Inspection Reports for
Lutheran Home at Kane/Residential Care Center
100 HIGH POINT DRIVE,, KANE, PA, 16735
Back to Facility Profile19 Reports
Inspection Report — Oct 8, 2025
Renewal
Date: Oct 8, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the Lutheran Home at Kane/Residential Care Center to verify compliance and the implementation of the submitted plan of correction.
Findings
The facility was found to have discrepancies in the medication administration record related to a sliding scale order and lacked resident education on the right to refuse medication. The submitted plan of correction was accepted and fully implemented by the facility.
Citations (2)
187a - Medication Record: The medication administration record contained discrepancies in the sliding scale order that did not match the original physician order, causing potential medication errors.
191 - Resident Right to Refuse: Residents had not been educated on their right to question or refuse medication if they believed there was a medication error.
Report Facts
Residents Served: 25
Resident Supplemental Security Income: 10
Residents Age 60 or Older: 25
Residents Diagnosed with Mental Illness: 10
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report — Sep 19, 2024
Renewal
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Lutheran Home at Kane/Residential Care Center.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 25
Residents Age 60 or Older: 33
Residents Diagnosed with Mental Illness: 12
Residents Diagnosed with Intellectual Disability: 1
Residents Receiving Supplemental Security Income: 6
Inspection Report — Oct 4, 2023
Renewal
Date: Oct 4, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the Lutheran Home at Kane/Residential Care Center on 10/04/2023 and 10/05/2023.
Findings
The inspection found multiple deficiencies including improper placement of carbon monoxide alarms, incomplete administrator orientation documentation, lack of required staff training on care for residents with mental illness or intellectual disability, sanitary condition issues, incomplete evacuation during fire drills, medication labeling and administration errors, incomplete resident assessments, and incomplete documentation in resident support plans. Plans of correction were accepted and implemented by 11/30/2023.
Citations (9)
Carbon monoxide alarm was installed approximately 6 feet from gas hot water tanks/boilers, not meeting the required minimum distance of 15 feet.
Staff person A, the administrator, had not successfully completed an orientation program approved and administered by the Department.
Direct care staff persons B and C did not receive training in care for residents with mental illness or intellectual disability during the training year 8/1/22-7/31/23.
Unlabeled bar of soap and multiple plastic cups with unknown stains found in shared bathroom.
During fire drills on 2/27/23 and 8/29/23, not all residents evacuated to a designated meeting place away from the building or within the fire-safe area.
Medication labeling errors for three residents including missing alert stickers and inconsistent pharmacy labels.
Medication administration records lacked initials of staff administering medications and incorrect documentation of who administered injections.
Resident #4's initial assessment did not address the use/need of an enabler bar found on the bed.
Resident #3's support plan did not document refusal to participate in fire drills and how this need will be met.
Report Facts
Residents Served: 22
Staffing Hours: 22
Waking Staff: 17
Fire Drill Evacuation - 2/27/23: 19
Fire Drill Evacuation - 9/29/23: 23
Inspection Report — Jan 18, 2023
Complaint Investigation
Date: Jan 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and mistreatment at the facility.
Complaint Details
The complaint involved allegations of abuse by resident #1 towards resident #2, including unwanted physical contact and verbal harassment. Protective services and DHS were notified and conducted investigations. Resident #1 was relocated and provided with mental health appointments. Resident #2 reported feeling safe after interventions.
Findings
The investigation found that resident #1 engaged in inappropriate behavior towards resident #2, causing discomfort. Protective services were involved, and corrective actions including resident relocation and increased supervision were implemented. Additionally, deficiencies were found in documenting psychological services in the resident's support plan.
Citations (2)
Resident #1 engaged in inappropriate physical and verbal behavior towards resident #2, violating abuse prevention regulations.
The resident's support plan did not document the monthly psychological service visits as required.
Report Facts
Residents Served: 21
Staffing Hours - Total Daily Staff: 21
Staffing Hours - Waking Staff: 16
Residents Diagnosed with Mental Illness: 10
Residents Age 60 or Older: 20
Residents Receiving Supplemental Security Income: 6
Residents Diagnosed with Intellectual Disability: 2
Inspection Report — Sep 27, 2022
Renewal
Date: Sep 27, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Lutheran Home at Kane/Residential Care Center.
