Health inspection·November 19, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of 18 residents reviewed (Residents R1, R3, and R77). Findings include: Review of facility policy entitled Transfer or Discharge, Emergency dated 11/3/25, indicated Should it become necessary to make emergency transfer or discharge to a hospital or other related institution, our facility will prepare a transfer packet to send with the resident that includes; face sheet, administration record, order summary, bed hold policy, immunization report, recent weight and vitals, copy of advance directives, and complete e-interact form. Resident R1's clinical record revealed an admission date of 8/27/25, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), atrial fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and chronic obstructive pulmonary disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R1's progress notes revealed a note dated 8/29/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R3's clinical record revealed an admission date of 12/30/24, with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and heart failure (a condition where the heart cannot supply the body with enough blood). Resident R3's progress notes revealed notes dated 5/18/25, 8/11/25, and 8/14/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R77's clinical record revealed an admission date of 8/25/25, with diagnoses that included weakness, dysphagia (difficulty swallowing), and chronic respiratory failure. Resident R77's progress notes revealed a note dated 9/5/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 11/19/25, at 9:09 a.m. the Director of Nursing confirmed that Residents R1, R3, and R77s clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights 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 11/19/2025 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)