Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Home At Kane, The during CMS and state inspections, most recent first.
The facility failed to ensure that required clinical information was communicated to the receiving provider when three residents were transferred to the hospital. The residents had diagnoses including diabetes, A-Fib, COPD, HTN, hyperlipidemia, HF, weakness, dysphagia, and chronic respiratory failure, but their records lacked evidence that the transfer packet or necessary clinical information was sent with them. The DON confirmed the missing documentation during interview.
Respiratory equipment was not kept clean for two residents receiving O2 therapy. One resident with COPD, HF, and DM had a concentrator filter covered with a large amount of white fluffy substance while receiving continuous O2 via NC. Another resident with COPD, CHF, and chronic respiratory failure had a nasal cannula touching the floor and a concentrator filter also covered with a large amount of white fluffy substance. An RN confirmed the equipment conditions and stated the filters should be clean and the NC should not be on the floor.
An outdated Lispro insulin pen was found on the 300-hall med cart with an open date beyond the 28-day use period. The facility policy required outdated meds to be returned to the pharmacy or destroyed, and an LPN confirmed the pen should have been discarded.
The facility failed to ensure GFCI protection for electrical receptacles in the main floor dining area, specifically at the ice machine and coffee machine. This deficiency was confirmed by the maintenance supervisor.
The facility failed to properly date and discard medications in the 200-Hall medication storage room. An open vial of Aplisol PPD, used for tuberculosis testing, was found without an opened date, preventing staff from determining its discard date. This was confirmed by an LPN during an observation.
The facility failed to meet the required nurse aide staffing ratios, with shortages identified during day, evening, and overnight shifts across multiple dates. The Director of Nursing confirmed these deficiencies, as the facility did not maintain the mandated minimum staffing levels for nurse aides.
Failure to Send Required Transfer Information With Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when three residents were transferred to the hospital. Facility policy for emergency transfer or discharge stated that a transfer packet should accompany the resident and include items such as the face sheet, administration record, order summary, bed hold policy, immunization report, recent weight and vitals, copy of advance directives, and complete e-interact form. However, the clinical records for Residents R1, R3, and R77 lacked evidence that the required clinical information was sent with them upon transfer. Resident R1 was admitted with diagnoses including diabetes, A-Fib, and COPD, and progress notes showed a hospital transfer. Resident R3 was admitted with diagnoses including hypertension, hyperlipidemia, and heart failure, and progress notes documented multiple hospital transfers. Resident R77 was admitted with diagnoses including weakness, dysphagia, and chronic respiratory failure, and progress notes documented a hospital transfer. During interview, the DON confirmed that the records lacked evidence that the necessary clinical information was provided to the receiving health care provider when the transfers occurred.
Respiratory Equipment Not Kept Clean
Penalty
Summary
The facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two residents receiving oxygen therapy. One resident had diagnoses including COPD, heart failure, and diabetes, with physician’s orders for oxygen at 2 to 4 liters via nasal cannula continuously. The resident’s care plan included continuous oxygen, and the task record included oxygen tubing/cannula change and concentrator filter cleaning. On observation, the resident was lying in bed receiving oxygen, and the oxygen concentrator filter had a large amount of fluffy white substance covering it. A second resident had diagnoses including COPD, CHF, and chronic respiratory failure, with an order for oxygen at 2 liters via nasal cannula every evening and night shift. The care plan included oxygen at 2 liters per minute at hour of sleep, and the task record included oxygen tubing/cannula change and concentrator filter cleaning. On observation, the resident’s oxygen concentrator was in the room with the nasal cannula lying over the concentrator and touching the floor, and the concentrator filter also had a large amount of fluffy white substance covering it. An RN confirmed that both residents’ oxygen concentrator filters were covered in a large amount of white fluffy substance and that one resident’s nasal cannula was touching the floor.
Outdated Insulin Pen Left on Medication Cart
Penalty
Summary
The facility failed to appropriately discard an outdated medication on the 300-hall medication cart. Review of the facility policy on storage of medications stated that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed. Manufacturer guidance for Lispro Insulin indicated that an open pen must be used within 28 days after opening or discarded, even if insulin remains in the pen. During observation of drug storage, surveyors found an open Lispro Insulin pen on the 300-hall medication cart with an open date of 10/3/25 and an expiration date of 10/31/25. An LPN confirmed at the time of observation that the pen was beyond the expiration date and should have been discarded.
