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Complaint Investigation

The Bellefontaine Healthcare Center

August 27, 2025 · Pasadena, CA · 150 Bellefontaine St
Citations 1
CMS Rating 3/5
Beds 130
Provider ID 056080
Healthcare Facility
The Bellefontaine Healthcare Center
Pasadena, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

THE BELLEFONTAINE HEALTHCARE CENTER in PASADENA, CA — inspection on August 27, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0755
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

ampicillin with GACH 1 after finding out Resident 1 had a history of PCN allergy instead of not putting the order in.

The DON also stated the ampicillin order should have been reconciled accurately/ completely and continued when Resident 1 was admitted back at the facility on 8/1/2025 to make sure that Resident 1 received appropriate treatment for the resident's infection During a review of the facility's P&P titled, Reconciliation of Medications on Admission, revised July 2017, the P&P indicated its purpose was to ensure medication safety by accurately accounting for the resident's medication, routes and dosages upon admission to the facility.

The P&P also indicated its guidelines was to compare pre-discharge medications to post -discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care.

The P&P further indicated that medication reconciliation reduces medication errors and enhance resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruptions, in the correct dosages and routes, during admission/transfer process.

The P&P also indicated that medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the attending physician and care team.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PASADENA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE BELLEFONTAINE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.