Cedar Pine Post Acute: Catheter Care Harm Violations - CA
The inspection, conducted by federal surveyors under the CMS complaint process, cited the facility at the "actual harm" level for failures tied to catheter care. That designation means inspectors determined a resident suffered real injury, not a theoretical risk.
Cedar Pine's own catheter care policy spelled out what nurses were supposed to do every single shift for residents using indwelling Foley catheters. The steps were not complicated. Look at the urine. Check for sediment. Check for color changes. If anything looks wrong, call the doctor and notify the resident's representative. Document what you did.
None of that happened the way it was supposed to.
The facility's policy on changes in condition was equally direct. Any sudden change was to be communicated to a physician within 30 minutes to one hour. Nursing actions taken in response were to be documented in the licensed progress notes as soon as possible after the resident's needs were met. The policy existed, had been revised as recently as August 2025, the same month inspectors arrived, and still the care described in the inspection record did not match what the policy required.
Foley catheters, which drain urine directly from the bladder through a tube, carry a well-documented risk of infection. Cloudy urine, sediment, and color changes are among the earliest warning signs that something is going wrong. Catching those signs early, and getting a physician involved quickly, is the difference between a treatable urinary tract infection and a bloodstream infection that can kill a frail elderly person. That is why the monitoring protocol exists. That is why the notification requirement has a one-hour window, not a "when you get around to it" window.
The inspection found that the gap between Cedar Pine's written policies and its actual practice was wide enough to cause harm to at least one resident, and inspectors noted that a few residents were affected.
The facility's person-centered care plan policy added another layer of obligation. Every resident was supposed to have a comprehensive care plan with measurable objectives and a timetable for meeting their physical needs. Residents had the right to participate in developing that plan and the right to receive the services it described. A catheter care protocol that goes unobserved shift after shift is not a care plan being implemented. It is a document sitting in a binder while a resident's condition goes unmonitored.
What makes this inspection notable is not the complexity of what went wrong. There was no equipment failure, no staffing crisis described in the report, no unusual circumstance that made monitoring difficult. The policy was clear. The steps were basic. Someone was supposed to look at the catheter drainage every shift, note what they saw, and make a phone call if something changed.
That did not happen. A resident was harmed.
Cedar Pine Post Acute is a post-acute and rehabilitation facility, meaning many of its residents arrive after hospitalizations, often already medically fragile. Catheter use is common in that population. The stakes of missed monitoring are not abstract.
The August 2025 revision date on the change-in-condition policy is its own detail worth sitting with. The facility had updated that document in the weeks before or during the inspection period. The policy said the right things. Surveyors still found actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Pine Post Acute from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 10, 2026 · Our methodology
Cedar Pine Post Acute in PASADENA, CA was cited for violations during a health inspection on August 28, 2025.
That designation means inspectors determined a resident suffered real injury, not a theoretical risk.
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.