Electrical Receptacle Deficiency in Main Floor Dining Area
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with NFPA 101 standards, specifically regarding ground fault circuit interrupter (GFCI) protection. During an observation on December 23, 2024, it was noted that two receptacles on the main floor did not have the required GFCI protection. These receptacles were located at the dining/kitchen ice machine and the dining room coffee machine. The maintenance supervisor confirmed these deficiencies during an interview conducted immediately after the observation.
Plan Of Correction
The Lutheran Home at Kane will make all corrections to comply with the national fire protection regulations. We will install ground fault circuit interrupter protections in the main floor, dining/kitchen ice machine receptacle and the main floor, dining room coffee machine receptacle. The Maintenance Director/designee will inspect the GFIC receptacles weekly for one month, then monthly for three months.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner, specifically in the 200-Hall medication storage room. During a review of the facility's policy on labeling medication containers, it was noted that stock medications should include necessary information such as the expiration date. Manufacturer's recommendations for Aplisol PPD, a solution used for tuberculosis testing, indicated that vials in use for more than 30 days should be discarded. However, an observation revealed an open vial of Aplisol in the medication storage room refrigerator without an opened date, making it impossible for staff to determine the discard date. This was confirmed by an LPN who acknowledged the lack of an opened date on the vial.
Plan Of Correction
It is the practice of this facility to ensure drugs and biologicals are stored properly. Immediately upon notification of unlabeled open PPD solution, open solution was discarded. All PPD inventory was checked for opened bottles with no open date. All licensed nursing staff to be educated by the DON/designee regarding the handling of the administration of PPD solution with emphasis on the importance of dating vials upon opening by 1/31/2024. Staff will be provided with clear reminders to date open PPD vials. The DON/designee to audit the medication refrigerators weekly x 4 weeks, monthly x 3 months, and quarterly x 2 quarters to assure ongoing compliance. This corrective action will be monitored through the facility Quality Assurance and Performance Improvement Program (QAPI). Findings will be submitted to the QAPI Committee for review and follow up.
Nurse Aide Staffing Shortages
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift on two occasions, one NA per 11 residents during the evening shift on one occasion, and one NA per 15 residents during the overnight shift on eight occasions. These deficiencies were identified through a review of the facility's nursing staffing documents covering specific periods in July, November, and December 2024. The Director of Nursing confirmed the staffing shortages during an interview, acknowledging the facility's failure to meet the minimum NA ratio requirements on the specified dates and shifts. The census numbers and the corresponding number of NAs required versus those who actually worked were documented, highlighting the shortfall in staffing levels across various shifts and dates.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days of 7/2, 7/4, 7/5, 7/7, 11/7, 12/12, 12/13, 12/14, 12/15 where minimal staffing ratio was not met, but PPD was met on all days. Residents of The Lutheran Home at Kane will be protected from future nurse aide staff ratios below the 1:10 nurse aide for days, 1:11 nurse aide for evenings and 1:15 for nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The scheduler or designee will review projected staffing levels and audit to ensure staffing levels were met with the Director of Nursing or designee, 3 times a week x2 weeks, two times a week x2 and then monthly X2 months to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. The Lutheran Home will continue to aggressively advertise externally for the recruitment of nursing assistant applicants to enhance current staffing levels. The Lutheran Home at Kane is an approved site of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing nurse aide training classes quarterly. The Lutheran Home has 8 NA students who are ready to complete their skills testing and have yet to be able to complete the testing as their tests have been cancelled several times. The Lutheran Home has scheduled them at different sites and the tests are still being consistently cancelled. This plan of correction will be followed but call offs and no call no shows are unpredictable, and we continue to cover them to the best of our abilities. The Lutheran Home is currently offering call-in incentives to entice employees to pick up unscheduled shifts and has instituted a positive points program as an incentive. The Lutheran Home at Kane will utilize agency staffing as appropriate. Staffing will be considered when reviewing referrals. Results of the audits will be reviewed at Quality Assurance Performance Improvement meetings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elk Haven Nursing Home | 19.6 mi | ★★★★★ | 6 | 0 |
| Pinecrest Manor | 19.8 mi | ★★★★★ | 3 | 0 |
| Bradford Manor Nursing And Rehab | 20.4 mi | ★★★★★ | 0 | 0 |
| Lakeview Healthcare And Rehab | 21 mi | ★★★★★ | 3 | 0 |
| Sena Kean Nursing And Rehabilitation Center | 21.7 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.