The citation, tagged F0686, was tied to Complaint Number 2604004 and connected to an earlier annual survey completed in August 2025.
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The crash happened on September 16, 2025.
She died on July 18, 2025, after being admitted to the hospital with an NSTEMI, sepsis, and cellulitis.
The citation, classified as having minimal harm or potential for actual harm, affected a small number of residents.
The incident centered on Resident 108.
The inspection at Autumn Lake Healthcare at Long Green, located at 115 East Melrose Avenue, was completed on October 6, 2025, and was triggered by complaints.
The finding at Northampton County-Gracedale, a publicly owned facility in Nazareth, Pennsylvania, followed a complaint inspection completed October 2, 2025.
The complaint inspection, conducted at the facility on Honadel Boulevard, identified a deficiency in how the nursing home handled medication administration.
The Director of Nursing confirmed it herself.
The resident, identified in inspection records as R2, had a tracheostomy.
That arrangement, federal inspectors concluded, caused actual harm to residents.
That finding sits at the center of a complaint inspection completed October 3, 2025, at the Santa Monica nursing home.