TORRANCE, CA - Vermont Healthcare Center reported multiple deficiencies during a March 2025 inspection, including delayed medication administration affecting numerous residents and failures to address mental health concerns, according to state health officials.
Widespread Medication Administration Delays Documented
Inspectors documented systematic delays in morning medication administration within the facility's sub-acute unit on multiple days during the survey period. On March 12, 2025, seven of 26 residents received their scheduled 9:00 a.m. medications after the allowable two-hour window had closed. The following day, four of 25 residents experienced similar delays.
The sub-acute unit provides specialized care for individuals requiring more intensive medical attention than typical skilled nursing but less than hospital-level care. Many residents in this unit receive medications through gastrostomy tubes, a process that facility staff acknowledged requires between 20 minutes to one hour per resident.
Licensed Vocational Nurse 6, who was assigned 12 of the unit's 26 residents on March 12, reported that three assigned residents had not received morning medications by 11:47 a.m. - nearly three hours after the scheduled administration time. Regulatory standards permit medication administration within one hour before or after the scheduled time, creating a two-hour window for 9:00 a.m. medications.
The Director of Nursing acknowledged that medications scheduled at 9:00 a.m. should be administered between 8:00 a.m. and 10:00 a.m. The facility's own policy, dated January 2022, specifies that "medications are administered within 60 minutes of schedule time - one hour before and one hour after."
Mathematical analysis of staffing ratios revealed systemic issues. With 26 residents requiring G-tube medication administration averaging 30 minutes each, and only two licensed vocational nurses on duty, each nurse would need six hours to complete morning medication rounds - far exceeding the two-hour regulatory window. Even with three nurses and 24 residents, the calculated time requirement of four hours per nurse exceeded allowable limits.
The timing of medication administration directly affects therapeutic outcomes. Medications prescribed at specific intervals are designed to maintain consistent blood levels of drugs, particularly important for antibiotics, cardiac medications, and diabetes treatments. Delays can result in subtherapeutic drug levels, allowing infections to progress or chronic conditions to destabilize.
Critical Gaps in Mental Health Care and Monitoring
Inspectors identified significant deficiencies in behavioral health services after discovering that Resident 48, who had diagnoses of paranoid schizophrenia and major depressive disorder, repeatedly verbalized wanting to die without receiving appropriate interventions or monitoring.
On March 11, 2025, at 9:48 a.m., Resident 48 was observed yelling "I want to die" in the presence of Licensed Vocational Nurse 4. While the nurse stated she would notify her charge nurse immediately, subsequent investigation revealed no documentation, physician notification, care plan implementation, or monitoring protocols were initiated.
Licensed Vocational Nurse 1 later confirmed she was aware of these statements but "did not document these comments" and "did not inform anyone" including the resident's physician. The nurse acknowledged no change of condition assessment or care plan was implemented, stating "she should have informed Resident 48's doctor so the staff could monitor him more closely because Resident 48 could try to commit suicide."
During an interview on March 12, 2025, Resident 48 reported thinking about dying daily, stating: "I wake up feeling like sh*t everyday and it goes downhill from there. I'm sick of it. This is a miserable existence." The resident indicated these thoughts began upon admission to the facility and occurred even in dreams.
Suicidal ideation represents a psychiatric emergency requiring immediate assessment and intervention. Clinical protocols dictate that any verbalization of wanting to die should trigger immediate physician notification, psychiatric evaluation, implementation of safety precautions, and enhanced monitoring. The failure to recognize and respond to these statements placed the resident at risk for self-harm.
The Registered Nurse Supervisor, when informed of the situation on March 12, confirmed she was unaware of the resident's statements and identified them as suicidal ideation requiring immediate physician notification. She noted the absence of any change of condition documentation, care plan updates, nursing notes, or monitoring protocols that should have been implemented "to prevent Resident 48 from potentially committing suicide."
A Certified Nurse Assistant reported hearing the resident verbalize wanting to die and stated she reported it to her charge nurse, indicating the concerning statements were not isolated incidents but represented a pattern that failed to trigger appropriate clinical responses.
The facility's policy on Behavioral Assessment, Intervention, and Monitoring requires that "nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including onset, duration, intensity, and frequency of behavioral symptoms." None of these required actions occurred.
Pharmacy Communication Failures Create Medication Errors
Inspectors documented failures in medication verification processes that resulted in two residents receiving intravenous antibiotic medications that did not match their physician orders. Both Resident 22 and Resident 44 were prescribed Zosyn (piperacillin-tazobactam) antibiotic mixed in dextrose solution, but the pharmacy delivered the medication mixed in normal saline solution at twice the ordered volume.
On March 13, 2025, inspectors observed a nurse preparing to administer Zosyn 3.375 mg in 100 ml of normal saline to Resident 22. The physician order dated March 3 specified the medication should be mixed in 50 ml of dextrose solution. A similar discrepancy was identified for Resident 44 on March 14, when the nurse appropriately held the medication after recognizing the label did not match the physician order.
The facility pharmacist explained that due to a shortage of dextrose 5% in water, the pharmacy automatically changed all Zosyn orders to normal saline in 100 ml according to their internal protocol. However, the pharmacist confirmed there was no record of clarifying the original order, notifying the prescriber of the change, or informing the facility of the substitution.
While both dextrose and normal saline are acceptable diluents for Zosyn, the concentration difference affects infusion rates and monitoring requirements. The pharmacy protocol reviewed during the inspection listed both normal saline and dextrose as acceptable fluids but did not indicate the pharmacy would automatically substitute fluids or change volumes without notification.
The Director of Nursing confirmed that licensed nurses did not perform complete verification of the "five rights" of medication administration - right medication, right resident, right dose, right time, and right route. The facility's Medication Administration Policy requires that "medications are administered as prescribed," yet systematic failures in the verification process allowed medications that did not match physician orders to reach the point of administration.
Nurses who received pharmacy deliveries failed to sign delivery receipts or verify medications against physician orders before storage, missing the opportunity to identify discrepancies before administration time. This represents a breakdown in multiple safeguards designed to prevent medication errors.
Additional Issues Identified
Inaccurate Staffing Information: The facility posted incorrect staffing numbers on four separate dates in January, February, and March 2025. On January 13, posted information indicated two registered nurses were working, but sign-in sheets documented only one. Similar discrepancies occurred on February 12, March 9, and March 10, with posted staffing numbers consistently exceeding actual nursing staff present.
Accurate staffing information serves multiple purposes, including allowing residents and families to understand care capacity and enabling administrators to ensure adequate coverage. The Director of Staff Development acknowledged that inaccurate posting "could cause residents to have a delay in their care" including delays in answering call lights, administering medications, and providing overall care.
Emergency Kit Documentation Deficiencies: The emergency drug kit log contained incomplete entries, with one record showing removal of 1000 ml of IV fluid for Resident 22 but lacking required information including date, time, quantity removed, and the licensed nurse's signature. The facility's Emergency Pharmacy Services policy requires recording the name, dose, date, time of administration, and signature of the person administering medications from the emergency kit.
The inspection findings reveal systemic issues affecting medication safety, mental health care, and documentation accuracy at Vermont Healthcare Center. The deficiencies affected multiple residents across various aspects of care, indicating gaps in staff training, supervision, and quality assurance processes. The facility's policies and procedures contained appropriate requirements, but implementation and oversight failed to ensure compliance with established standards and regulatory requirements.
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.
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