Quality Life Services Westmont: Care Plan Failure - PA
Federal inspectors documented the gap during a February 2025 visit to the facility at 787 Goucher Street. Of 26 residents whose records were reviewed, one stood out: Resident 6, a cognitively intact man dependent on staff for daily care, whose situation had accumulated months of physician orders with no corresponding documentation to guide the staff responsible for carrying them out.
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See the Derila PillowThe orders themselves were specific. A physician directed in May 2024 that the resident could not be showered because of the percutaneous drain implanted to manage his gallbladder. A month later, in June 2024, a second order instructed staff to flush the drain vigorously every day. Both orders were in the record. Neither had generated a formal care plan.
By February 18, 2025, when inspectors arrived at the resident's room at 10:08 in the morning, the precautions were visible. A sign on the door indicated Enhanced Barrier Precautions were in effect. Personal protective equipment, gowns for staff to put on before entering, sat outside the door. A nurse aide interviewed at that same moment confirmed what the sign said: staff were required to wear a gown when entering the room and providing care.
The aide knew the protocol. The protocol just wasn't written down anywhere in the care plan.
Enhanced Barrier Precautions are used when a resident carries certain resistant organisms or has a condition that creates infection risk for others, and they require staff to take specific protective steps during care. The point of a care plan is to translate that kind of clinical situation into documented, actionable instructions so that every staff member providing care, not just those who happen to know, follows the same steps.
There was no documented evidence that any such care plan existed for Resident 6's Enhanced Barrier Precautions needs.
When the nursing home administrator sat down with inspectors on February 20, 2025, at 10:29 in the morning, she confirmed it. The care plan did not address Resident 6's needs related to his Enhanced Barrier Precautions status.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, with few residents affected. The citation was the only deficiency documented in this inspection.
The finding raises a straightforward question about how care was being coordinated. A resident who cannot be showered because of a surgically implanted drain, who requires daily drain flushing, and who lives under infection control precautions visible enough to post on his door, is a resident whose care depends on staff knowing exactly what to do and when. A care plan is where that knowledge is supposed to live, formally, so it doesn't depend on which aide happens to be assigned that day or what they remember from a prior shift.
Resident 6 was described in his admission assessment, completed February 5, 2025, as cognitively intact. He understood his situation. Whether he understood that the documentation meant to coordinate his care had not been completed is not something the inspection report addresses.
The administrator's confirmation that the care plan was missing came at the end of a two-day inspection. By then, the drain had been in place for at least eight months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Quality Life Services - Westmont from 2025-02-20 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
QUALITY LIFE SERVICES - WESTMONT in JOHNSTOWN, PA was cited for violations during a health inspection on February 20, 2025.
Federal inspectors documented the gap during a February 2025 visit to the facility at 787 Goucher Street.
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.