Johnstown, PA

Arbutus Park Manor

3-star overall rating with 3-star inspections with $16,800 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

207 Ottawa Street, Johnstown, PA

(814) 266-8621

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

141

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2000-01-17

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.70

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.79

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.28

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.77

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.48

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.80

CMS adjusted RN staffing hours

Adjusted total hours

4.31

CMS adjusted total nurse staffing hours

Case-mix index

1.19

Higher values indicate more complex resident acuity

RN turnover

37%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

233

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

76.63

Composite VBP score used to determine payment impact.

Payment multiplier

1.0250

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

5.33

Performance 6.24% · Measure score 5.33 · Achievement 5.33 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

Baseline 4.42 hours · Performance 5.82 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.19%	10.72% 1.5 pts better	No Different than the National Rate · Eligible stays 45 · Observed rate 0% · Lower 95% interval 5.9%
Discharge to community	53.8%	50.57% 3.2 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 52.78% · Lower 95% interval 42.65%
Medicare spending per beneficiary	0.75	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 52 · Denominator 52
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 52
Discharge self-care score	49.02%	53.69% 4.7 pts worse	Numerator 25 · Denominator 51
Discharge mobility score	56.86%	50.94% 5.9 pts better	Numerator 29 · Denominator 51
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 52 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.24%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 29 · Observed rate 0% · Lower 95% interval 2.66%
Staff COVID-19 vaccination coverage	2.73%	8.2% 5.5 pts worse	Numerator 6 · Denominator 220
Staff flu vaccination coverage	75.97%	42% 34 pts better	Numerator 177 · Denominator 233
Discharge function score	39.22%	56.45% 17.2 pts worse	Numerator 20 · Denominator 51
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 32 · Denominator 32
Resident COVID-19 vaccinations up to date	34.29%	25.2% 9.1 pts better	Numerator 12 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	1.7 0.5 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.6 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.2 0.7 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.8%	86.9% 8.9 pts better	93.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 97.5% · Q3 95.4% · Q4 94.3% · 4Q avg 95.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.9%	93.5% 5.4 pts better	95.5% 3.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.2% 0.4 pts worse	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.5% · Q3 3.4% · Q4 4.6% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.6%	6.5% 4.9 pts better	11.4% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.6% · Q3 1.2% · Q4 0.0% · 4Q avg 1.6%
Percentage of long-stay residents who lose too much weight	5.6%	6.5% 0.9 pts better	5.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 7.1% · Q3 2.8% · Q4 1.4% · 4Q avg 5.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.5%	19.9% 2.6 pts worse	19.6% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 22.5% · Q3 23.3% · Q4 23.0% · 4Q avg 22.5%
Percentage of long-stay residents who received an antipsychotic medication	15.1%	18.7% 3.6 pts better	16.7% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 10.7% · Q3 18.8% · Q4 15.8% · 4Q avg 15.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	23.8%	19.6% 4.2 pts worse	16.3% 7.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 38.6% · Q3 20.3% · Q4 17.3% · 4Q avg 23.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.5%	18.3% 5.2 pts worse	14.9% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 29.0% · Q3 20.0% · Q4 26.8% · 4Q avg 23.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.9%	0.9% 2 pts worse	1.0% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 3.4% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	1.7% 0.8 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.7%	26.4% 1.3 pts worse	19.8% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 28.4% · Q3 28.7% · Q4 27.5% · 4Q avg 27.7%
Percentage of long-stay residents with pressure ulcers	4.2%	5.3% 1.1 pts better	5.1% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.1% · Q3 3.3% · Q4 3.5% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	29.9%	68.9% 39 pts worse	81.7% 51.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 33.1% · Q3 36.4% · Q4 26.9% · 4Q avg 29.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.4%	9.8% 4.4 pts better	12.0% 6.6 pts better	Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.0% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.5% 0.8 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	78.2%	68.7% 9.5 pts better	79.7% 1.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 78.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	6.5%	23.1% 16.6 pts better	23.9% 17.4 pts better	Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 5.0% · Expected 18.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-21 · Fire 2025-08-21

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-09-19 · Fire 2024-09-19

16 health deficiencies

Top issue: Resident Rights (5 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-10-19 · Fire 2023-10-19

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-08-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-08-20

E · Potential for more than minimal harm 2025-08-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-20

E · Potential for more than minimal harm 2025-08-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-08-20

E · Potential for more than minimal harm 2025-08-21

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-08-20

F · Potential for more than minimal harm 2024-09-19

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2024-11-11

F · Potential for more than minimal harm 2024-09-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-09-19

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-09-19

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-09-19

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-09-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-09-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-11-11

C · Minimal harm 2024-09-19

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-11-11

C · Minimal harm 2024-09-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-11

F · Potential for more than minimal harm 2023-10-19

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2023-12-16

E · Potential for more than minimal harm 2023-10-19

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-12-16

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-21

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-09-26

D · Potential for more than minimal harm 2025-08-21

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-26

D · Potential for more than minimal harm 2025-08-21

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-09-26

D · Potential for more than minimal harm 2025-08-21

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-09-26

D · Potential for more than minimal harm 2025-08-21

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-09-26

D · Potential for more than minimal harm 2025-07-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-26

E · Potential for more than minimal harm 2025-04-09

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-02

E · Potential for more than minimal harm 2024-09-19

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-11-08

E · Potential for more than minimal harm 2024-09-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-08