Vermont Healthcare Center in Torrance: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH received a complaint about a resident's quality of care on October 21, 2025, and made an unannounced visit on October 27. According to the citation, Resident 1 was a 71-year-old man with type 2 diabetes, chronic kidney disease and quadriplegia who depended on staff for bathing, dressing and moving in bed. His care plan called for blood sugar checks by finger stick and monitoring for signs of high blood sugar.

CDPH found that when Resident 1 was readmitted on October 13, 2025, his orders included only a long-acting insulin, Lantus, at bedtime. There were no orders for blood sugar monitoring or for the short-acting sliding scale insulin he had before, and licensed nurses did not tell his physician the orders were missing. According to the citation, nurses did not monitor his blood sugar or watch for signs of high or low blood sugar, and did not follow the facility's diabetes and insulin policy.

According to the citation, at 12:50 a.m. on October 21, 2025, his blood sugar was too high for the glucometer to read, and he had an altered level of consciousness, rapid breathing, low oxygen and low blood pressure. He was sent to a hospital, where his blood glucose was 1,824 mg/dl. He was admitted with diabetic ketoacidosis (DKA, a life-threatening complication when the body lacks insulin) with coma, was intubated (given a breathing tube) and started on an insulin drip. CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F684, on quality of care, at severity G, meaning actual harm.

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CDPH received a facility-reported incident on April 28, 2025, and made an unannounced visit the same day. According to the citation, Resident 2 was a 69-year-old woman with paraplegia (loss of movement or feeling in the legs) who was assessed as high risk for falls. Physical therapy found she was totally dependent for transfers and recommended a mechanical lift.

CDPH determined that on April 19, 2025, CNA 4 and RNA 1, a restorative nursing assistant, moved Resident 2 by hand from her bed to a shower chair without a mechanical lift. CNA 4 told inspectors Resident 2 did not want to wait while she looked for a lift and sling and insisted on a transfer without it. Resident 2 said the sling hurt her back. CNA 4 said they realized she was too heavy and lowered her to the floor. According to the citation, the facility had not developed a care plan for how she should be transferred, and staff did not follow the facility's mechanical lift and fall prevention policies.

According to the citation, Resident 2 complained of pain after the fall and was given acetaminophen. On April 24, 2025, she had pain and swelling in her left knee, and an x-ray showed a minimally displaced impacted fracture of the lower left thigh bone (femur). CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F689 at severity G, meaning actual harm.

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CDPH received a facility-reported incident on January 30, 2025, about an unwitnessed fall, and made an unannounced visit on February 4. According to the citation, Resident 4 was a 90-year-old woman with a history of falls, muscle weakness and osteoarthritis in both hips. A November 2024 evaluation rated her at high risk for falls.

CDPH found staff did not put her fall prevention measures in place, including landing pads (cushioned floor mats), a low bed and bed and chair alarms, and CNA 4 and CNA 5 were not told she was at high risk. According to the citation, her care plan was not updated after an earlier fall, recorded as January 4, 2024, when she tried to move from the toilet to her wheelchair alone. CNA 1 and LVN 5 told inspectors she had no landing pads or bed alarm and her bed was not low before the fall.

According to the citation and the 2567 report, Resident 4 fell at about 11:15 p.m. on January 26, 2025. LVN 5 said she slid off the bed while trying to remove her pants. X-rays showed a right femoral neck fracture (a break just below the hip joint) and a fracture of the right upper arm bone. She was sent to a hospital and had hip surgery. CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F689 at severity G, meaning actual harm.

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According to the 2567 report, Resident 154 was admitted on January 25, 2025, with a cerebral infarction (a stroke), chronic respiratory failure and functional quadriplegia (total immobility from severe disability). She could not make her own decisions, depended on staff for hygiene and bathing, and scored 10 on the Braden scale, which the report says meant high risk for pressure injuries (bed sores).

Inspectors found the facility did not make sure Resident 154 was turned and repositioned every two hours as her physician order and care plan required. According to the report, skin checks were not done on her shower and bed bath days, and staff did not carry out the daily CNA skin checks and weekly licensed nurse checks in her care plan.

