Vermont Healthcare Center: Repeat Care Failures - CA
The failures were not minor or obscure. Inspectors returned and documented repeat deficiencies in five distinct areas: daily living care provided for dependent residents, range of motion and mobility, pharmacy services and pharmacist records, medication error rates at five percent or above, and the labeling and storage of drugs and biologicals. Each of those categories had been cited during the facility's 2024 recertification survey. Each remained unresolved a year later.
For residents who cannot feed themselves, bathe themselves, or move without assistance, the category labeled "activities of daily living care provided for dependent residents" is not an administrative line item. It describes whether someone gets turned in bed, whether they receive help eating, whether their basic physical needs are met by the people assigned to meet them. Vermont Healthcare Center had been told this care was deficient. It was still deficient when inspectors came back.
The range of motion and mobility findings sit alongside that. When residents lose range of motion, they lose function, sometimes permanently. A joint that stiffens doesn't always recover. The facility had been cited for failing to help residents maintain or improve their mobility. Inspectors found the same problem still present.
The medication violations ran across three separate categories. Pharmacy services and pharmacist records. Medication error rates at or above five percent. Labeling and storage of drugs and biologicals. Three distinct ways a facility can fail the residents it gives medications to, and Vermont Healthcare Center had been cited for all three before and was cited for all three again.
The facility's own Quality Assessment and Assurance Committee, known as the QAA Committee, carries a specific responsibility under the facility's own written policy. That policy, dated August 2017, describes the committee's duties as identifying and responding to quality deficiencies, developing and implementing corrective action, monitoring whether performance targets are being achieved, and revising corrective action when it isn't working. The policy also lists what the committee is supposed to routinely monitor for all residents: nursing care, medication administration, pressure ulcers, dehydration, malnutrition, accidents and injuries, unexpected deaths, changes in mental or psychological status, and unplanned hospitalizations.
That is an extensive list of responsibilities. Inspectors found the committee had failed to exercise effective oversight and had failed to implement the facility's own plan of correction for the deficiencies identified the previous year.
When inspectors interviewed the administrator on the evening of March 14, 2025, the administrator acknowledged the deficiencies from the prior survey. "The facility will identify and work on the deficiencies," the administrator said. The administrator added that the facility "must have accountability" and that "the staff need to know how their actions affect the residents."
That statement was made a year after the same deficiencies were first cited. The facility had already submitted a plan of correction after the 2024 survey. That plan described what the facility intended to do. What inspectors found in March 2025 was that the doing had not followed the describing.
A plan of correction is a formal document. A facility identifies what went wrong, explains how it will fix it, and commits to a timeline. Surveyors use those plans to assess whether a facility is taking its obligations seriously. Vermont Healthcare Center submitted one. The QAA Committee, the body responsible for oversight and follow-through, did not ensure it was carried out.
The administrator's comment about accountability lands differently against that backdrop. Accountability is what the QAA Committee is designed to enforce internally, without waiting for inspectors to return. The committee monitors. The committee identifies when corrective action isn't working. The committee revises. That is the system. At Vermont Healthcare Center, the system did not work.
The harm level assigned to the oversight failure was listed as minimal harm or potential for actual harm. That classification applies to the QAA finding itself. It does not erase the underlying violations the committee failed to resolve. Dependent residents receiving deficient daily care. Residents losing mobility that may not come back. Medications stored, labeled, or administered incorrectly at a rate high enough to trigger federal citation, twice.
Medication errors at five percent or above affect real people. A resident who receives the wrong drug, the wrong dose, or a drug that wasn't properly stored may experience a reaction, a worsened condition, or a missed treatment. The labeling and storage citation compounds that risk. Drugs that aren't properly labeled or stored create the conditions for errors before anyone even reaches the medication cart.
Vermont Healthcare Center sits at 22035 South Vermont Avenue in Torrance, a city in Los Angeles County. The facility's CMS identification number is 056433. The inspection was completed March 14, 2025.
What the administrator said that evening about accountability and staff understanding how their actions affect residents is, on its face, the right thing to say. It is also what accountability looks like when it arrives too late, spoken to an inspector rather than enforced by the people inside the building whose job it was to enforce it.
The QAA Committee had the authority, the policy framework, and the explicit responsibility to catch these failures before they became repeat citations. Dependent residents received deficient care during the window the committee was supposed to be watching. Some of them lost range of motion they may never recover. The committee met, or was supposed to meet, and the violations persisted anyway.
The administrator said the facility must have accountability. The residents who couldn't move themselves, who needed help with the most basic functions of daily life, who received medications from a system that federal inspectors found deficient two years running, were depending on that accountability to already exist.
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 8, 2026 · Our methodology
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on March 14, 2025.
The failures were not minor or obscure.
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.