Pennsylvania Department of Health
JAMESON NURSING AND REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

JAMESON NURSING AND REHAB CENTER
Inspection Results For:

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JAMESON NURSING AND REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Follow-up Survey completed on April 15, 2025, it was determined that Jameson Nursing and Rehab Center corrected the federal deficiency cited during the survey of February 21, 2025, under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however remains out of compliance with the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of the facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents for the day shift for three of 14 days reviewed (4/04/25, 4/05/25, and 4/06/25 ); failed to ensure one LPN per 30 residents for the evening shift for one of 14 days reviewed (4/06/25); and failed to ensure one LPN per 40 residents for the overnight shift for two of 14 days reviewed (4/05/25, and 4/06/25).

Findings include:

Review of facility nursing staffing documents for the time period from 3/27/25 through 4/09/25, revealed the following LPN staffing shortages for the day shift where the LPN ratios were not met:

4/04/25 census of 74 residents 2.63 LPNs worked and 2.96 were required
4/05/25 census of 74 residents 2.43 LPNs worked and 2.96 were required
4/06/25 census of 74 residents 2.18 LPNs worked and 2.96 were required

Review of facility nursing staffing documents for the time period from 3/27/25 through 4/09/25, revealed the following LPN staffing shortage for the day shift where the LPN ratios were not met:

4/06/25 census of 73 residents 2.31 LPNs worked and 2.43 were required

Review of facility nursing staffing documents for the time period from 3/27/25 through 4/09/25, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

4/05/25 census of 74 residents 1.34 LPNs worked and 1.85 were required
4/06/25 census of 73 residents1.23 LPNs worked and 1.83 were required

During a telephone interview on 4/15/25, at 11:27 a.m. the Nursing Home Administrator confirmed the LPN ratios were not met for the above dates and shift.

Plan of Correction - To be completed: 05/13/2025

"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
1. The facility cannot correct that the Licensed Practical Nurse Ratio was not met on 4/4/25, 4/5/25, 4/6/25. There were no adverse resident effects on identified dates.
2. The facility Director of Nursing, scheduler and nursing supervisors will be re-educated regarding the State Licensed Practical Nurse Ratios by the Nursing Home Administrator/designee.
3. Twice daily meetings will be held Monday through Friday to review schedule with Licensed Practical Nurse ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet Licensed Practical Nurse ratio the scheduler/or designee will call off duty facility staff, and will utilize pick-up bonuses.
4. Licensed Nurse positions are actively posted in recruitment.
5. The facility has developed a Retention committee.
6. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure Licensed Practical Nurse ratio is being met.
7. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for five of 14 days reviewed (4/03/25, 4/04/25, 4/05/25, 4/06/25 and 4/07/25).

Findings include:

Review of facility nursing staffing documents for the time period from 3/27/25 through 4/09/25, revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) on the following dates:

4/03/25 2.88 PPD
4/04/25 2.86 PPD
4/05/25 2.93 PPD
4/06/25 2.94 PPD
4/07/25 3.18 PPD

During a telephone interview on 4/15/25, at 11:27 a.m. the Nursing Home Administrator confirmed that the facility did not meet the 3.2 minimum hours of direct resident care on above dates.

Plan of Correction - To be completed: 05/13/2025

1. The facility cannot correct that the State required PPD (per patient daily) minimum was not met on 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/7/25. There were no adverse resident effects on identified dates.
2. The facility Director of Nursing, scheduler and nursing supervisors will be re-educated regarding the State required PPD (per patient daily) minimum by the Nursing Home Administrator/designee.
3. Twice daily meetings will be held Monday through Friday to review schedule with State required PPD (per patient daily) minimum. Nursing supervisors will monitor on weekends. If the facility is projected to not meet the State required PPD (per patient daily) minimum the scheduler/or designee will call off duty facility staff, and will utilize pick-up bonuses.
4. All nursing positions are actively posted in recruitment.
5. The facility has developed a Retention committee.
6. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure the State required PPD (per patient daily) minimum is being met.
7. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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