Northampton County-Gracedale

In the surveyor’s words

From the most serious findings on record at Northampton County-Gracedale, in the surveyor’s own words.

• Immediate jeopardy, patternF689Sep 23, 2025

  Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of ten sampled residents at risk for elopement. (Resident 2) In addition, the facility failed to provide required education to staff related to elopement prevention on nursing unit Tower 3, affecting 29 residents assessed as at risk for elopement. This failure resulted in an Immediate Jeopardy situation. […]

• Immediate jeopardy, isolatedF689May 14, 2026

  Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts, prevent an elopement (unauthorized departure from the facility), and ensure that medications were administered as documented for one of six sampled residents. (Resident 1) In addition, the facility failed to provide adequate supervision to a resident with known behaviors and a history of substance abuse (Resident 2). This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed December 18, 2025, revealed staff were to assure the safety and security of all residents. […]

• Immediate jeopardy, isolatedF628Oct 2, 2025

  Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that a provider (physician or designee) was notified in a timely manner of a resident who left the facility against medical advice (AMA). In addition, the facility failed to ensure that a resident was capable of safely making the decision to independently discharge from the facility without interventions or services for one of six sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. […]

• Immediate jeopardy, isolatedF689Sep 19, 2025

  Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed March 25, 2025, revealed that staff were to assure the safety and security of all residents and that facility staff were to list prevention strategies on residents' care plans. […]

• Actual harm, isolatedF600Oct 17, 2025

  Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents were free from abuse for two of ten sampled residents (Residents 2 and 4), resulting in physical harm for one resident. (Resident 2)Findings include: Review of the facility policy entitled, Abuse Prevention, last reviewed March 24, 2025, revealed that residents had the right to be free from abuse. Review of the facility policy entitled, Resident to Resident Altercations, last reviewed March 24, 2025, revealed that facility staff would monitor residents for aggressive behavior towards other residents or staff. […]