Vermont Healthcare Center: Therapy Records Failures - CA
That resident is identified in a March 2025 federal inspection report as Resident 109. The inspection at Vermont Healthcare Center, a skilled nursing facility on South Vermont Avenue, found that therapists working with her had left gaps across weeks of treatment notes, and in the case of speech therapy, left no notes at all.
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See the Derila PillowThe speech language pathologist assigned to Resident 109 had evaluated her on February 28, 2025. The evaluation documented that she had impaired receptive language, meaning her ability to understand spoken language was compromised. Her expressive language was also impaired, limiting her ability to communicate through words, gestures, writing, or facial expressions. Her cognitive-communicative skills, the mental processes that allow a person to attend, remember, and problem-solve during conversation, were impaired as well. The treatment plan called for speech, language, voice, and communication sessions three times per week for four weeks.
When inspectors reviewed her electronic records on March 13, the Director of Rehabilitation could not locate a single treatment note. There were none.
The speech language pathologist, reached by phone the following day, said he had tried to see Resident 109 at the end of February and on an unspecified weekend. He said she was not alert enough during those attempts to participate. He did not write notes about the attempts because, he said, he lacked access to the facility's electronic documentation system at those times. He also did not leave a handwritten note in her paper chart.
So the record showed a plan. Then silence.
The documentation problems extended to physical and occupational therapy as well. Resident 109 required splints on multiple parts of her body, including her knees, ankles, elbows, wrists, and fingers. The physical therapy assistant and occupational therapy assistant working with her both told inspectors that splints were applied at every treatment session. The physical therapy assistant was direct about what that meant for the paperwork: the facility had no documented evidence the splints were ever applied during PT or OT sessions.
The Director of Rehabilitation confirmed it during record reviews conducted on March 15. For physical therapy, treatment notes from February 27, February 28, March 3, March 5, March 6, and March 10 contained no indication that splints were applied. For occupational therapy, notes from February 27, March 3, March 5, March 6, and March 7 showed the same gap.
The therapists said they did the work. The record did not reflect it.
That distinction matters in ways that go beyond paperwork. For a resident who cannot describe her own experience, cannot say whether a splint was too tight or left off entirely, cannot tell a nurse or a family member what happened in a therapy session, the medical record is often the only account that exists. It is how her physicians track her progress. It is how the next shift knows what was done. It is how anyone, after the fact, could determine whether she received the care she was supposed to receive.
Vermont Healthcare Center's own medical records policy, reviewed by inspectors, stated that the facility maintained records that are complete and accurately documented, and that those records must accurately reflect a resident's treatments.
During the inspection period, therapists were observed working with Resident 109. On March 11, the occupational therapy assistant and physical therapy assistant applied her arm splints together. On March 12, the physical therapy assistant performed range-of-motion exercises on her hips, knees, and ankles and applied her leg splints. The care, at least in those observed moments, appeared to be happening.
What remained unresolved was the weeks before, and the speech therapy that a plan had promised her and that no note confirmed she ever received.
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 13, 2026 · Our methodology
VERMONT HEALTHCARE CENTER in TORRANCE, CA was cited for violations during a health inspection on March 14, 2025.
That resident is identified in a March 2025 federal inspection report as Resident 109.
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.