Vermont Healthcare Center: PASARR Screening Gaps - CA
The March 2025 inspection, conducted by the Centers for Medicare and Medicaid Services, cited the facility for deficiencies in what is known as the PASARR process, short for Preadmission Screening and Resident Review. The citation was classified as causing minimal harm or potential for actual harm, and inspectors noted that few residents were affected. But the process exists for a reason, and its failure, even in limited cases, carries consequences that are difficult to walk back once a vulnerable person is already through the door.
The PASARR process works in two stages. In the first, an incoming resident is screened to determine whether they might have a mental disorder, intellectual disability, or related condition. If that screen suggests they might, the case is supposed to be referred to the state's PASARR representative for a deeper evaluation. That second stage, the Level II evaluation, is where a qualified evaluator determines whether the person actually has such a condition, what specialized services they would need, and whether a nursing home is even the right place for them at all.
At Vermont Healthcare Center, the admitting nurse is supposed to notify the social services department when a resident is identified as possibly having one of these conditions. That handoff, from nursing to social services, is where the inspection record points. Whether that notification was delayed, skipped, or simply not documented in a way that satisfied inspectors, the report does not elaborate. What it establishes is that the facility's execution of this required process was deficient.
The significance of PASARR failures is not always obvious from the outside. No one collapsed. No wound went untreated. The harm the regulation is designed to prevent is subtler and, in some ways, harder to undo. A person with a serious mental illness placed in a nursing home without proper evaluation may spend weeks or months in an environment that cannot meet their needs, without access to the psychiatric or rehabilitative services their condition requires. By the time anyone revisits the question of whether the placement was appropriate, the person has already been living there.
Vermont Healthcare Center is a licensed skilled nursing facility operating in a residential stretch of Torrance, south of Los Angeles. The inspection was completed March 14, 2025.
The inspection report does not name the residents involved, does not describe what happened to them after admission, and does not specify how many admissions were affected beyond the notation that "few residents" were impacted. It does not indicate whether any resident was found to have been placed inappropriately as a result of the screening failure, or whether any was subsequently referred for the Level II evaluation they should have received at the outset.
What the record does show is a facility where a process meant to function as a safeguard did not function as designed. The admitting nurse, the social services department, the state PASARR representative: each has a defined role in a chain that is only as reliable as its weakest link. Inspectors found that chain had a weak link at Vermont Healthcare Center.
For the residents who passed through that process during the period in question, the question of whether they received the evaluation they were owed, and whether the placement they ended up in was the right one, remains unanswered in the public record.
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: 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 7, 2026 · Our methodology
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on March 14, 2025.
The citation was classified as causing minimal harm or potential for actual harm, and inspectors noted that few residents were affected.
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.