Incident investigation·April 2, 2026

04/02/2026 01:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director April Kale. Today’s visit is regarding an incident report and subsequent death report that were submitted to licensing. This is a follow-up visit for case management. It was reported that on 01/28/2026 06:39 AM staff were assisting Resident 1 (R1) and observed blood coming from R1’s rectum. EMS transported R1 to Oroville Hospital. On 01/29/2026 the memory care director was informed that R1 had been diagnosed with a GI bleed. On 02/06/2026 the facility submitted a death report to licensing for R1. The death report states that R1 passed away at the hospital on 02/01/2026 at 06:15 AM. The death report states that R1 passed away “due to GI bleed.” During the investigation it was learned that R1 was transported to the facility on 01/28/2026 via medical transport from a hospital which is located a good distance away from the facility. On 01/20/2026 the facility staff conducted a pre-admission appraisal call with an RN and physician that were representing the discharging hospital. The resident was deemed suitable for admission based on this appraisal, documents, and statements that were provided to the facility during the pre-appraisal call. Per the ED during the pre-appraisal call the hospital did not disclose that R1 required the dispensing of suppository bisacodyl to stimulate bowel movements as needed. Once the facility realized this was required for R1 they contacted the hospital and informed them that R1 was not appropriate for the facility unless the hospital had sent orders for home health to dispense the suppository to R1. LPA reviewed discharge summary dated 01/21/2026 from the discharging hospital to include “continue with as needed suppository for rectal stimulation ... can be done by home health nurse.” Plan of care note dated 01/22/2026 “Orders have been faxed to Butte Home Health requesting PT (physical therapy) and skilled nursing.” It was determined that the discharging hospital planned for R1 to receive home health nursing care at the facility for assistance with the rectal suppository as needed. The resident lived at the facility for seven days prior to being sent out to the local hospital due to GI bleeding. The facility filled out new patient paperwork to establish R1 with a new primary care physician but due to the short period of time that R1 lived at the facility R1 did not get the chance to be seen by the new primary care physician. The resident passed away at the hospital three days after admission to the hospital. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Executive Director April Kale.