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 (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: 555184 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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)