Inspection Reports for Concordia Lutheran Ministries – Oertel Building
615 NORTH PIKE ROAD,, CABOT, PA, 16023
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 48
Capacity: 60
Deficiencies: 8
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.
Deficiencies (8)
| Description |
|---|
| 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
License Capacity: 60
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
Inspection Report
Renewal
Census: 50
Capacity: 60
Deficiencies: 9
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.
Deficiencies (9)
| Description |
|---|
| 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
License Capacity: 60
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
Follow-Up
Census: 50
Capacity: 60
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 60
Residents Served: 50
Total Daily Staff: 59
Waking Staff: 44
Residents with Mobility Need: 9
Residents 60 Years or Older: 50
Inspection Report
Renewal
Census: 52
Capacity: 60
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 60
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
Renewal
Census: 53
Capacity: 60
Deficiencies: 6
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.
Deficiencies (6)
| Description |
|---|
| 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
License Capacity: 60
Residents Served: 53
Staffing Hours: 64
Waking Staff: 48
Undated Containers: 5
Notice
Capacity: 60
Deficiencies: 0
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
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 44
Capacity: 60
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 60
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
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