Complaint Investigation Report

Alamitos Belmont Rehabilitation Hospital Order Summary Report (dated: 06/30/2023), Alamitos Belmont Health Care Discharge Summary (dated: 07/07/2023), medical records from Alamitos Belmont Rehabilitation Hospital (dated: 07/07/25), medical records from St. Mary Medical Center-Long Beach, and Home Health Notes from Mission Home Health of Irvine. Additionally, the department conducted a tour of the facility. On 05/29/24, the department conducted interviews with staff #1-#2 (S1-S2). On 06/10/24, the department obtained medical records from Los Alamitos Medical Center (dated: 04/24/24 and 05/10/24). On 06/20/24, the department conducted interviews with residents #2-#4 (R2-R4) and staff #3-#5 (S3-S5). Furthermore, on 12/11/25, the department conducted interviews with staff #6-#7 (S6-S7) and residents #5-#8 (R5-R8).

The investigation revealed the following:

Allegation: Resident developed multiple pressure injuries while in care resulting in hospitalization. It is being alleged that R1 developed multiple pressure injuries while at the facility. During the course of the investigation, the department conducted interviews with S1-S7. Of those interviewed, 4 out 7 staff interviewed acknowledged that R1 developed multiple pressure injuries while in care. An interview conducted with S3 revealed that R1 did not have any pressure injuries when they initially arrived at this facility, and that R1’s pressure wounds got worse in just a few days because they were bed bound. During the course of the investigation, the department conducted interviews with R2-R8. The department was unable to interview R1 as they were no longer at the facility. Of those interviewed, 5 out of 7 residents could not corroborate with the allegation, and 2 out of 7 residents did not provide an answer. 7 out of 7 residents reported that staff check on them frequently.

The department’s review of R1’s Admission Agreement confirms that R1 was admitted and moved into the facility on 07/07/23. The department reviewed Resident Assessment Form (dated: 07/07/23) for R1 and it revealed the following: R1 had no healing wounds or bedsores and had no skin breakdown. R1 is non-ambulatory due to physical impairment and requires an assistive/adaptive devise. R1 had no history of falls. R1 requires one-person transfer assistance. R1 requires status checks routinely, approximately every hour, due to recent hospitalization, change in status, confusion, illness, history of falls, medication change, etc. The department reviewed R1’s Physician’s Report (dated: 07/03/23) and noted the following: R1 is non-ambulatory due to both physical and mental condition and has no history of skin breakdown or condition.