According to the report, Resident 154 developed a deep tissue injury (a purple or maroon area of damaged tissue under intact skin or a blood-filled blister) on the side of her right foot, measuring 2.5 by 2.0 centimeters, and another on her right buttock, measuring 3.5 by 1.5 centimeters. On March 12, 2025, inspectors saw a black discolored area on the right foot and open red skin on the right buttock. The treatment nurse said the buttock injury began as a blister. The facility was cited under F686, on treatment and services to prevent and heal pressure ulcers, at severity G, meaning actual harm.

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During its annual recertification survey on March 8, 2024, CDPH found problems in the care of Resident 39, a 65-year-old man with quadriplegia, a bladder that did not work normally because of nerve damage, a long-term indwelling urinary catheter (a tube left in the bladder) and a history of urinary tract infections (UTIs).

CDPH found nursing staff did not carry out physician orders on February 15 and February 21, 2024, for a urine test and culture after he complained of painful urination. According to the citation, the first sample was mislabeled and not processed by the laboratory, and staff did not collect a new one. CDPH found that abnormal results received on February 25 and February 26, 2024, were not reported to his physician so that treatment could start in time. Licensed nurses also did not complete a change of condition form to alert his physician and care team, as facility policy required.

According to the citation, on February 28, 2024, Resident 39 had low blood pressure, lethargy (fatigue and lack of energy) and an oxygen level of 88 percent on room air. He was sent to a hospital and diagnosed with severe sepsis (a life-threatening response to infection) from a catheter-associated urinary tract infection and pyelonephritis (a kidney infection). CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F690, on incontinence, catheters and UTIs, at severity G, meaning actual harm.

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According to the 2567 report, Resident 1 was admitted on January 16, 2024, after a fall at home on January 12, with a history of falling, difficulty walking, heart failure, sleep apnea and anemia. He had moderately impaired decision making, needed maximal help with walking and transfers, and was taking a blood thinner.

Inspectors found RNS 3, a registered nurse supervisor, did not correctly complete his fall risk assessment to reflect his thinking, mobility, medications and diagnoses. According to the report, the facility did not put landing pads (cushioned floor mats) or a bed alarm in place when he was admitted, and licensed nurses did not develop a care plan with measures to prevent falls and limit injury. LVN 1 and RNS 1 told inspectors he should have had landing pads and a bed alarm in place.

According to the report, CNA 1 found Resident 1 on the floor during rounds at 12:45 a.m. on January 18, 2024. Resident 1 told inspectors he had tried to get out of bed without calling for help, hit his head on the bed and lay on the floor for an hour before staff came. He had skin tears (skin that peels back) on both arms and a fracture of his left 10th rib, and he was taken to a hospital and returned the same day. The facility was cited under F689, on accident hazards, supervision and devices, at severity G, meaning actual harm.

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CDPH received a complaint and a facility-reported incident on November 10, 2022, about an incident the day before, when Resident 1 set his clothing on fire, and made an unannounced visit on November 15. According to the citation, Resident 1 had paralysis and weakness on one side of his body, epilepsy and loss of feeling in his left arm and leg. His smoking assessment found he was a dependent smoker who needed staff help and supervision and might need a protective smoking apron.

CDPH determined the facility failed to give Resident 1 a fire-retardant smoking apron and did not supervise and assist him while he smoked on November 9, 2022, as his care plan and the facility's smoking policy required. According to the citation, CNA 1 told inspectors Resident 1 kept his own cigarettes and lighter and was allowed to smoke anytime without supervision. CNA 1 said CNA 3 heard a resident screaming, ran out and saw his shirt on fire, and that he had a lit cigarette in his pocket. During the visit, inspectors saw three residents smoking on the patio without aprons while an apron hung on a nearby rack.

According to the citation, Resident 1 had third-degree burns (burns through the full thickness of the skin) to his left chest, left arm and left neck. He was admitted to a hospital burn intensive care unit, where he had two skin graft surgeries. CDPH issued a Class A citation with a $20,000 penalty.

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