Findings
The facility was found to have multiple deficiencies including incomplete staff orientation, lack of an annual staff training plan, unsecured resident equipment posing entrapment hazards, uncovered trash receptacles, outdated food items, and incomplete medical evaluations. Plans of correction were submitted and fully implemented by February 18, 2023.
Citations (11)
Staff person did not complete orientation in required topics including fire safety and emergency preparedness.
Staff person did not complete orientation in emergency medical plan and mandatory reporting of abuse and neglect.
The home did not have an annual staff training plan for training year 8/1/22 to 7/31/23.
Buckles securing the pouch covering the enabler bar on resident #1's bed were not secure, posing a potential entrapment hazard.
Trash cans in the main kitchen had 10 inch holes in the lids, allowing penetration of insects and rodents.
Outdated or undated food items found in the freezer section of the kitchenette refrigerator/freezer.
Fire safety inspection and fire drill were not conducted annually as required.
Resident #2's initial medical evaluation did not indicate cognitive functioning; section was blank.
Resident #3's most recent medical evaluation was delayed beyond the annual requirement.
Resident #4's prescription medication label dosage did not match the administration instructions.
Resident #1's medication administration record did not include initials of staff who administered medication.
Report Facts
Residents Served: 21
Staffing Hours - Total Daily Staff: 21
Staffing Hours - Waking Staff: 16
Deficiency Count: 11
Notice — Sep 7, 2021
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Lutheran Home at Kane/Residential Care Center following receipt of their renewal application dated July 26, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations, and enforcement actions will be taken if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Aug 5, 2021
Renewal
Date: Aug 5, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Lutheran Home at Kane/Residential Care Center on 08/05/2021 and 08/06/2021.
Findings
The inspection identified several deficiencies including issues with surfaces (detached cove base and water damage), food storage violations (uncovered and unsealed food items), outdated food labeling, obstructed egress due to a stuck fire exit door, and medication record deficiencies related to self-administered medications and labeling of sliding scale insulin. Plans of correction were accepted and implemented.
Citations (8)
Detached cove base next to fire exit door with water damage to the wall.
Uncovered and unsealed food items in walk-in cooler and freezer.
Outdated or unlabeled food (uncovered and unlabeled bowl of chocolate ice cream).
Fire exit door stuck shut due to rust on door and jamb/threshold.
No record of resident currently self-administering medication kept at bedside.
Sliding scale not indicated on pharmacy label for insulin.
Resident's glucometer not calibrated to correct time.
Sliding scale not indicated on resident's August 2021 Medication Administration Record (MAR).
Report Facts
Residents Served: 22
Uncovered pie tarts: 15
Unsealed pinwheel pastries: 12
Notice — Sep 28, 2020
Date: Sep 28, 2020
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for Lutheran Home at Kane/Residential Care Center, a Personal Care Home. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Inspection Report — Nov 26, 2019
Complaint Investigation
Date: Nov 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The inspection was complaint-driven and the plan of correction was fully implemented as of April 15, 2020.
Findings
The facility was found to have a deficiency related to the resident's support plan not documenting the need for a Wanderguard device. The submitted plan of correction was reviewed and determined to be fully implemented.
Citations (1)
Regulation 227d requires documentation in the resident's support plan for medical and behavioral care services. Resident #1's support plan did not document the need for a Wanderguard or who is responsible for this need despite the resident wearing one since admission.
Report Facts
Residents Served: 21
Current Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 21
Waking Staff: 16
Residents Receiving Supplemental Security Income: 6
Residents Age 60 or Older: 19
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Avenali | LPN PCHA | Signed the plan of correction dated 2/21/2020 |
Inspection Report — Oct 23, 2019
Renewal
Date: Oct 23, 2019
Visit Reason
The inspection was a renewal visit conducted on October 23, 2019, to review the facility's compliance with licensing requirements.
