Vermont Healthcare Center: Resident Care Failures - CA
A separate resident missed a dose of her thyroid medication. Nobody called the doctor.
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See the Derila PillowFederal inspectors cited Vermont Healthcare Center, located at 22035 S. Vermont Avenue in Torrance, for failing to act on significant changes in residents' conditions during an inspection completed March 14, 2025. The deficiencies touched at least two residents and drew direct acknowledgment from the facility's own Director of Nursing that the failures were unacceptable.
When Resident 48 told staff he wanted to die, the facility was required to complete what it calls a change-of-condition report, a documentation form that alerts the care team and sets closer monitoring in motion. It did not happen. The Director of Nursing, speaking with inspectors on March 4, 2025, confirmed the form was critical precisely because of what it triggers. "It's a communication tool between the staff and will trigger closer monitoring of the resident," the DON told inspectors.
The monitoring never started because the paperwork was never done.
The second case involved Resident 361, who takes thyroid medication regularly. She missed a dose. The Director of Nursing told inspectors that missing a thyroid dose "is unacceptable and should have been immediately communicated to the doctor because it can cause a significant change in the body's system." Thyroid medication, taken consistently, regulates metabolism and organ function. A missed dose in a patient who depends on it daily is not a minor scheduling error.
No one called her physician.
The facility's own written policies made the obligations explicit. Its physician notification policy states that the attending physician must be notified immediately when there is a significant change in a resident's physical, mental, or psychosocial status, and that nurses and licensed staff are responsible for recognizing those changes and making the call promptly. Its behavior assessment policy states that new onset or changes in behavior will be documented regardless of the degree of risk. Its change-of-condition policy instructs the nurse supervisor or charge nurse to notify the attending or on-call physician when there has been a significant change in a resident's physical, emotional, or mental condition.
Three separate policies. The same result each time: nothing was done.
Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected. That language, in federal inspection terminology, sits below the threshold of actual injury, but it does not mean the failures were minor. A resident expressing a desire to die without receiving the monitoring that statement is supposed to trigger is a resident left more exposed than the facility's own protocols are designed to allow.
The Director of Nursing did not dispute what happened. On the question of Resident 48, the DON confirmed that a change-of-condition report was important and should have been completed. On the question of Resident 361, the DON confirmed the missed thyroid dose should have gone to the doctor immediately. The acknowledgment was clear. So was the gap between what the DON described as the standard and what the staff had actually done.
Vermont Healthcare Center has a plan of correction on file with the state survey agency, as required following any cited deficiency. The contents of that plan were not included in the inspection materials reviewed for this report.
What the inspection captured is a facility whose nursing director could articulate, in precise terms, why both failures mattered, and whose staff failed anyway. Resident 48 said he wanted to die. The form that would have put more eyes on him was never filed. Resident 361 missed medication her body depends on. Her doctor was never told.
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 14, 2026 · Our methodology
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on March 14, 2025.
A separate resident missed a dose of her thyroid medication.
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.