Cedar Pine Post Acute: Fall Risk Patient Left Alone - CA
The resident, identified in federal inspection records as Resident 1, suffered from hemiplegia and hemiparesis following a stroke. Physical therapy notes from May 9 showed the patient required minimal assistance to propel a wheelchair just 40 feet and needed moderate help to walk the same distance on level surfaces.
"Staff need to be propelling Resident 1's wheelchair," the physical therapist documented, noting the patient needed help when trying to move independently.
The facility's MDS nurse told federal inspectors during an August interview that Resident 1 was completely dependent on staff for basic transfers between chair and bed, sitting and lying positions, and getting in and out of the shower. The assessment classified the patient as needing assistance with activities of daily living "all the time."
"If Resident 1 was not assisted, it could lead to possible falls that could possibly cause harm and injury to the resident," the MDS nurse explained to inspectors.
Beyond the physical limitations, Resident 1 struggled with cognitive issues. The MDS assessment documented memory problems and episodes of confusion, creating additional safety concerns for staff.
The physical therapist emphasized that Resident 1 "was always a fall risk" due to the combination of stroke-related paralysis and poor safety awareness. Both the physical therapist and occupational therapist had evaluated the patient upon admission, documenting a "functional mobility decline" that made independent movement dangerous.
Despite these documented risks and care requirements, staff left Resident 1 unattended on May 10, 2025.
"Resident 1 should not have been left unattended or unsupervised," the MDS nurse told federal inspectors three months later. "With supervision from staff, the falls could have been prevented."
The incident violated the facility's own fall prevention policies. Cedar Pine's Fall Risk Assessment policy, revised in March 2024, requires nursing staff to work with doctors, pharmacists and therapists to identify fall risk factors and establish prevention plans based on assessment information.
The facility's Fall Risk Intervention and Monitoring policy goes further, mandating that staff try various interventions until falling stops or is reduced to unavoidable levels. When falls continue despite initial interventions, the policy requires additional or different approaches.
For residents who keep falling, the policy states that "staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions." It also calls for doctors to help identify previously unrecognized causes of falls.
The policy emphasizes ongoing monitoring: "The staff will monitor and periodically document the resident's response to interventions intended to reduce falling or the risks of falling."
Yet on May 10, none of these safeguards prevented Resident 1 from being left alone, despite clear documentation that the patient required constant assistance and supervision.
The physical therapy notes paint a picture of someone whose mobility limitations were severe and well-documented. On May 12, just two days after the fall incident, therapy notes continued to show the same level of assistance needed for basic movement.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents. But for Resident 1, the consequences of inadequate supervision were immediate and preventable.
The case illustrates a gap between written policies and daily practice. While Cedar Pine had detailed procedures for fall prevention and monitoring, staff failed to follow basic supervision requirements for a resident whose vulnerability was thoroughly documented across multiple assessments.
The MDS nurse's admission that supervision could have prevented the fall underscores how staffing decisions directly impact resident safety. For someone with Resident 1's combination of physical limitations, cognitive impairment and documented fall risk, leaving them unattended represented a fundamental breakdown in care.
Three months after the incident, when federal inspectors interviewed staff about what happened, the facility's own nurses acknowledged the supervision failure. But for Resident 1, that recognition came too late to prevent the May 10 fall that proper oversight should have stopped.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Pine Post Acute from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
Cedar Pine Post Acute in PASADENA, CA was cited for violations during a health inspection on August 15, 2025.
The resident, identified in federal inspection records as Resident 1, suffered from hemiplegia and hemiparesis following a stroke.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.