Facility Evaluation Report

06/24/2026 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director April Kale and Jay Tippens. Today’s visit is regarding an incident report that was submitted to licensing.

It was reported that on 05/11/2026 at approximately 08:30 PM Resident 1 (R1) was observed on the floor of their room lying flat on their back. R1 had blood on the back of their head. EMS were called to evaluate R1 and transported R1 to Oroville Hospital. On 05/13/2026 R1 left the hospital against medical advice from Oroville Hospital with a diagnosis of head strike with brain bleed - resolved. On 05/18/2026 R1 was started on hospice services.

During the investigation it was learned that after the fall on 05/11/2026 R1 was admitted to the ICU to be monitored for a brain bleed and scans showed a small brain bleed. During a subsequent scan it showed the brain bleed had diminished. At this time R1 was placed in a step-down unit for observation. R1 decided to leave the hospital against medical advice because they did not want to go through more tests and treatment. R1 returned to the facility and was admitted to hospice for protein calorie malnutrition. The hospice admission was not related to the brain bleed. R1 passed away end of May 2026 on hospice.

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.