NAZARETH, PA — Gracedale Nursing Home has been placed on a six-month provisional license and downgraded to a one-star Medicare rating following multiple safety violations documented throughout 2025, according to state and federal records.
The county-operated facility in Upper Nazareth Township was subject to 21 inspections by the Pennsylvania Department of Health in 2025, resulting in seven safety reports that identified deficiencies ranging from inadequate supervision to incidents where residents sustained injuries, as reported by The Morning Call.
County Executive Tara Zrinski acknowledged the severity of the violations in a public statement. "We take these violations extremely seriously," Zrinski said, according to The Morning Call. "A plan of correction has been submitted for each of the deficiencies, and all such plans of correction have been accepted by CMS and fully implemented, except for one related to minimum staffing requirements that will be addressed later in February."
Immediate Jeopardy Determinations
State inspectors issued two immediate jeopardy determinations for Gracedale in 2025, the most serious classification available under federal nursing home regulations. An immediate jeopardy finding indicates that a facility's deficiencies have caused or are likely to cause serious injury, harm, impairment, or death to residents.
According to inspection documents reviewed by The Morning Call, one immediate jeopardy citation stemmed from a June incident in which a licensed practical nurse allegedly assaulted a resident. The nurse, later identified by police as Octavia Robinson, reportedly isolated herself with three residents on June 23 while wearing full personal protective equipment.
State reports indicate Robinson instructed two residents to put on protective equipment to shield themselves from what she described as "demons," then proceeded to attack a third resident. According to the inspection report, Robinson placed her fingers in the resident's mouth and forced washcloths and towels down their throat while sprinkling water on them.
Two residents in the room activated the call bell for assistance. When a nurse aide responded, Robinson shut the door and the aide did not report the incident to supervisors, according to state documentation. Approximately 15 minutes later, one of the residents used a personal cellphone to contact emergency services.
The assaulted resident sustained injuries including lacerations to the lip, bleeding in the mouth, and facial swelling, and required emergency room treatment. "I was so scared. I thought I was going to die," the resident stated, according to the state inspection report.
Resident-on-Resident Violence
A second serious incident occurred in October when a resident with documented aggressive behavior severely injured another resident who entered his room, according to state inspection documents reviewed by The Morning Call.
The aggressive resident had a documented history of mental health disorders and previous incidents of refusing treatment, attempting to strike staff members, and displaying territorial behavior regarding his room. Despite this known pattern of behavior, facility staff did not implement measures to prevent other residents from entering his room, according to the Department of Health report.
On October 6, another resident wandered into the aggressive resident's room and was severely beaten, sustaining a fractured tailbone, extensive bruising, and an altered mental state that left him confused and unable to perform basic functions like feeding himself, according to inspection documents.
Elopement Pattern
State inspection reports documented a recurring pattern of residents leaving the facility without authorization, including two incidents in September involving a resident diagnosed with dementia, insomnia, wandering behavior, restlessness, and agitation.
This resident had a documented history of attempting to leave the facility and had been observed accessing elevators, searching for exit routes, and striking a window. A psychology consultant recommended that staff maintain either arm's length proximity or continuous visual contact with this resident, according to inspection documents.
Two days after this recommendation was made, the resident escaped using an elevator. Inspectors found that a piece of paper containing elevator and door access codes had been hidden in the resident's sock, according to The Morning Call's review of state documents.
Days later, the same resident disappeared again despite having an assigned staff monitor. Police located him the following day at a convenience store approximately two miles from the facility. State inspectors determined that after the assigned monitor's shift ended, no replacement staff member was assigned and the resident was left unsupervised.
CMS Inspection History
Federal Medicare records show Gracedale's overall rating dropped to one star, the lowest possible rating in the Centers for Medicare & Medicaid Services five-star quality rating system. The one-star designation indicates much below average performance compared to other nursing homes nationwide.
The facility's quality measures, health inspections, and staffing levels all contributed to the overall rating decline. The provisional license status means Gracedale must demonstrate sustained compliance with state and federal regulations over a six-month period to regain full licensure.
Pennsylvania Department of Health inspectors conducted 21 separate visits to the facility in 2025, an inspection frequency significantly higher than typical annual surveys. The high volume of inspections indicates ongoing compliance concerns requiring repeated verification visits.
Ownership & Operations
Gracedale is operated by Northampton County, making it a public facility funded through county taxpayer revenue and resident Medicare and Medicaid reimbursements. As a county-run facility, oversight responsibility falls to county elected officials and administrators.
County officials stated that corrective action plans have been submitted and accepted by the Centers for Medicare & Medicaid Services for all deficiencies except one related to minimum staffing requirements, which county leadership indicated would be addressed in February 2026.
Resources for Families
Families with concerns about care quality at nursing homes can contact the Pennsylvania Long-Term Care Ombudsman Program, which provides independent advocacy for nursing home residents. The National Long-Term Care Ombudsman Resource Center operates a hotline at 1-800-677-1116.
Residents and families can also file complaints directly with the Pennsylvania Department of Health's Division of Nursing Care Facilities, which investigates allegations of substandard care, abuse, neglect, and regulatory violations. Federal regulations require nursing homes to post information about how to contact state survey agencies and ombudsman programs.
Additional information about nursing home quality ratings, inspection reports, and enforcement actions is available through Medicare's Nursing Home Compare website at medicare.gov/care-compare.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.