Cedar Pine Post Acute: Fall Prevention Failures - CA
Federal inspectors who arrived at the facility on August 15 found that Resident 1, as he is identified in inspection records, had been assessed repeatedly as someone who should never be left alone. An occupational therapist had flagged him as a fall risk from the moment he was admitted, citing the hemiplegia and hemiparesis he carried from his stroke, along with what the therapist described as poor safety awareness. His left side did not work the way it once had. His judgment about his own limits was unreliable.
The facility's own assessment records, reviewed during the inspection, showed exactly how dependent he was. According to the MDS, a standardized federal assessment that nursing homes complete on every resident, he was wheelchair bound and needed staff assistance for every transfer, from chair to bed, from sitting to lying down, into and out of a shower. He needed help with all activities of daily living, all the time.
The MDS Nurse who spoke with inspectors on August 15 did not dispute any of this. She confirmed that the assessment showed he needed constant assistance, that his memory problems and confusion were documented, and that without staff present, falls were predictable. "If Resident 1 was not assisted," she told inspectors, "it could lead to possible falls that could possibly cause harm and injury to the resident." She said directly that Resident 1 should not have been left unattended or unsupervised on May 10. She said that with supervision, the fall could have been prevented.
That is the whole of it, stated plainly by the facility's own nurse: a man who could not safely move himself, who could not reliably recognize danger, who had been assessed as a fall risk since admission, was left alone. And then he fell.
Cedar Pine's written policies described an elaborate system for preventing exactly this. The fall risk intervention policy, revised as recently as December 2024, laid out a process for monitoring residents after falls, re-evaluating interventions, and adjusting approaches when a resident kept falling. The fall risk assessment policy, revised in March 2024, called for nursing staff, physicians, pharmacists, and therapy staff to work together to identify risk factors and build individualized prevention plans.
The gap between those documents and what happened on May 10 is not subtle. The policies describe a facility that tracks fall risks carefully and responds when interventions fail. What the inspection found was a resident whose risk factors were thoroughly documented, whose need for constant supervision was recorded in his assessment, and who was nonetheless left alone.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, the lower end of the federal harm scale. That classification reflects the regulatory framework's language, not necessarily the experience of a stroke survivor who fell while no one was watching.
The inspection was triggered by a complaint. The report does not describe the extent of any injuries Resident 1 sustained, or whether he fell once or more than once before inspectors arrived. It does not say how long he was alone before the fall, or what staff were doing at the time. Those details are not in the record.
What is in the record is the MDS Nurse's own words: he should not have been left unsupervised. With supervision, the falls could have been prevented.
Resident 1 was still living at Cedar Pine Post Acute at the time of the inspection.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
Cedar Pine Post Acute in PASADENA, CA was cited for violations during a health inspection on August 15, 2025.
His left side did not work the way it once had.
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.