Inspection Reports for
Concordia Lutheran Ministries – Oertel Building
615 NORTH PIKE ROAD,, CABOT, PA, 16023
Back to Facility Profile21 Reports
Inspection Report — Jun 4, 2026
Follow-Up
Date: Jun 4, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven, focusing on verifying correction of a reported disrespectful treatment of a resident.
Findings
The submitted plan of correction was determined to be fully implemented. The report documents a prior violation involving disrespectful treatment of a resident by direct care staff, which was addressed by staff suspension, termination, and education on dignity and respect.
Citations (1)
42c. A resident was treated with disrespect by direct care staff who used inappropriate language and refused to assist the resident properly. Staff person A was suspended and terminated, and education was provided to all staff on treating residents with dignity and respect.
Report Facts
Residents Served: 51
Current Residents: 3
Residents 60 Years or Older: 51
Residents Diagnosed with Mental Illness: 25
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report — Apr 16, 2026
Renewal
Date: Apr 16, 2026
Visit Reason
The inspection was conducted as a renewal visit for licensing purposes at Concordia Lutheran Ministries - Oertel Building.
Findings
No regulatory citations or deficiencies were identified during the inspection. The facility was found to be in compliance with licensing requirements.
Report Facts
Residents Served: 48
Current Hospice Residents: 3
Residents Diagnosed with Mental Illness: 25
Residents with Mobility Need: 15
Residents Age 60 or Older: 48
Residents with Physical Disability: 1
Inspection Report — Apr 22, 2025
Renewal
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 04/22/2025 to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, incomplete training records, inoperable bathroom exhaust fan, incomplete first aid kit supplies, improper freezer temperatures, unsealed food storage, obstructed egress due to keypad lock without posted code, and medication labeling discrepancies. All deficiencies had plans of correction accepted and were reported as implemented by 05/14/2025.
Citations (8)
Resident privacy coding document with names of multiple residents was attached to the licensing inspection summary.
Training records did not record the duration of multiple trainings conducted in 2024.
Shared powder room in bedroom #207 lacked an operable window and the exhaust fan was inoperable.
First aid kit did not include scissors and tweezers.
Silver upright freezer and walk-in freezer measured 11 degrees Fahrenheit, above required 0°F.
Several food items in walk-in freezer were opened and not sealed.
Door leading from activity room to emergency exit had keypad lock without posted code or delay mechanism.
Medication labels for Resident #3 and Resident #1 did not match physician orders.
Report Facts
Residents Served: 48
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 18
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Notice — Feb 13, 2025
Date: Feb 13, 2025
Visit Reason
This document is a response to a request for a waiver of Pennsylvania Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications.
Findings
The waiver outlines training requirements for direct care staff administering GLP-1 agonist injections, including completion of a Department-approved medication administration course, in-person training by licensed health care professionals, and annual training hours related to GLP-1 medications and diabetes management. The facility must also have policies and clinical contacts in place to support safe medication administration.
Inspection Report — Apr 8, 2024
Renewal
Date: Apr 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, including an unannounced full inspection on 04/08/2024 and 04/09/2024.
Findings
The facility was found to have multiple deficiencies related to compliance with health and safety laws, resident personal equipment, lighting, portable space heaters, medication storage and administration, and adverse reaction management. Plans of correction were accepted and implemented by 06/10/2024.
Citations (9)
Expired certificates for boilers were found; boilers were reinspected and certificates updated.
Bedside enabler attached to resident #1’s bed was not properly secured, posing a fall hazard.
Resident #2’s bedside lamp was inoperable and not positioned properly.
A portable electric space heater was found in the laundry room, which is prohibited.
Resident #3 had an unlocked Albuterol inhaler accessible in an unlocked bedroom.
Medications were removed from original containers more than 2 hours before administration.
Resident #1's medications were unlocked, unattended, and accessible on a breakfast tray.
Medication administration records were signed before medications were actually administered.
Failure to immediately consult a physician or seek emergency treatment for resident #4's suspected adverse reaction to medication.
Report Facts
Residents Served: 50
Total Daily Staff: 60
Waking Staff: 45
Hospice Residents: 3
Residents Age 60 or Older: 50
Residents with Mobility Need: 10
Inspection Report — Jul 7, 2023
Follow-Up
Date: Jul 7, 2023
Visit Reason
The inspection was an unannounced partial review conducted as a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Two deficiencies were noted related to resident record confidentiality and medication storage, both corrected during the survey with staff reeducation and ongoing monitoring planned.
Citations (2)
Resident records were found unsecured and accessible on an unlocked treatment cart in a hallway.
A container with prescribed medication was left unlocked and unattended on a treatment cart.
