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
Staffing
Hours and turnover
RN hours / resident day
3.08
Registered nurse staffing
LPN hours / resident day
1.12
Licensed practical nurse staffing
Aide hours / resident day
2.22
Nurse aide staffing
Weekend hours
5.73
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
23%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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