Nursing Care Index

The Bellefontaine Healthcare Center

Pasadena, Los Angeles County, California · CCN 056080 · For-profit (LLC) · part of Links Healthcare Group (32 facilities, chain average 2.9 stars)

CMS rates The Bellefontaine Healthcare Center 3 of 5 overall as of August 2026. 130 certified beds, 118 residents a day on average. 58 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $14,414.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★★★☆☆ 3 of 5
Quality measures★★★★★ 5 of 5
Quality: long-stay / short-stay5 / 4 of 5

Staffing

Total nurse staffing4.01602 hours per resident per day
Registered nurses0.55511 hours per resident per day
Weekend total3.68524 hours per resident per day
Nursing staff turnover35.2% (registered nurses 42.1%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-06-05 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-02
2026-06-05 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-02
2026-06-05 Keep all essential equipment working safely.
Environmental Deficiencies · tag F0908
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-02
2026-06-05 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-02
2026-06-05 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies · tag F0636
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies · tag F0685
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies · tag F0699
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · tag F0814
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-05 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2025-12-08
complaint survey
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-22
2025-09-09
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-19
2025-08-27
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-16
2025-05-21
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-06-13
2025-05-05 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · tag F0578
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-28
2025-05-05 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-28
2025-05-05 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-05-28
2025-05-05 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-05-05 Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Nutrition and Dietary Deficiencies · tag F0813
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-28
2025-04-16
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-25
2024-08-13
complaint survey
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-30
2024-08-13
complaint survey
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-30
2024-08-13
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-30
2024-05-16 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-06-07
2024-05-16 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-06-07
2024-05-16 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-06-07
2024-05-16 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-06-07
2024-05-16 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-06-07
2024-05-16 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies · tag F0803
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · tag F0847
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Keep all essential equipment working safely.
Environmental Deficiencies · tag F0908
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-07
2024-05-16 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · tag F0732
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-06-07

Fines and payment denials

DatePenaltyAmount
2025-05-21Fine$14,414

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Forbright Bank
Organization
5% or greater security interest2024-02-01
Links Healthcare Group LLC
Organization
adp of the snf2025-06-18
Links Support Services, LLC
Organization
adp of the snf2025-06-18
Links Healthcare Group LLC
Organization
operational/managerial control2024-02-01
Links Support Services, LLC
Organization
operational/managerial control2024-02-01
Beardsley, Mary
Individual
adp of the snf2024-02-01
Bernholz, Victoria
Individual
adp of the snf2024-02-01
Carter, Melissa
Individual
adp of the snf2024-02-01
Chapman, Maynor
Individual
adp of the snf2024-02-01
Ehman, Christopher
Individual
adp of the snf2024-02-01
Frojelin, Antonette
Individual
adp of the snf2024-02-01
Penuela, Leizl
Individual
adp of the snf2024-02-01
Rodriguez, Curtis
Individual
adp of the snf2024-02-01
Tilford, Toby
Individual
adp of the snf2024-02-01
Rodriguez, Curtis
Individual
corporate officer2024-02-01
Tilford, Toby
Individual
corporate officer2024-02-01
Beardsley, Mary
Individual
operational/managerial control2024-02-01
Bernholz, Victoria
Individual
operational/managerial control2024-02-01
Carter, Melissa
Individual
operational/managerial control2024-02-01
Chapman, Maynor
Individual
operational/managerial control2024-02-01
Ehman, Christopher
Individual
operational/managerial control2024-02-01
Frojelin, Antonette
Individual
operational/managerial control2024-02-01
Penuela, Leizl
Individual
operational/managerial control2024-02-01
Rodriguez, Curtis
Individual
operational/managerial control2024-02-01
Tilford, Toby
Individual
operational/managerial control2024-02-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Los Angeles County.