Report Facts
Residents Served: 50
Total Daily Staff: 59
Waking Staff: 44
Residents with Mobility Need: 9
Residents 60 Years or Older: 50
Inspection Report — Mar 22, 2023
Renewal
Date: Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal review of Concordia Lutheran Ministries - Oertel Building, including on-site visits on 03/22/2023 and 03/23/2023 and an off-site review on 03/28/2023.
Findings
The facility was found to have deficiencies related to staff training on required topics, sanitary conditions involving improper use of glucometers, medication storage procedures, and following prescriber's orders for insulin administration. Plans of correction were accepted and implemented by 07/14/2023.
Citations (5)
Direct care staff persons A and B did not receive required annual training on multiple topics including medication self-administration, infection control, and care for residents with mental illness or intellectual disability.
Staff persons A and B did not receive training on fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, falls and accident prevention during the training year.
Resident glucometers were shared between residents, violating sanitary conditions.
Incorrect documentation and calibration of resident glucometers leading to inaccurate blood glucose records on medication administration records (MAR).
Failure to follow prescriber's orders for insulin administration based on sliding scale for residents #2 and #4, including incorrect insulin doses given.
Report Facts
Residents Served: 52
Total Daily Staff: 59
Waking Staff: 44
Current Hospice Residents: 2
Residents with Mobility Need: 7
Residents Age 60 or Older: 52
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Jan 27, 2022
Renewal
Date: Jan 27, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for Concordia Lutheran Ministries - Oertel Building.
Findings
The inspection identified several deficiencies including improper placement and absence of carbon monoxide detectors, bloodstains on resident linens, undated leftover food containers, medication labeling errors, medication record discrepancies, and incomplete resident assessments related to assistive devices. Plans of correction were accepted and implemented for all deficiencies.
Citations (6)
Carbon monoxide detector was affixed too close to hot water heaters and missing near the activities storage area furnace.
Bloodstains found on resident #1's bedsheet and pillowcase.
Five undated plastic containers containing various dry cereals found on kitchen shelf.
Medication label for resident #3 did not match prescribed dosage instructions.
Medication administration record for resident #2 showed inconsistent insulin dosages on several dates.
Resident #2's assessment and support plan did not address use of a bed halo device for transferring.
Report Facts
Residents Served: 53
Staffing Hours: 64
Waking Staff: 48
Undated Containers: 5
Notice — Jun 15, 2021
Date: Jun 15, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Concordia Lutheran Ministries – Oertel Building, a Personal Care Home, following receipt of a renewal application. It also advises that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — May 5, 2021
Renewal
Date: May 5, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Concordia Lutheran Ministries - Oertel Building facility on 05/05/2021 and 05/06/2021.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were noted related to resident privacy, sanitary conditions, medication storage procedures, and timely completion of resident assessments, all of which had corrective plans accepted and implemented.
Citations (4)
Notes posted near resident #1's bedroom door revealing private information violating privacy rights.
Multiple stains and drip marks in the tub and surrounding bathroom area in a resident's private bathroom.
Resident #1's glucometer was not calibrated to the current date and time.
Resident #1 did not have an initial assessment completed within 15 days of admission.
Report Facts
Residents Served: 44
Current Residents in Hospice: 3
Resident Support Staff: 1
Total Daily Staff: 50
Waking Staff: 38
Residents Age 60 or Older: 44
Residents with Intellectual Disability: 1
Residents with Mobility Need: 5
Notice — Mar 10, 2020
Date: Mar 10, 2020
Visit Reason
The document serves as a renewal approval for Concordia Lutheran Ministries - Oertel Building to operate as a Personal Care Home, confirming receipt of the renewal application and outlining the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative renewal notice confirming the license issuance and future inspection requirements.
Report Facts
Inspection Report — Jan 7, 2020
Annual Inspection
Date: Jan 7, 2020
Visit Reason
Annual licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Notice — Mar 8, 2019
Date: Mar 8, 2019
Visit Reason
The document serves as a renewal notification and license issuance for Concordia Lutheran Ministries - Oertel Building to operate as a Personal Care Home.
Findings
The Department has approved the renewal application and issued a regular license. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — Nov 27, 2018
Renewal
Date: Nov 27, 2018
Visit Reason
The inspection was a full, unannounced renewal inspection of Concordia Lutheran Ministries Oertel Building conducted by the Department’s Bureau of Human Services Licensing.
Findings
The inspection identified violations related to medication labeling and administration instructions, and the calibration of a resident's glucometer. Plans of correction were approved and partially implemented as of April 29, 2019.
Citations (2)
55 Pa.Code §2600.184(a): The original container for prescription medications lacked complete dosage and administration instructions on the pharmacy label for Resident #2's Lorazepam medications.
55 Pa.Code §2600.185(a): The home failed to ensure Resident #1's glucometer was calibrated to the current time, compromising safe medication monitoring.
