Vermont Healthcare Center: Suicide Risk Left Unplanned - CA
That was the central finding from a March 2025 federal inspection of the facility at 22035 S. Vermont Avenue. Inspectors cited the home for failing to implement a care plan for Resident 48, a man with a documented history of psychiatric illness and cognitive impairment who had been admitted and later readmitted to the facility.
The incident happened on the morning of March 11, 2025. At 9:48 a.m., Resident 48 yelled out that he wanted to die. Licensed Vocational Nurse 4 was present and told inspectors she would notify her charge nurse immediately.
The next day, inspectors asked another nurse about it.
Licensed Vocational Nurse 1 told inspectors there was no care plan for Resident 48's statements about wanting to die, then added there should be one, because Resident 48 could potentially commit suicide.
That same afternoon, the facility's Registered Nurse Supervisor said the same thing in plainer terms. A care plan, she explained, is a guideline for staff, with specific interventions to follow when providing care. Resident 48 should have one for his verbalization of wanting to die, she said, so staff would know to monitor him more closely and potentially prevent him from committing suicide.
By the time inspectors spoke with the Director of Nursing on March 14, the position hadn't changed. The DON acknowledged Resident 48 should have a care plan because it is a guideline for how to care for the resident.
Three days after a nurse watched a man say he wanted to die, the facility's own nursing leadership, from floor nurses to the director, agreed a plan was needed. None existed.
Resident 48's records showed he was moderately cognitively impaired as of a January 2025 assessment, meaning his ability to think, understand, and remember was significantly compromised. He needed substantial help with bathing, dressing, and personal hygiene. His diagnoses included not only paranoid schizophrenia and major depression but also cerebral infarction, a loss of blood flow to the brain.
The care plan is not a bureaucratic formality. It is the document that tells a night-shift aide, a weekend nurse, or a new employee what to watch for and what to do. Without one, a staff member who hasn't personally witnessed Resident 48's statements has no written record of the risk and no instructions for responding to it.
The facility's own policy on care plans states they are designed to incorporate identified problem areas and risk factors, and that assessments are ongoing, with plans revised as a resident's condition changes. A resident expressing a wish to die is precisely the kind of change that triggers that process. It didn't.
Inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. The citation applies to Resident 48 alone among the three residents sampled during this inspection.
Vermont Healthcare Center did not contest the finding. The inspection report notes that anyone seeking information on the facility's plan to correct the deficiency should contact the home or the state survey agency directly.
What the report does not say is whether, in the days between March 11 and March 14, anyone sat with Resident 48 and asked him how he was doing.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 10, 2026 · Our methodology
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on March 14, 2025.
That was the central finding from a March 2025 federal inspection of the facility at 22035 S.
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.