South Pasadena Care: Itching Resident Ignored - CA
The woman, identified only as Resident 3, complained of itching all over her body. Staff knew she was scratching herself constantly. They applied lotion to her arms, legs and back during routine care. But nobody called her physician.
CNA 1 told inspectors on September 2 that she changed Resident 3's briefs and put lotion on her skin. The certified nursing assistant said staff knew the resident "had been itching and scratching herself."
That was the extent of the treatment.
LVN 2 admitted to inspectors that he "did not immediately inform the physician about Resident 3's generalized itching complaint." The licensed vocational nurse said the resident complained of itching all over her body before 10 AM and he "still have not called Resident 3's physician" by the time of the afternoon interview.
The itching had been going on since August 23. Two weeks of constant scratching with no medical intervention.
LVN 1 reviewed Resident 3's medication orders with inspectors at 12:01 PM. "Resident 3 has no medications for itching," the nurse stated. The logical consequence seemed obvious to the nurse: "If there was no medication for itching, Resident 3 will continue to scratch her skin, and it can get worse."
LVN 2 confirmed the same problem nineteen minutes later during his interview. No medication. No treatment orders. Nothing for the generalized itching that had persisted for two weeks. "The staff should have follow-up with the physician," he told inspectors. "The staff should have called the physician for a follow up treatment for Resident 3's skin issue."
But LVN 2 had his own excuse for the delay. He told inspectors he "must do the SBAR Form before calling the physician." The SBAR communication tool requires nurses to organize information about a patient's Situation, Background, Assessment and Recommendation before contacting doctors.
The Director of Nursing didn't buy the excuses when inspectors interviewed her at 3:28 PM. She reviewed Resident 3's medication orders and confirmed no treatments had been ordered for the itching. Her assessment was blunt: "The staff should have called the physician as soon as we identify the problem."
The DON understood the medical risks staff were ignoring. "The sooner the staff notified the physician the better, to prevent delays treatment for Resident 3's itching," she said. "Resident 3 will continue scratching her skin and might have skin breakdown."
Nine minutes later, the DON discovered another failure. Resident 3 had no care plan addressing her itching problem. Care plans are supposed to guide staff interventions and track whether treatments work.
"There was no CP for Resident 3's itching," the DON confirmed to inspectors. "The staff should have formulated a CP to provide treatment and evaluate if treatment was effective."
Without a care plan, staff had no systematic approach to help the resident. "If it is not effective, the staff can approach in a different way to solve the problem," the DON explained. "If there was no CP, there were no interventions and no way to see if the treatment was effective or not."
The facility's own policies required exactly what staff failed to do. South Pasadena Care Center's "Changes in Resident Condition" policy, dated January 2024, states that physicians must be notified of "a significant change in the residents' physical, mental or psychosocial status."
Two weeks of constant itching and scratching qualified as a significant change. The policy also required that "changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers."
No revisions were made because no care plan existed in the first place.
LVN 1 spelled out the consequences during her interview with inspectors. With no medication orders and no treatment plan, "Resident 3 will still experience itching and possibly have a skin breakdown."
The inspection occurred on September 2, 2025, in response to a complaint. By then, Resident 3 had been scratching herself for ten days without any medical intervention beyond lotion applied during routine personal care.
Staff knew she was suffering. They acknowledged the risks of continued scratching. They understood their facility's policies required physician notification. But Resident 3 continued to scratch while nurses filled out paperwork and made excuses for delays that stretched into weeks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Pasadena Care Center from 2025-09-02 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 20, 2026 · Our methodology
SOUTH PASADENA CARE CENTER in SOUTH PASADENA, CA was cited for violations during a health inspection on September 2, 2025.
The woman, identified only as Resident 3, complained of itching all over her body.
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.