Findings
The facility submitted a plan of correction which was determined to be fully implemented. Several violations related to fire drill records, evacuation procedures, medical evaluations, medication storage, support plan documentation, and record entries were identified and corrected.
Citations (6)
132c - Fire Drill Records: The fire drill records did not include the time it took to evacuate in minutes and seconds for drills conducted on multiple dates.
132d - Evacuation: On 4/23/19, 2 of 19 residents did not evacuate during a fire drill.
141a - Medical Evaluation Information: Resident #1's initial medical evaluation dated 1/3/19 lacked evaluation of body positioning, health status, and cognitive functioning.
185a - Implement Storage Procedures: Resident #1 was prescribed Triamcinolone ointment, but the medication was not available in the home on 10/23/19.
227d - Support Plan Medical/Dental: Resident #2's support plan did not document how the need for total physical assistance managing finances would be met.
251b - Record Entries Legible: Correction fluid was used on the signature line of resident #3's contract addendum dated 1/11/19, violating record entry requirements.
Report Facts
Residents served: 19
Staffing: 19
Staffing: 14
Residents not evacuated: 2
Residents present during fire drill: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Avenali | LPN PCHA | Named as Legal Entity Representative and involved in plan of correction approvals |
Notice — Jul 30, 2019
Date: Jul 30, 2019
Visit Reason
The document serves as a renewal notification and license issuance for Lutheran Home at Kane/Residential Care Center to operate as a Personal Care Home. It also informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notification letter with an enclosed certificate of compliance.
Report Facts
Inspection Report — Oct 24, 2018
Annual Inspection
Date: Oct 24, 2018
Visit Reason
The inspection was conducted as an annual renewal inspection of the Lutheran Home at Kane Residential Care Center to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Violations of 55 Pa. Code Chapter 2600 were found during the inspection, including fire hazard risks due to lint accumulation and improper medication storage with expired medications. Plans of correction were implemented with staff education and procedural changes.
Citations (2)
55 Pa.Code §2600,105(g)(1) - A layer of lint approximately ½ inch thick covered about two-thirds of the lint trap screen in the bottom dryer at 10:20 AM, creating a fire hazard.
55 Pa.Code §2600,183(d) - Resident #1's Ventolin inhaler expired in December 2017 and was still stored in the medication cart, violating medication storage regulations.
Report Facts
Staffing: 29
Waking Staff: 22
Notice — Jul 26, 2018
Date: Jul 26, 2018
Visit Reason
The document serves as a renewal notification for the Lutheran Home at Kane/Residential Care Center's license to operate as a Personal Care Home and informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Mar 9, 2018
Routine
Date: Mar 9, 2018
Visit Reason
The Department's Bureau of Human Services Licensing conducted an inspection of the Lutheran Home at Kane Residential Center on March 9, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Oct 26, 2017
Annual Inspection
Date: Oct 26, 2017
Visit Reason
The inspection was the Department of Human Services' annual licensing inspection of the Lutheran Home at Kane Residential Center conducted on October 26, 2017.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to staff training, safety hazards, maintenance issues, medication storage, and resident assessments. Plans of correction were submitted and partially implemented as of February 2018.
Citations (6)
55 Pa.Code §2600.65(f) - Direct care staff did not receive annual training on meeting resident needs, dementia care, and personal care service needs during the 7/31/16-8/1/17 training year.
55 Pa.Code §2600.84 - The steam table in the dining room was on and measured 145.4 degrees, posing a risk of resident contact with a hot surface.
55 Pa.Code §2600.86(b) - The exhaust fan in the shared bathroom of rooms 101 and 102 was inoperable and there was no window in the bathroom.
55 Pa.Code §2600.183(e) - Resident #3's prescription eye drops were undated and stored improperly, making it impossible to determine when the vial was opened.
55 Pa.Code §2600.226(a) - Resident #3's initial assessment did not include diagnoses of atrial fibrillation, heart failure, acute kidney failure, and abnormal weight loss as indicated in medical documentation.
55 Pa.Code §2600.226(c) - Resident #4's assessment dated 5/14/17 did not include diagnoses of depression, chronic obstructive pulmonary disease, and deep vein thrombosis as indicated in physician orders.
