Pennsylvania Department of Health
LUTHERAN HOME AT KANE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LUTHERAN HOME AT KANE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on November 20, 2025, at Lutheran Home at Kane, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #902802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 20, 2025, it was determined that Lutheran Home at Kane was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (200), unprotected, ordinary building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Receptacles:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles, per NFPA 70, in one of over fifty rooms.

Finding include:

Observation on November 20, 2025, at 10:25 a.m., revealed the kitchen, PC side, had an outlet located within six feet of a sink that was not protected by a ground fault circuit interrupter (GFCI) .

Interview with the maintenance supervisor on November 20, 2025, at 10:25 a.m., confirmed the receptacle deficiency.

Plan of Correction - To be completed: 12/15/2025

The Lutheran Home at Kane has made all the corrections to comply with national fire protection by installing a ground fault interrupter protection in the personal care facility kitchen area near the sink.

The maintenance staff will inspect GFIC receptacles weekly for one month and then monthly for 3 months.

All maintenance staff have been educated on this matter.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain one of one diesel generator, affecting the entire facility.

Findings include:

Document review on November 20, 2025, at 11:00 a.m., revealed the monthly conductance test had not been completed.

Interview with the maintenance supervisor on November 20, 2025, at 11:00 a.m., confirmed the conductance test had not been completed.

Plan of Correction - To be completed: 12/15/2025

The Lutheran Home at Kane will do the diesel generator conductance testing weekly for one month. Then once a month thereafter to be in compliance with all life safety codes and NFPA regulations.
The maintenance director or designee will conduct education to all maintenance staff on testing regulations.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in two of two utility rooms.

Findings include:

Observation on November 20, 2025, revealed the following oxygen cylinder storage deficiencies:
1. (10:22 a.m.) PC side clean utility room, located near the nurse station, had a full oxygen cylinder in the empty cylinder storage area;
2. (10:45 a.m.) Oxygen storage room had four empty/used oxygen cylinders stored on the full cylinder rack.

Interview with the maintenance supervisor on November 20, 2025, at 10:45 a.m., confirmed the oxygen cylinder deficiencies during the survey.

Plan of Correction - To be completed: 12/08/2025

The Lutheran Home at Kane has made all the corrections to comply with regulations.

Partially used oxygen cylinders will be stored in their own labeled tank stand.

All nursing staff have been educated on this matter.

Plan of correction will be complete by 12/15.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #902802
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on November 20, 2025, it was determined that Lutheran Home at Kane was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain one of one diesel generator, affecting the entire facility.

Findings include:

Document review on November 20, 2025, at 11:00 a.m., revealed the monthly conductance test had not been completed.

Interview with the maintenance supervisor on November 20, 2025, at 11:00 a.m., confirmed the conductance test had not been completed.

Initial comments:Name: KITCHEN AND DEMENTIA WING - Component: 03 - Tag: 0000

Facility ID #902802
Component 03
Main Building/New Addition

Based on a Medicare/Medicaid Recertification Survey completed on November 20, 2025, it was determined that Lutheran Home at Kane was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V, protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: KITCHEN AND DEMENTIA WING - Component: 03 - Tag: 0918

Based on document review and interview, the facility failed to maintain one of one diesel generator, affecting the entire facility.

Findings include:

Document review on November 20, 2025, at 11:00 a.m., revealed the monthly conductance test had not been completed.

Interview with the maintenance supervisor on November 20, 2025, at 11:00 a.m., confirmed the conductance test had not been completed.

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