South Pasadena Care Center: Cancer Appointment Missed - CA
The patient, identified in inspection records only as Resident 1, was scheduled to see an oncologist on May 9, 2025. The appointment did not happen. Staff at South Pasadena Care Center did not reschedule it. They did not tell the attending physician it had been missed. Nobody followed up.
The failure came to light during a complaint inspection conducted in October 2025.
When inspectors interviewed the facility's Director of Nursing on October 16, the director did not dispute any of it. The facility had not followed its own policy to ensure the resident was seen by the oncologist as prescribed, the director said. The attending physician, identified as MD 1, was not notified, and should have been. The appointment was not rescheduled, and should have been.
"Without the oncology appointment, we could not ensure Resident 1 received all necessary care for cancer," the Director of Nursing told inspectors.
The attending physician, interviewed separately, told inspectors he should have been notified when the appointment fell through so he could find another oncology specialist who accepted the resident's insurance. That detail matters: the original oncologist may not have been an option at all, which made the failure to loop in the physician not just a procedural lapse but a practical dead end. The resident could not simply be rescheduled with the same doctor. Someone needed to find a different one. Nobody did.
The Director of Nursing told inspectors that an appointment of this significance, once cancelled, should have been escalated to the registered nurse supervisor for follow-up. That escalation did not happen either.
The facility's own written policy, last updated January 6, 2025, less than four months before the missed appointment, described its purpose in plain terms: to ensure timely, appropriate, and coordinated referral of residents to medical specialists. The policy assigned responsibility to the Social Services Designee or unit nurse to contact the specialist's office and schedule appointments. It called for referrals to be documented and followed up.
None of that happened for Resident 1.
Inspectors rated the violation as carrying minimal harm or potential for actual harm, a designation that reflects the lower end of the federal harm scale. What it does not reflect is what the Director of Nursing said out loud in that interview: that without the appointment, the facility could not guarantee this resident received everything needed to treat their cancer.
That is not a paperwork problem. A cancer patient's care depends on oncologists. Oncologists are not on staff at nursing homes. When the system meant to connect a resident to that specialist breaks down entirely, and stays broken for months without anyone in the building noticing or acting, the resident is left without a piece of their medical care that nobody inside the building can provide.
The inspection was triggered by a complaint, not a routine survey. That means the gap between the missed appointment in May and the investigation in October was not caught by any internal process. It was caught because someone reported it.
South Pasadena Care Center is a skilled nursing facility in South Pasadena, California. The inspection covered events from May 2025 and was conducted on site in October 2025.
Resident 1's oncology care, as of the inspection record, remained unresolved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Pasadena Care Center from 2025-11-25 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: August 29, 2026 · Our methodology
SOUTH PASADENA CARE CENTER in SOUTH PASADENA, CA was cited for violations during a health inspection on November 25, 2025.
The patient, identified in inspection records only as Resident 1, was scheduled to see an oncologist on May 9, 2025.
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.