Report Facts
Staffing: 22
Walking Staff: 17
Residents 60 or Older: 19
Residents with Mental Illness: 6
Residents Receiving Supplemental Security Income: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce T. Kimball | Legal Entity Representative | Signed plan of correction documents |
| Vicky Summers | Inspection conducted by Vicky Summers on 10/26/2017 |
Notice — Jul 26, 2017
Date: Jul 26, 2017
Visit Reason
The document serves as a renewal notification for the Lutheran Home at Kane/Residential Care Center's license to operate as a Personal Care Home and informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice with an enclosed certificate of compliance.
Inspection Report — Nov 2, 2016
Renewal
Date: Nov 2, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on November 2, 2016, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations related to resident contracts, personal care service hours, fire drill documentation, exit route usage during drills, resident assessments, and bed enabler usage. Plans of correction were partially implemented with adequate progress noted.
Citations (8)
55 Pa.Code §2600.26(c)(2) - The resident-home contract did not include the monthly fee charged for room and board.
55 Pa.Code §2600.26(c)(12) - Resident contracts did not include charges for holding a bed during hospitalization or extended absence.
55 Pa.Code §2600.57(b) - The home failed to provide the required minimum of 1 hour of personal care services per mobile resident and 2 hours per resident with mobility needs on certain days.
55 Pa.Code §2600.57(b) - At least 75% of personal care service hours were not provided during waking hours on certain days.
55 Pa.Code §2600.132(c) - The fire drill record did not include the number of residents in the home at the time of the drill.
55 Pa.Code §2600.132(f) - Alternate exit route #2 was not used during a monthly fire drill from April to November 2016.
55 Pa.Code §2600.226(o) - Resident #1's assessment did not include a diagnosis of COPD as indicated in the medical evaluation.
55 Pa.Code §2600.227(d) - Resident #3 uses a bed enabler but this was not indicated in the support plan dated 10/17/16.
Report Facts
Staffing: 26
Working Staff: 10
Supplemental Security Income Recipients: 10
Residents 60 Years or Older: 21
Residents with Mental Illness: 3
Residents with Intellectual Disability: 1
Residents with Physical Disability: 1
Notice — Jul 20, 2016
Date: Jul 20, 2016
Visit Reason
The document is a renewal notification and license certificate issued in response to the facility's renewal application to operate a Personal Care Home.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states the requirement for an annual onsite inspection within the next twelve months.
Report Facts
Inspection Report — Feb 4, 2016
Renewal
Date: Feb 4, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection with additional incident investigation.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident assistance, medical evaluations, smoking hazards, medication administration, medication records, and resident support plans. Plans of correction were submitted and partially implemented at the time of the report.
Citations (7)
55 Pa.Code §2600.23(a) - The resident requires assistance with managing health care daily and medication administration but the home failed to provide consistent monitoring and support for blood glucose levels and medication administration.
55 Pa.Code §2600.141(b)(1) - Resident #2 did not have a medical evaluation completed annually as required; the most recent was over two years old at the time of inspection.
55 Pa.Code §2600.144(c)(1) - The home failed to provide proper safeguards to prevent fire hazards in the smoking area; flammable chairs were present in the gazebo smoking area.
55 Pa.Code §2600.181(c) - Resident #1 was self-administering insulin without assessment by a qualified medical professional regarding ability and need for medication reminders.
55 Pa.Code §2600.182(b) - Staff person A did not complete the annual medication administration practicum fully; only 3 of 4 reviews were completed and only 1 of 2 medication observations were done.
55 Pa.Code §2600.187(a) - Medication Administration Record was not properly maintained; staff failed to sign or initial MAR for medication administered and glucometer readings were incorrectly documented.
55 Pa.Code §2600.227(b) - Resident #1's support plan did not include use of a bed enabler or protection plan despite the resident having a bed enabler removed after discharge.
Report Facts
Number of Residents Served: 28
Number of Deficiencies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Copenhaver | NHA Administrator | Signed plan of correction and legal entity representative on multiple violations |
| Jason Harvey | Inspector conducting the violation report |
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