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

Chain footprint

8 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

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

0.78

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.01

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.85

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.64

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.79

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.39

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.63

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.71

CMS adjusted RN staffing hours

Adjusted total hours

3.32

CMS adjusted total nurse staffing hours

Case-mix index

1.50

Higher values indicate more complex resident acuity

RN turnover

15%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

32%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

683

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

Performance score

65.39

Composite VBP score used to determine payment impact.

Payment multiplier

1.0196

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.19

Performance 18.10% · Measure score 7.19 · Achievement 7.19 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

5.85

Baseline 5.75% · Performance 6.09% · Measure score 5.85 · Achievement 5.85 · Improvement 0

Total nurse turnover

9.14

Baseline 46.24% · Performance 26.32% · Measure score 9.14 · Achievement 9.14 · Improvement 8.81

Adjusted total nurse staffing

3.98

Baseline 4.15 hours · Performance 4.21 hours · Measure score 3.98 · Achievement 3.98 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.91%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 144 · Observed rate 10.42% · Lower 95% interval 8.2%
Discharge to community	71.42%	50.57% 20.9 pts better	Better than the National Rate · Eligible stays 130 · Observed rate 69.23% · Lower 95% interval 61.58%
Medicare spending per beneficiary	0.73	1.02 0.3 pts better
Drug regimen review with follow-up	96%	95.27% 0.7 pts better	Numerator 96 · Denominator 100
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 100
Discharge self-care score	60%	53.69% 6.3 pts better	Numerator 48 · Denominator 80
Discharge mobility score	41.25%	50.94% 9.7 pts worse	Numerator 33 · Denominator 80
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 100 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.09%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 82 · Observed rate 3.66% · Lower 95% interval 3.69%
Staff COVID-19 vaccination coverage	5.04%	8.2% 3.2 pts worse	Numerator 6 · Denominator 119
Staff flu vaccination coverage	26.02%	42% 16 pts worse	Numerator 32 · Denominator 123
Discharge function score	51.25%	56.45% 5.2 pts worse	Numerator 41 · Denominator 80
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient	98.51%	96.28% 2.2 pts better	Numerator 66 · Denominator 67
Resident COVID-19 vaccinations up to date	12.73%	25.2% 12.5 pts worse	Numerator 7 · Denominator 55

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 · Q1 85.0% · Q2 82.9% · Q3 81.8% · Q4 81.8% · 4Q avg 83.0%
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 · 4Q avg 87.8%
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 · Q1 10.0% · Q2 9.8% · Q3 6.1% · Q4 3.0% · 4Q avg 7.5% · Used in QM five-star
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 · Q1 17.1% · Q2 15.0% · Q3 20.0% · Q4 25.0% · 4Q avg 19.0%
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 · Q1 3.1% · Q2 10.0% · Q3 0.0% · Q4 11.1% · 4Q avg 6.1%
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 · Q1 40.6% · Q2 33.3% · Q3 30.8% · Q4 48.1% · 4Q avg 38.3%
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 · Q1 22.7% · Q2 22.7% · Q3 28.6% · Q4 33.3% · 4Q avg 26.7% · 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	18.4%	19.6% 1.2 pts better	16.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% · Used in QM five-star
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 · Q1 14.8% · Q2 24.1% · Q3 16.7% · Q4 12.0% · 4Q avg 17.1% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.5% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 39.5% · Q2 26.7% · Q3 24.0% · Q4 25.3% · 4Q avg 29.0%
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 · Q1 14.7% · Q2 4.0% · Q3 2.2% · Q4 1.9% · 4Q avg 6.0% · Used in QM five-star
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 · Q1 59.3% · Q2 61.2% · Q3 68.6% · Q4 83.3% · 4Q avg 69.0%
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 · Adjusted 13.6% · Observed 13.4% · Expected 11.0% · Used in QM five-star
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 · Q1 0.6% · Q2 0.6% · Q3 1.7% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star
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 · 4Q avg 24.6%
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 · Adjusted 34.9% · Observed 32.9% · Expected 22.5% · Used in QM five-star

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