognitive Function and Safety Perception.Interventions: Check resident's whereabouts. Care plan indicated, no instruction for how often or when to check resident's whereabouts. DON stated, the care plan intervention for Resident 1 does not specify how often to observe the resident, it is not specific.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. During a review of Resident 1's Order Summary dated 2/25/26 indicated, an order for Wandering/Elopement: Monitor number of times per shift resident attempts exit-seeking behavior, every day shift.start dated 1/30/26.During a concurrent interview and record review on 2/25/26, at 1:01 p.m., with DON, Resident 1's Medication Administration Record (MAR) dated February 2026 was reviewed. The MAR indicated, order for Monitor number of times per shift resident attempts exit-seeking behavior, every day shift was charted as 0 on 2/19/26. DON stated, the staff should have Residents Affected - Few Page 1 of 2 555184 555184 02/25/2026 Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591

F 0684 Level of Harm - Minimal harm or potential for actual harm charted a 1 for his elopement attempt on 2/19/26.During a review of the facility's P&P titled, Wandering and elopements dated 2025, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm.1. If identified as at risk for wandering, elopement, or other safety concerns, the residents care plan will include strategies and interventions to maintain the resident's safety. Residents Affected - Few 555184 Page 2 of 2