Health inspection·September 19, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. The policy further indicated that residents capable of removing their alert bracelets (an electronic device that prevents doors from opening and/or sounds an alarm) were to be issued a stronger tamper resistant band. If the resident was able to remove the stronger band and was independently ambulatory (walked without assistance), the resident would require a one to one (1:1) observation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, syncope and collapse (fainting), and cerebral infarction (stroke). According to the Minimum Data Set assessment (a periodic evaluation of resident care needs) dated August 27, 2025, the resident had memory impairment and could walk without assistance. Review of the elopement assessment dated [DATE], revealed 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. On September 13, 2025, a nurse noted that he had self-removed his alert bracelet and the nurse questioned if the unlocked unit was appropriate for the resident. On September 17, 2025, at 2:20 p.m., a nurse noted that Resident 1 was observed on the first floor. The resident was returned to the second-floor unit where he resided, and a new alert bracelet was applied. On September 17, 2025, at 2:54 p.m., another nurse noted that Resident 1's alert bracelet could not be located, and another new one was applied. At 4:11 p.m., a nurse noted that the physician group ordered for Resident 1 to be on every 15 minute checks due to wandering and removing his alert bracelet. Review of the facility documentation dated September 17, 2025, revealed that Resident 1 could not be located on the unit at 4:30 p.m., and the facility began a search. When Resident 1 could not be located on the facility grounds, the police were contacted. The police observed the resident walking along a road one mile from the facility. He was returned to the facility by the police on September 17, 2025, at 8:10 p.m. There was no documented evidence that Resident 1 was provided a stronger alert bracelet band or placed on 1:1 observation after removing his alert bracelet on September 13 and 17, 2025, as per facility policy. There was no documented evidence that Resident 1 had care plan interventions developed to address his elopement risk, wandering behavior, and alert bracelet use. In an interview on September 19, 2025, at 11:55 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1 was issued a stronger alert bracelet band per policy and that no care plan interventions were developed to (continued on next page) 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 Page 1 of 2 Event ID: 395476 Printed: 05/15/2026 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 395476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 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)