Complaint Investigation Report

Allegation: Staff physically assulted a resident causing injury resulting in hospitalization

On 09/06/2025, R1 was admitted to Sutter Roseville Medical Center for complaint of left foot pain. An MRI confirmed moderate second proximal phalangeal bone marrow edema and severe second phalangeal bone marrow edema suspicious for osteomyelitis. Doctors subsequently amputated R1’s left index toe. R1 reported that a caregiver, S2, intentionally hit the toe with a standing lift. No other information contained in the medical records indicates that R1’s toe wound resulted from an intentional impact with an object like a standing lift. Historically, R1 suffered from foot cellulitis related to their diabetes diagnosis. Prior to their hospitalization, R1 received regular wound care treatment from InnovAge for various preexisting pressure wounds to their left foot. There was no indication of a left index toe injury until 04/22/2025 when redness was observed on the top of R1’s left index toe; however, the toe injury was not concerning until an open wound was observed on 08/14/2025. S2 denied the allegation to the Rocklin Police Department and the Investigations Branch and stated that R1 often threatened to have them terminated. On 09/04/2025, S2 told facility Administration that R1 threatened to report them and tell lies that would “spread like wildfire.” S2 subsequently documented the interaction in a handwritten letter. No other residents reported similar allegations against S2. R2 claimed to have been close with R1 and R1 expressed their frustrations related to the facility. R2 indicated that R1 never mentioned any physical abuse by S2 or another caregiver.

Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and report provided.