Northampton County-gracedale

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of ten sampled residents. (Residents 1, 2)Findings include: Clinical

record review revealed that Resident 1 was admitted to the facility on [DATE REDACTED], and had diagnoses that included vascular dementia, syncope and collapse (fainting), and cerebral infarction (stroke). According to

the Minimum Data Set (MDS) assessment, dated August 27, 2025, the resident had memory impairment and could walk without assistance. Review of the elopement assessment dated [DATE REDACTED], revealed that the resident wandered and was at risk for elopement. On August 20, 2025, a nurse noted that an alert bracelet was applied to the resident's leg. There was no documented evidence that the facility included interventions

on the care plan to monitor the resident's risk for elopement, wandering behavior and the use of this device.

Clinical record review revealed that Resident 2 was admitted to the facility on [DATE REDACTED], and had diagnoses that included dementia, insomnia (difficulty falling or staying asleep), wandering, restlessness, and agitation. According to the MDS assessment, dated September 5, 2025, the resident was Spanish speaking and rarely understood others when spoken to in English. The MDS Care Area Assessment summary noted that the resident's communication was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 2's communication barrier were included in the care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northampton County-Gracedale

Gracedale Avenue Nazareth, PA 18064

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

per his physician's order and care plan, and eloped from nursing unit Tower 3 and the building unwitnessed.

Further review of facility documentation revealed that Resident 2 was later observed on camera footage exiting through a stairwell door on Tower 3 after using the code to open the door. There was no documented evidence that the nurse aide (NA 1) and nurse (LPN 1) assigned to Resident 2 on Tower 3 on September 20, 2025, at the time of the elopement, had received the required training prior to the start of their shifts as indicated in the facility's Immediate Jeopardy action plan dated September 19, 2025. Review of additional facility documentation revealed that 29 residents on Tower 3 were assessed to have been at risk for elopement on September 20, 2025. There was no documented evidence that the facility implemented or evaluated the psychology consultant's recommendation for 1:1 supervision until September 17, 2025. There was no documented evidence that the door codes where changed on September 17, 2025, after the resident was found with the codes, or on September 20, 2025, when the resident used the code to exit the facility. In an interview on September 23, 2025, at 11:30 a.m., the Risk Management Nurse confirmed that

the door codes were not changed until September 22, 2025. On September 23, 2025, at 11:43 a.m., the Administrator was notified that the failure to provide adequate interventions and supervision to prevent elopement constituted an Immediate Jeopardy situation at F-F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented

the following corrective action plan: 1. Resident 2's room was changed to a secure unit.2. The facility changed all the door and elevator codes on September 22, 2025.3. The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.4. The facility educated all staff regarding the new 1:1 policy and not sharing door codes beginning on September 21, 2025. The remainder of staff will be educated by September 24, 2025.5. The facility educated staff that a search should occur immediately if a door alarm is sounding beginning on September 21, 2025. The remainder of staff will be educated by September 24, 2025.6. The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.7. The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events. 8. The Nursing Home Administrator will update the pre-admission review of elopement risk by September 24, 2025, to ensure the facility can safely manage a resident at risk of elopement. 9. Monthly department head meetings will be held for the leadership team to discuss elopement events beginning September 25, 2025.10. Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action. The survey team validated that the Immediate Jeopardy was removed on September 23, 2025, at 4:05 p.m., through

review of the facility training, and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 483.25(d) Accidents.Previously cited 9/19/25 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northampton County-Gracedale

Gracedale Avenue Nazareth, PA 18064

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and a review of facility documentation, it was determined that the facility failed to provide sufficient and competent staff needed to implement a resident's care plan interventions. (Resident 2)Findings include:Clinical record review revealed that Resident 2 was admitted to the facility on [DATE REDACTED], and had diagnoses that included dementia, insomnia, wandering, restlessness, and agitation. According to

the Minimum Data Set assessment dated [DATE REDACTED], the resident had memory impairment and could walk without assistance. Review of Resident 2's care plan revealed that he was at risk for elopement with interventions for one to one (1:1) observation. On September 17, 2025, the physician ordered for staff to provide 1:1 supervision due to the resident being an elopement risk. Review of facility documentation dated September 21, 2025, revealed that the staff member assigned to provide 1:1 supervision for Resident 2 left

the assignment at 8:00 p.m. on September 20, 2025, and was not replaced by another staff member.

Resident 2 was then left without 1:1 supervision which resulted in him eloping from the facility on September 20, 2025, at 11:21 p.m.Review of the facility staffing documentation for Saturday, September 20, 2025, revealed that the facility failed to meet the state required Nurse Aide ratios and minimum direct care hours per resident.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(4)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northampton County-Gracedale

Gracedale Avenue Nazareth, PA 18064

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility job descriptions, clinical record review, and review of facility documentation, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure that adequate interventions and supervision were provided to prevent the elopement of two of 10 sampled residents. (Residents 1 and 2) In addition, the NHA and DON failed to ensure staff education was completed as indicated in their Immediate Jeopardy Action Plan on nursing unit Tower 3, affecting 29 residents at risk for elopement. Findings include:Review of the NHA's job description revealed that the Administrator was responsible to plan, direct, and control the organization and management of administrative, patient care, ancillary, and service functions, and was to ensure the facility's compliance with State, Federal, and other regulations governing facility licensing. Review of the DON's job description revealed that the Director of Nursing was responsible for the planning, coordination, and control of all services provided through the Nursing department. Work included the development and implementation of nursing services, standards, staffing, and provision of overall administrative management functions.Clinical record review revealed that Resident 1 eloped from the facility on September 17, 2025,

after self-removing his roam alert bracelet (an electronic device that prevents doors from opening and/or sounds an alarm). This resulted in an Immediate Jeopardy Situation. The facility's action plan, dated September 19, 2025, indicated that each nurse would receive education related to elopement prevention prior to the start of their next scheduled work shift and that all staff would receive the education by September 22, 2025.Clinical record review revealed that Resident 2 had a physician's order for staff to provide one to one supervision due to exit seeking behavior . Further review of the clinical record revealed that the resident had eloped from the facility on September 20, 2025, after being left unsupervised by the staff assigned to provide 1:1 supervision. This resulted in a second Immediate Jeopardy situation. There was no documented evidence that the nurse aide (NA 1) assigned to provide the 1:1 supervision had received elopement training before September 22, 2025, and that the nurse (LPN 1) assigned to oversee

the nurse aide and the resident on September 20, 2025, at the time of the elopement, had received the required training prior to the start of the shift as indicated in the facility's Immediate Jeopardy action plan dated September 19, 2025. Review of additional facility documentation revealed that 29 residents on Tower 3 were assessed to have been at risk for elopement on September 20, 2025.The NHA and DON failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the two Immediate Jeopardy situations.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet