Cedar Pine Post Acute
Cedar Pine Post Acute in PASADENA, CA — inspection on August 15, 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
During an interview on 8/15/2025 at 12:26 PM with the MDS Nurse, the MDS Functional Abilities section dated 5/8/2025 was reviewed.
The Functional Abilities section indicated Resident 1 was wheelchair bound, was dependent on chair to bed, sit lying, tub/shower transfer.
The MDS Nurse stated that according to the assessment, Resident 1 needed staff to assist with Activities of Daily Living (ADLs-tasks a person does to take care of the body and overall well-being) all the time.
The MDS nurse stated that 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 stated Resident 1 was assessed as having memory problems and with episodes of confusion.
The MDS nurse stated Resident 1 should not have been left unattended or unsupervised on 5/10/2025.
The MDS nurse stated that with supervision from staff, the falls could have been prevented.
During a review of the facility's Policy and Procedures (P&P) titled, Fall Risk Assessment, revised 3/2024, the P&P indicated: The nursing staff, in conjunction with the Attending MD, consultant pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information.During a review of the facility's P&P, titled Fall Risk Intervention and Monitoring, revised 12/2024, the P&P indicated: If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable.
For monitoring subsequent falls and fall risk, the staff will monitor and periodically document the resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.
The MD may help the staff reconsider possible causes that may not previously have been identified.
Frequently Asked Questions
More Reports
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.