Cycle 1
Health 2025-02-20 · Fire 2025-02-20
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Johnstown, PA
Conemaugh Memorial Medical Center Tcu
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
320 Main Street, Johnstown, PA
(814) 534-6111
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
19
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifepoint Health
Operator or chain grouping
Approved since
2006-01-11
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
3.08
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
6.42
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
4.20
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
5.73
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
2.41
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
3.27
CMS adjusted RN staffing hours
Adjusted total hours
6.81
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,494
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0113
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.95% · Performance 21.25% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.87
Baseline 5.83% · Performance 5.78% · Measure score 6.87 · Achievement 6.87 · Improvement 0.05
Total nurse turnover
10
Baseline 20.00% · Performance 8.70% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 91 · Observed rate 9.89% · Lower 95% interval 7.4% |
| Discharge to community | 63.96% |
50.57%
13.4 pts better
|
Better than the National Rate · Eligible stays 91 · Observed rate 67.03% · Lower 95% interval 53.68% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 80 · Denominator 82 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 82 |
| Discharge self-care score | 89.55% |
53.69%
35.9 pts better
|
Numerator 60 · Denominator 67 |
| Discharge mobility score | 89.55% |
50.94%
38.6 pts better
|
Numerator 60 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 82 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 0% · Lower 95% interval 2.07% |
| Staff COVID-19 vaccination coverage | 4.17% |
8.2%
4 pts worse
|
Numerator 2 · Denominator 48 |
| Staff flu vaccination coverage | 92.31% |
42%
50.3 pts better
|
Numerator 72 · Denominator 78 |
| Discharge function score | 88.06% |
56.45%
31.6 pts better
|
Numerator 59 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 73 · Denominator 73 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.32% |
25.2%
17.9 pts worse
|
Numerator 3 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
68.9%
31.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
9.8%
5.4 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
68.7%
30.1 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.9% |
23.1%
12.2 pts better
|
23.9%
13 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 8.2% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-26 · Fire 2024-03-26
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-05 · Fire 2023-04-05
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-20
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-03-10
E · Potential for more than minimal harm
2024-03-26
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-04-11
E · Potential for more than minimal harm
2024-03-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-11
C · Minimal harm
2024-03-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-11
E · Potential for more than minimal harm
2023-04-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-04-05
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-04-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-20
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 2025-04-04
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2024-03-26
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-04-26
E · Potential for more than minimal harm
2023-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
Ownership
Dlp Conemaugh Holding Company LLC
5% Or Greater Direct Ownership Interest · Organization
Dlp Lima Partner, LLC
5% Or Greater Indirect Ownership Interest · Organization
Dlp Partner LLC
Operational/Managerial Control · Organization
Dsb Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Grooms, John
Corporate Officer · Individual
Lawrence, Charlotte
Corporate Officer · Individual
Lifepoint Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Lima Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Monte, Christopher
Corporate Officer · Individual
Polite, Elmer
Corporate Officer · Individual
Poppell, Marcus
Corporate Officer · Individual
Reider, Rodney
Corporate Officer · Individual
Reider, Rodney
W-2 Managing Employee · Individual
Rials, Loren
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Heritage Ridge Senior Living At Johnstown
Johnstown, PA
1-star overall rating with 1-star inspections with $10,824 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Quality Life Services - Westmont
Johnstown, PA
2-star overall rating with 2-star inspections with 11 recent health deficiencies
#3
Hilltop Heights Health & Rehab Center
Johnstown, PA
1-star overall rating with 1-star inspections with $13,128 in total fines with 27 recent health deficiencies
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