California ›Pasadena

The Bellefontaine Healthcare Center

150 Bellefontaine St, Pasadena, CA 91105 · Los Angeles County · 130 certified beds · avg 118 residents/day · certified since Jan 1, 1970

Part of chain: LINKS HEALTHCARE GROUP (32 facilities, chain avg rating 2.9★)

2/5
Health inspection rating (on-site)
1
Serious findings on record
$14,414
Fines, last 3 years
3.84
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · May 21, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 13, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (58)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 5, 2026E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jun 5, 2026E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 5, 2026E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Jun 5, 2026E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Jun 5, 2026D · Potential for harm, one-offThe facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Jun 5, 2026D · Potential for harm, one-offThe facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Jun 5, 2026D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 5, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 5, 2026D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jun 5, 2026D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 5, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jun 5, 2026D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
Jun 5, 2026D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 5, 2026D · Potential for harm, one-offThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Dec 8, 2025D · Potential for harm, one-offThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint
Sep 9, 2025E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Aug 27, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
May 21, 2025▲ J · Immediate jeopardy, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 5, 2025E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 5, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 5, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 5, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 5, 2025D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
May 5, 2025D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
May 5, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 5, 2025D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
May 5, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 5, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
May 5, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 5, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 5, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 5, 2025D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
May 5, 2025D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Apr 16, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 13, 2024E · Potential for harm, repeatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Aug 13, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Aug 13, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
May 16, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 16, 2024E · Potential for harm, repeatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 16, 2024E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 16, 2024E · Potential for harm, repeatedThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
May 16, 2024E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 16, 2024D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 16, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
May 16, 2024D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 16, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 16, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 16, 2024D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 16, 2024D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 16, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
May 16, 2024D · Potential for harm, one-offThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
May 16, 2024D · Potential for harm, one-offThe facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign.
May 16, 2024D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
May 16, 2024D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
May 16, 2024B · Minimal risk, repeatedThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 17).

YearCitationsSerious (G–L)Worst severity that year
2024210E
2025201J ▲
2026170E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $14,414.

DateTypeAmount / length
May 21, 2025Fine$14,414

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.844.313.95bottom 29% in California; top 47% in the U.S.
Registered Nurse hours0.530.610.69top 42% in California; bottom 42% in the U.S.
Weekend total nurse staffing3.523.903.50bottom 33% in California; top 41% in the U.S.
Weekend RN hours (not acuity-adjusted)0.500.510.48top 30% in California; top 32% in the U.S.
Total nursing staff turnover (%)35.236.745.8top 47% in California; top 25% in the U.S.
RN turnover (%)42.138.142.9bottom 40% in California; bottom 49% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.02, RN 0.56, weekend 3.69. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Beardsley, MaryIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Beardsley, MaryIndividualADP of the SNFNOT APPLICABLE02/01/2024
Bernholz, VictoriaIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Bernholz, VictoriaIndividualADP of the SNFNOT APPLICABLE02/01/2024
Carter, MelissaIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Carter, MelissaIndividualADP of the SNFNOT APPLICABLE02/01/2024
Chapman, MaynorIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Chapman, MaynorIndividualADP of the SNFNOT APPLICABLE02/01/2024
Ehman, ChristopherIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Ehman, ChristopherIndividualADP of the SNFNOT APPLICABLE02/01/2024
Forbright BankOrganization5% or Greater Security InterestNOT APPLICABLE02/01/2024
Frojelin, AntonetteIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Frojelin, AntonetteIndividualADP of the SNFNOT APPLICABLE02/01/2024
Links Healthcare Group LLCOrganizationOperational/Managerial ControlNOT APPLICABLE02/01/2024
Links Healthcare Group LLCOrganizationADP of the SNFNOT APPLICABLE06/18/2025
Links Support Services, LLCOrganizationOperational/Managerial ControlNOT APPLICABLE02/01/2024
Links Support Services, LLCOrganizationADP of the SNFNOT APPLICABLE06/18/2025
Penuela, LeizlIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2024
Penuela, LeizlIndividualADP of the SNFNOT APPLICABLE02/01/2024
Rodriguez, CurtisIndividualCorporate OfficerNOT APPLICABLE02/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

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Pasadena Grove Health Center2.7 miPasadena, CA★★☆☆☆2/5
Foothill Heights Care Center2.8 miPasadena, CA★★★☆☆3/5
Pasadena Nursing Center2.9 miPasadena, CA★★☆☆☆2/5abuse
Alhambra Hospital Med Ctr DP/SNF2.9 miAlhambra, CA★★★★☆4/5
Cedar Pine Post Acute3.0 miPasadena, CA★★☆☆☆1/5abuse
Ivy Creek Healthcare & Wellness Centre3.0 miSan Gabriel, CA★★★★☆4/5
San Gabriel Valley Medical Ctr D/P SNF3.0 miSan Gabriel, CA★★★★☆3/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 056080.