Health inspection·January 31, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and Resident Council minutes, and resident and staff interviews, it was determined that the facility failed to ensure that residents were updated in a timely manner regarding Resident Council concerns, and the facility failed to correct Resident Council concerns for a period of three months (November 2023 through January 2024). Residents Affected - Some Findings include: Review of facility policy entitled, Resident Council, dated 1/2/24, revealed Resident Council is a social forum where residents are encouraged to discuss and make decisions about the environment in which they live. Residents are free to make grievances and recommendations to benefit all residents living in the nursing home. Procedure of Resident Council meeting indicated, Activity Director or designated staff will conduct the meeting (as per Resident vote). It is the department's director's responsibility to fully investigate and answer concerns. If any department fails to address/investigate concerns, necessary actions will be taken. Review of the Resident Council minutes and Grievances over the past three months, for November 2023 through January 2024, revealed a pattern/trend with issues regarding lengthy waiting times to go to the bathroom. During a Resident Council meeting on 1/29/24, at 10:00 a.m. interviews with Resident R22, Resident R44, and Resident R58, who all attend Resident Council meetings regularly, indicated that concerns of wait times for toileting have been voiced in several past monthly meetings with no resident update or resolution. An interview with the Activity Director on 1/30/24, at approximately 10:00 a.m. confirmed that he/she attends Resident Council meetings and reviews past monthly concerns in new business and old business with residents; and the concerns of lengthy wait times have been voiced by residents during the meetings in November 2023, December 2023, and January 2024 with no resolution. An interview with the Director of Nursing on 1/30/24, at 12:25 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding lengthy waiting times to go to the bathroom from the November 2023, December 2023, and January 2024 Resident Council meetings. No evidence was provided to ensure the residents' concerns verbalized and further stated in the Resident Council minutes for the past three months reviewed was noted of timely corrective actions, in addition to no evidence of the residents being updated in a timely manner of those actions. 28 Pa. Code 201.14 (a) Responsibility of licensee (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395816 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home at Kane, The 100 High Point Drive Kane, PA 16735 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)