Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
5’23
28’24
34’25
22’26
89 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jun 26, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 26, 2026 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 26, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jun 26, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jun 26, 2026 | E · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Jun 26, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 26, 2026 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jun 26, 2026 | E · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Jun 26, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 26, 2026 | E · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Jun 26, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 26, 2026 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jun 26, 2026 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Jun 26, 2026 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 26, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jun 26, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jun 26, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| May 6, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Apr 23, 2026 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Complaint |
| Apr 23, 2026 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Apr 14, 2026 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Apr 14, 2026 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Dec 23, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Dec 19, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 9, 2025 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Complaint |
| Nov 26, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 28, 2025 | G · harm | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Aug 15, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 30, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| May 23, 2025 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| May 23, 2025 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| May 23, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| May 23, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| May 23, 2025 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 23, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| May 23, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| May 23, 2025 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| May 23, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| May 23, 2025 | D · potential | Provide routine and 24-hour emergency dental care for each resident. | Routine |
| May 23, 2025 | D · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| May 23, 2025 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| May 23, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 23, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| May 23, 2025 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Apr 19, 2025 | J · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 19, 2025 | D · potential | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Complaint |
| Apr 1, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 25, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 13, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Feb 5, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 3, 2025 | E · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Jan 3, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 3, 2025 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Complaint |
| Jan 3, 2025 | D · potential | Provide or get specialized rehabilitative services as required for a resident. | Complaint |
| Jan 3, 2025 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jan 3, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 14, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 14, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 14, 2024 | E · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Routine |
| Jun 14, 2024 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Jun 14, 2024 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jun 14, 2024 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Jun 14, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jun 14, 2024 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Jun 14, 2024 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Jun 14, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Jun 14, 2024 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jun 14, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 14, 2024 | E · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Jun 14, 2024 | E · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Jun 14, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 14, 2024 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jun 14, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Jun 14, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 14, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 14, 2024 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| Jun 14, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 14, 2024 | E · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Jun 14, 2024 | E · potential | Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Routine |
| Jun 14, 2024 | E · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| Jun 14, 2024 | D · potential | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Routine |
| Jun 14, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 14, 2024 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Jan 5, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 8, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Dec 8, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 7, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Nov 7, 2023 | D · potential | Assist a resident in gaining access to vision and hearing services. | Complaint |
| Oct 25, 2023 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Cedar Pine Post Acute
1640 N. Fair Oaks Avenue, Pasadena, CA 91103 · (626) 773-7969
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555213
- Certified beds
- 99
- Legal owner
- Pasadena Care Center LLC
- Part of
- Eva Care Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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