Report Facts
Number of Residents Served: 54
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 17
Number of Residents 60 Years of Age or Older: 54
Number of Residents with Mobility Need: 8
Number of Residents Receiving Supplemental Security Income: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jody Garvey | Department representative conducting the inspection and named in violation reports. | |
| Lori Gillette | Department representative conducting the inspection and named in violation reports. | |
| Anne Denny | Administrator | Named in relation to the facility and plan of correction signatures. |
Notice — Mar 23, 2018
Date: Mar 23, 2018
Visit Reason
Notification of license renewal for Concordia Lutheran Ministries - Oertel Building Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
The document confirms issuance of a regular license following the renewal application and advises that an annual onsite inspection will be conducted within the next twelve months.
Inspection Report — Dec 5, 2017
Renewal
Date: Dec 5, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of Concordia Lutheran Ministries Personal Care Home.
Findings
Violations of 55 Pa.Code Chapter 2600 were found related to medication administration and resident support plan documentation. Plans of correction were submitted to address these deficiencies.
Citations (2)
55 Pa.Code §2600.185(a) - The home failed to record blood glucose measurements and staff initials for resident #1 as required during ordered blood glucose monitoring.
55 Pa.Code §2600.227(d) - The support plan for resident #1 did not address how the home would meet the resident's needs for extensive supervision, immobility, and cognitive impairments.
Report Facts
Number of Residents Served: 54
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Denny | Administrator | Named in plan of correction signatures and legal entity representative |
| Josh Hoover | Inspector conducting the inspection | |
| Patricia Bartlett | Inspector conducting the inspection |
Notice — Mar 10, 2017
Date: Mar 10, 2017
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Inspection Report — Dec 15, 2016
Annual Inspection
Date: Dec 15, 2016
Visit Reason
The inspection was an annual licensing inspection conducted by the Pennsylvania Department of Human Services for Concordia Lutheran Ministries - Oertel Building.
Findings
The inspection identified multiple violations related to resident record confidentiality, poisonous materials accessibility, sanitary conditions, and safety hazards such as uncovered electrical outlets and combustible materials near heat sources. Plans of correction were submitted with partial implementation progress noted.
Citations (6)
55 Pa.Code §2600.17 requires resident records to be confidential and inaccessible to unauthorized persons. Multiple binders and boxes of resident records were found unlocked, unattended, and accessible in various locations.
55 Pa.Code §2600.82(c) mandates poisonous materials be locked and inaccessible to residents. A can of Lysol disinfectant was unlocked and accessible in a bathroom, posing a poisoning risk.
55 Pa.Code §2600.85(a) requires sanitary conditions be maintained. Resident #10's blood glucose testing supplies were improperly shared and test strips were missing.
55 Pa.Code §2600.95 requires furniture and equipment to be in good repair and free of hazards. Resident #9's bedroom had an uncovered electrical outlet, leaking water in the bathroom, and mildew and brown stains in the bathtub.
55 Pa.Code §2600.100(b) requires removal of ice, snow, and obstructions from walkways and exits. Snow and leaves covered steps outside the exit doors on the second floor and basement.
55 Pa.Code §2600.125(a) prohibits combustible and flammable materials near heat sources. A plastic container with oil and water was located one foot from the boiler ignitor.
Report Facts
Number of Residents Served: 49
Total Daily Staff: 54
Waking Staff: 41
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 12
Residents Age 60 or Older: 49
Residents Receiving Supplemental Security Income: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Denny | Administrator | Named in relation to plan of correction signatures and legal entity representative. |
| Vicky Summers | Inspection conducted by Vicky Summers as listed on page 2 and in violation report headers. |
Notice — Aug 18, 2016
Date: Aug 18, 2016
Visit Reason
This letter responds to a request for a waiver of Pennsylvania Code Chapter 2600 relating to personal care homes, specifically regarding resident medical evaluation and health care documentation requirements.
Findings
The letter requests additional information to support the waiver request, including specific documentation requirements for medical evaluation forms and special diet-check options.
Report Facts
Waiver request code reference: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the letter regarding the waiver request |
| Jill Kachmar | Regulatory Implementation Manager | Contact person for returning requested documentation |
Notice — Aug 2, 2016
Date: Aug 2, 2016
Visit Reason
Response to a request for a waiver of Pennsylvania Code Chapter 2600 requirements related to resident medical evaluation and health care forms for multiple licensed personal care homes.
Findings
The Department determined that a waiver is required for resident medical evaluation and health care forms but not for the Resident-Assessment Support Plan forms if they include the same information as the Department's forms. The waiver request was returned for additional information.
Report Facts
Waiver request: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the letter regarding waiver request |
Inspection Report — Mar 3, 2016
Annual Inspection
Date: Mar 3, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for the facility.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes following the inspections on March 3 and March 4, 2016.
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