Ligonier Gardens
Limited public data on Ligonier Gardens. Call, tour, and ask to meet current residents' families — your own impression matters most.
based on 5 Google reviews
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What this means for your family
While some family members find the staff patient with dementia and compassionate during end-of-life care, the recent trend of reviews indicates severe risks regarding resident supervision and medication accuracy. If you consider this facility, you must perform an intensive inspection of their safety protocols and medication administration logs.
Google Reviews
Google Reviews
5 reviews on Google“Families should exercise extreme caution due to serious allegations regarding resident safety, including lost residents, medication errors, and unexplained injuries. While one reviewer praised the compassionate care provided during end-of-life stages and dementia management, other recent reviews highlight significant concerns regarding staff attentiveness and facility odors.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate end-of-life care
- Patient approach to dementia care
Concerns
- Serious safety and supervision issues including lost residents and unexplained injuries
- Medication management errors
- Staff unresponsiveness and lack of attentiveness (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 6 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1We've heard wonderful things about the compassion shown during end-of-life care here; how does the team support families during those sensitive transitions?
- 2What specific protocols are in place to ensure residents are supervised and safe, especially when moving between different areas of the facility?
- 3Could you walk us through your process for medication administration and how you double-check for accuracy?
- 4How does the staff communicate important updates or changes in a resident's health to the family members?
- 5What does a typical day of social activities and engagement look like for the residents here?
- 6In the event of a medical emergency after hours, what is the immediate response plan and how is the family notified?
Personalized based on this facility's data
Key Review Excerpts
“They took fantastic care of my mom in her last days. Very caring staff. My dad has dementia and they are very patient with him which is very much appreciated.”
“You get the privlidge of paying $150 a day for the gardens to lose track of your Loved one for hours on end, forget their meds, and have no idea how they got injured.”
State Inspection History
State Inspections
Source: PA State Licensing Agency
Key Findings
Between 2021 and 2025, Ligonier Gardens underwent 39 inspections, resulting in 16 clean reports and 61 recorded violations. The inspection findings include issues regarding medication management, documentation accuracy, and the secure storage of hazardous materials. Additionally, some reports noted incidents involving staff misconduct and theft.
Sep 23, 2025RoutineCleanReport
No deficiencies found during this inspection.
Mar 28, 2025Routine
The administrator did not meet the required qualifications, such as having a registered nurse license, an associate's degree, or a nursing home administrator license.
There was an approximately 1-inch accumulation of lint on top of and behind the lint trap of the commercial dryer.
Medication administration records (MAR) for a resident's blood glucose checks did not match the readings recorded on the resident's glucometer.
Aug 2, 2024Routine
House glucometers were not calibrated to the current date and time, showing incorrect dates and times across multiple readings.
Jun 10, 2024Routine
Direct care staff failed to notify the local Area Agency on Aging regarding a suspected resident abuse incident in a timely manner.
The facility failed to notify the Department of the incident within the required 24-hour timeframe.
A staff member was witnessed using disrespectful language toward a resident, violating the requirement to treat residents with dignity and respect.
May 9, 2024RoutineCleanReport
No deficiencies found during this inspection.
Mar 20, 2024Routine
The home failed to verbally report an allegation of abuse to older adult protective services until 3/1/24 and did not submit the written report until 3/3/24.
A resident's medical evaluation was missing information in the weight section.
The resident's initial assessment inaccurately documented minimal mobility needs, failing to note that the resident requires assistance for transfers and emergency evacuation.
Feb 1, 2024Routine
The home's record of direct care staff training does not include the length of each course.
The dumpster lid was found open with trash extending above the top edge.
Fire drill records failed to document evacuation time, exit routes, and alarm operability for several drills.
No residents were evacuated to a public thoroughfare or fire-safe area during the fire drill.
May 1, 2023RoutineCleanReport
No deficiencies found during this inspection.
Ownership & Operations
Who Operates This Facility
The Bethlen Home of Hungarian Reformed Federation of Americ
nonprofit
Contact
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References & Resources
Google Maps
Photos, directions & neighborhood info
Google Reviews
5 reviews from families & visitors
Medicare data downloads
Original nursing home datasets
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