Vermont Healthcare Center: Care Planning Failures - CA
That's what the social services director told inspectors during an interview on March 14, 2025, at 5:48 p.m. The meeting, known as an interdisciplinary team meeting, should have happened within 72 hours of the resident's admission. It hadn't. There was, the social services director acknowledged, no documentation showing the family had ever been notified that one was coming.
The resident is identified in inspection records only as Resident 218.
The interdisciplinary team meeting is how a nursing home is supposed to bring together the people responsible for a resident's care — the attending physician, a registered nurse, a nursing assistant, dietary staff, activities staff, rehabilitation staff, social services, and case management — and sit down with the resident and their family to explain what treatment looks like and why.
The Director of Nursing described Resident 218 as alert and oriented, someone who knew their name, where they were, and what day it was. That made the failure harder to explain. The Director of Nursing said the meeting should have been held within seven days of admission. It wasn't held at all.
The Director of Nursing also said Resident 218 "can get mad and depressed and may want to leave the facility early if care and services were not explained." That consequence, the risk that a resident who doesn't understand their own care plan might simply refuse it or walk out, was framed not as a hypothetical but as something the facility already understood about this particular person.
Nobody had scheduled the meeting anyway.
The social services director told inspectors that the purpose of the interdisciplinary team meeting was to discuss the resident's plan of care while they were in the facility, and that it should happen within 72 hours of admission. A registered nurse interviewed earlier that day said the meetings exist to inform residents they're receiving the correct treatment, and that a resident who didn't understand their plan of care could refuse it.
The facility's own written policies said the same thing. One policy described the interdisciplinary team as responsible for educating residents and families about treatments and medications, documenting treatment preferences, and addressing end-of-life care. Another stated that residents have the right to be involved in care planning and to refuse care. A third said care plan meetings should be scheduled at the best time of day for the resident and family when possible.
Vermont Healthcare Center's policies were thorough. The meeting for Resident 218 still didn't happen.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a few residents. That classification sits at the lower end of the federal harm scale, but the Director of Nursing's own words suggested the stakes for Resident 218 were more specific than that framing implies. A resident who is alert, oriented, prone to depression, and capable of deciding to leave early is a resident whose understanding of their care plan matters in a direct and immediate way.
The social services director made a phone call to the family on March 14, the day inspectors arrived, to finally schedule the meeting. Whether Resident 218 was present for that call, or was told what it was about, the inspection report doesn't say.
What the report does say is that when inspectors asked about prior documentation, about any earlier notice to the family, about any record that the facility had been working toward this meeting before that afternoon, there was nothing to show them.
Resident 218 had been in the facility, receiving care under a plan that had never been explained to them or their family, waiting for a meeting that the people responsible for their care had simply never gotten around to scheduling.
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.
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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.
That's what the social services director told inspectors during an interview on March 14, 2025, at 5:48 p.m.
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.