Ligonier, PA

Bethlen Hm Of The Hungarian Rf Of America

2-star overall rating with 2-star inspections with 17 recent health deficiencies

66 Carey School Road, Ligonier, PA

(724) 238-6711

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Concordia Lutheran Ministries

Operator or chain grouping

Approved since

1983-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.78

Registered nurse staffing

LPN hours / resident day

1.01

Licensed practical nurse staffing

Aide hours / resident day

1.85

Nurse aide staffing

Weekend hours

3.39

Weekend nurse staffing

RN turnover

15%

Annual RN turnover

Total nurse turnover

32%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	83.0%	86.9% 3.9 pts worse	93.4% 10.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	87.8%	93.5% 5.7 pts worse	95.5% 7.7 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	7.5%	3.2% 4.3 pts worse	3.3% 4.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	19.0%	6.5% 12.5 pts worse	11.4% 7.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	6.1%	6.5% 0.4 pts better	5.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	38.3%	19.9% 18.4 pts worse	19.6% 18.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	26.7%	18.7% 8 pts worse	16.7% 10 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	18.4%	19.6% 1.2 pts better	16.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	17.1%	18.3% 1.2 pts better	14.9% 2.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.9% 0.4 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.0%	26.4% 2.6 pts worse	19.8% 9.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	6.0%	5.3% 0.7 pts worse	5.1% 0.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	69.0%	68.9% 0.1 pts better	81.7% 12.7 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	13.6%	9.8% 3.8 pts worse	12.0% 1.6 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.5% 0.3 pts better	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	24.6%	68.7% 44.1 pts worse	79.7% 55.1 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.9%	23.1% 11.8 pts worse	23.9% 11 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-05 · Fire 2025-09-05

17 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-08-15 · Fire 2024-08-15

25 health deficiencies

Top issue: Resident Assessment and Care Planning (10 deficiencies)

7 fire-safety deficiencies

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

Cycle 3 Health 2023-09-21 · Fire 2023-09-21

21 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-08-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-21

E · Potential for more than minimal harm 2024-08-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-21

E · Potential for more than minimal harm 2024-08-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-21

E · Potential for more than minimal harm 2024-08-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-08-21

C · Minimal harm 2024-08-15

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-08-21

C · Minimal harm 2024-08-15

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-21

C · Minimal harm 2024-08-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-08-21

E · Potential for more than minimal harm 2023-09-21

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 2023-09-27

E · Potential for more than minimal harm 2023-09-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-27

E · Potential for more than minimal harm 2023-09-21

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2023-09-27

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-05

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-10-12

E · Potential for more than minimal harm 2025-09-05

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-20

E · Potential for more than minimal harm 2025-09-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-05

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-05

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 2025-10-20

D · Potential for more than minimal harm 2025-09-05

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-05

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 2025-10-20

D · Potential for more than minimal harm 2025-09-05

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 2025-10-20

D · Potential for more than minimal harm 2025-09-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-05

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-05

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 2025-10-20

D · Potential for more than minimal harm 2025-09-05

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 2025-10-20

D · Potential for more than minimal harm 2025-09-05

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-09-05

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-06-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-06-20

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 2025-07-28

D · Potential for more than minimal harm 2025-03-27

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 2025-05-02

D · Potential for more than minimal harm 2024-12-30

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-02-13

D · Potential for more than minimal harm 2024-12-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-02-13

E · Potential for more than minimal harm 2024-08-15

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 2024-09-27

E · Potential for more than minimal harm 2024-08-15

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-09-27

E · Potential for more than minimal harm 2024-08-15

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-09-27

E · Potential for more than minimal harm 2024-08-15

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-15

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 2024-09-27

D · Potential for more than minimal harm 2024-08-15

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-06-19

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-07-30

E · Potential for more than minimal harm 2024-05-13

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-06-24

E · Potential for more than minimal harm 2024-05-13

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 2024-06-24

D · Potential for more than minimal harm 2024-05-13

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-06-24

D · Potential for more than minimal harm 2024-05-13

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2024-06-24

D · Potential for more than minimal harm 2024-03-25

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-05-03

D · Potential for more than minimal harm 2024-03-25

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-05-03

E · Potential for more than minimal harm 2023-11-16

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2023-12-27

D · Potential for more than minimal harm 2023-10-26

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 2023-11-23

E · Potential for more than minimal harm 2023-09-21

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-09-21

F675 · Quality of Life and Care Deficiencies

Health

Honor each resident's preferences, choices, values and beliefs.

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-09-21

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-10

E · Potential for more than minimal harm 2023-09-21

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 2023-11-10