Vermont Healthcare Center: Missing Dentures, Infection Control - CA
The resident was seen by a dentist on February 3, 2025, for evaluation for full upper and lower dentures. But when federal inspectors arrived at the facility on March 11, she was still missing her bottom dentures. "I don't like the way food tastes without my bottom dentures," she told them.
The facility's Social Services Director admitted during the March 14 inspection that there had been no follow-up appointment after the February dental visit. The director said the resident's insurance wouldn't pay for x-rays or denture fitting, and staff didn't follow up with the dentist until the day before inspectors questioned them about it.
"It is important for residents to have teeth it can affect the way they eat," the Social Services staff member told inspectors. "They could have weight loss. It can also affect the way they feel about their appearance."
The facility's own policy required referral for dental services within three days if dentures were damaged or lost. The Director of Nursing was blunt about the failure: "It did not matter if Resident 10's insurance would not pay for her dentures it is the facility's responsibility to make sure Resident 10 has her bottom dentures."
Meanwhile, the facility was putting residents at risk through multiple infection control failures that inspectors documented throughout the building.
In the kitchen, the ice machine pipe leading to the drain was covered in black grime and dirt, with no air gap to prevent contaminated water from backing up into the ice supply. The Assistant Dietary Supervisor, Registered Dietician, and Maintenance Supervisor all admitted they weren't aware of the federal regulation requiring the air gap.
The Maintenance Supervisor, who had worked at the facility for years, said there was a possibility residents could get sick stomachs from contaminated ice. The Administrator acknowledged the violation could cause water-borne illness and stomach issues for residents.
Federal food code requires an air gap of at least one inch between water supply outlets and drains to prevent contamination during periods of negative pressure in water systems.
Staff routinely failed to follow basic hand hygiene protocols. Inspectors observed a certified nursing assistant exit one resident's room carrying a water pitcher, then enter another resident's room without washing her hands. When questioned, the assistant admitted she should have performed hand hygiene to prevent transmitting germs between residents.
In the laundry room, a worker sorted dirty linens outside, then entered the clean side of the facility and began unloading washers without removing his gloves or washing his hands. The Infection Prevention Nurse called this "a breach in the infection control process."
The facility's laundry equipment was also failing basic safety standards. One of three dryers was operating at only 130 degrees Fahrenheit instead of the required 160-170 degrees needed to kill germs. The Maintenance Supervisor was unsure why the temperature was so low.
All three washer temperature gauges were broken and not functioning properly. Staff had been using a thermometer in a nearby sink to estimate washer temperatures, claiming the sink used the same water pipeline. The Laundry Aide said washers should reach 160 degrees to kill bacteria and prevent infection outbreaks, but admitted the broken gauges had been non-functional for several weeks without being reported.
The facility's infection control failures extended to equipment used directly on residents. Staff used cloth gait belts on three different residents without proper disinfection between uses. Inspectors observed a restorative nursing aide wipe down a walker with disinfectant wipes, then place the same cloth gait belt that had been used on one resident onto another resident.
The Infection Prevention Nurse reviewed the manufacturer's recommendations for the disinfecting wipes and found they were only effective on hard, non-porous surfaces. The cloth gait belts were made of cotton, a porous material that couldn't be properly disinfected with the wipes staff were using.
"The disinfecting wipes were ineffective on the cloth gait belts," the nurse told inspectors. "There was a potential for transmission of infection without proper disinfection of cloth gait belts between residents' use."
The manufacturer's label stated it was a violation of federal law to use the disinfecting wipes inconsistent with their labeling, which specified use only on hard, non-porous surfaces.
Documentation failures compounded the facility's problems with resident care. Inspectors found that five of 11 reviewed residents with limited mobility weren't receiving the range-of-motion exercises and therapy treatments ordered by their physicians, or staff weren't documenting the care properly.
One resident's documentation showed tasks for range-of-motion exercises on the left leg but omitted the right leg, despite physician orders for both. Another resident was supposed to receive passive range-of-motion exercises on the left arm, but the task was incorrectly entered for night shift when the restorative nursing aides work during the day.
A physician order for one resident incorrectly specified active-assistive range-of-motion exercises for a paralyzed right leg. The Director of Rehabilitation said this was a clinical record error since the resident couldn't move the right side of their body. The error wasn't corrected for eight months.
For a resident receiving physical and occupational therapy, treatment notes failed to document application of multiple splints during several sessions, even though therapists told inspectors they applied the splints every time.
The facility also failed to monitor antibiotic use properly. One resident was prescribed two different antibiotics simultaneously for a urinary tract infection, despite having an indwelling catheter and showing no symptoms like fever or pain that would justify antibiotic treatment under clinical guidelines.
The Infection Prevention Nurse said the dual antibiotic treatment didn't follow established criteria and could lead to antibiotic resistance or dangerous infections like C. difficile. She admitted not verifying with the physician why the resident needed two antibiotics.
Equipment failures affected basic resident safety. One resident's call light wasn't working, leaving him unable to summon help when he needed assistance. The resident was described as having repeated falls, muscle weakness, dementia, and legal blindness, making the working call system essential for his safety.
When the resident pressed his call light after soiling himself, no audible sound or visible light appeared. Staff discovered the malfunction only when inspectors questioned them about it. The facility's policy required the maintenance department to routinely test call systems, but the Maintenance Supervisor said he didn't check each resident's call light routinely.
The pattern of deficiencies represented repeat violations from the facility's previous inspection. The Quality Assessment and Assurance Committee had failed to ensure effective oversight and implementation of previous correction plans, leading to ongoing problems with activities of daily living, range-of-motion care, pharmacy services, medication errors, and drug storage.
The resident without dentures remained on a finely chopped mechanical soft diet while waiting for her dentures to become available, her care plan noting she was at risk for difficulty chewing and weight loss.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vermont Healthcare Center from 2025-03-14 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
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on March 14, 2025.
The resident was seen by a dentist on February 3, 2025, for evaluation for full upper and lower dentures.
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.