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 Page 1 of 3 395816 395816 01/31/2024 Lutheran Home at Kane, The 100 High Point Drive Kane, PA 16735

F 0565 28 Pa. Code 201.18 (e)(1)(4) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(a) Resident rights Residents Affected - Some 395816 Page 2 of 3 395816 01/31/2024 Lutheran Home at Kane, The 100 High Point Drive Kane, PA 16735

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of facility policy, resident and staff interviews, it was determined the facility failed to ensure the provision of a substantial evening snack when up to 14 hours and 45 minutes elapsed from the supper meal to breakfast the next day. Findings include: A review of facility's policy entitled Meal times and frequency with a policy review date of 1/2/2024, revealed meals and evening snack will be served at the following times: Breakfast 7:30 a.m., Lunch 11:00 a.m., Dinner 4:45 p.m., Evening snack 7:00 p.m. In nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day. All residents will be offered a bedtime snack. If a nourishing snack is served at bedtime, then up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the next day. Interviews conducted with residents during Resident Council meeting on 1/29/2024, revealed that three of three residents in the meeting indicated that a nourishing evening snack is not consistently served. During an interview on 1/29/2024, at 1:00 p.m. the Dietary Manager and Registered Dietitian confirmed that there was no evidence that dietary staff or nursing staff provided residents with a nourishing evening snack. The Dietary Manager and Registered Dietitian also confirmed that there was more than 14 hours from the evening meal until breakfast the next day. 28 Pa. Code 211.6(a)(b) Dietary services 395816 Page 3 of 3