Gracedale Nursing Home has been placed on a six-month provisional license by the state and its Medicare rating downgraded to one star after a series of safety reports were issued over the past year, some of which claim residents were harmed or allowed to wander from the facility, state and federal records show. The situation at the county-run facility is so serious that the Northampton County executive’s office publicly announced last week it has created a plan to address these issues.“We take these violations extremely seriously,” county Executive Tara Zrinski said. “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.” The Upper Nazareth Township nursing home was visited by the department 21 times and the subject of seven safety reports in 2025 and one at the beginning of 2026 that found that its safety standards were not up to par, at times causing harm to residents. Two incidents resulted in the Pennsylvania Department of Health declaring Gracedale in immediate jeopardy, the most serious determination possible from a safety inspection, and one that can result in facilities losing Medicaid and Medicare certification if they do not remediate issues as soon as possible. Among those incidents cited by the department was the case of nurse Octavia Robinson, who was accused of attacking a resident in June. According to the state report, a licensed practicing nurse identified later by police as Robinson closed herself in a room with three patients June 23. Robinson, who was wearing full personal protective equipment, woke up one resident and then instructed that resident and another to put on PPE to protect them from the “demons.” She then proceeded to attack a third resident identified as “resident 1,” stick her fingers in their mouth, shove washcloths and towels down their throat and sprinkled water on them. Robinson later told an officer there were demons in the patient that “needed to come out,” police allege. The two other residents pressed the call bell to get help. Though a nurse aide responded, Robinson shut the door in her face, and the nurse aide did not push the issue further, nor did they report what happened to anyone else. About 15 minutes later, one of the residents in the room called 911 on their cellphone. The resident who was attacked suffered minor injuries, including cuts to the lip, bleeding on the roof of their mouth and a swollen eye, and was taken to the emergency room. According to the state’s report, they said, “I was so scared. I thought I was going to die.” Gracedale also was cited after an October incident in which one resident was assaulted by another resident who was known to be both physically and verbally aggressive. This resident, who had a series of mental health disorders, had on previous occasions refused medication or other treatments, tried to hit staff and didn’t like it when people entered his room. According to the Department of Health, the facility did nothing to prevent other residents from entering the aggressive resident’s room, and on Oct. 6, the man severely beat another resident who wandered into his room. The injured resident suffered a fractured tailbone and bruising, and was experiencing an altered mental state that left him confused, unable to feed himself and stumbling when he walked. Gone missing The department reports also show a recurring issue with residents leaving the facility, including two in September. Days later, although a staff member was assigned to the resident, he still disappeared from Gracedale. The next day, police found him 2 miles away at a convenience store. A review of documents by inspectors showed that after the staff member assigned to him signed off, they weren’t replaced and the resident was left alone. State inspectors also uncovered that the facility hadn’t changed the door or elevator codes after they found them in the resident’s sock. That same month, another patient, who was diagnosed with dementia and had a history of strokes and fainting, also wandered out of Gracedale. According to documents, this patient frequently wandered and was considered a flight risk. He removed an alert bracelet placed on his leg to track his location, and because of this, a nurse questioned why the door to his room was kept unlocked. A stronger bracelet was put on his leg and he was ordered to be checked on every 15 minutes, but his room remained unlocked. However, he was able to remove the stronger bracelet and disappeared. He was found hours later walking on a road a mile away. According to facility policy, he should have been placed on one-on-one supervision. In both cases, the state determined Gracedale placed the patient in immediate jeopardy. The department also identified an instance where a resident who had many medical and life assistance needs, and nowhere to go or anyone willing to take care of him, was allowed to leave the facility, after telling staff he wanted to call a taxi and that a physician assistant had determined he was competent to leave. Ten minutes later, the police called Gracedale inquiring about the man. According to the report, the physician assistant later told inspectors he had not evaluated the patient. However, a social worker took the resident’s word. On top of that, in violation of facility policy, the resident physician was not notified that the man left against medical advice until two days later. This incident also led to an immediate jeopardy determination for Gracedale. Other issues and corrective measures In April, the state also found multiple deficiencies that put patients at minimal harm but were still notable. For instance: patients didn’t receive medications or treatments needed to promote a better quality of life; a medication cart was left unlocked, unattended and accessible to anyone; and, on average, over 21 consecutive days, residents were receiving 3 hours and nine minutes of direct care when they were required to receive a minimum of 3 hours and 12 minutes. In November, a follow-up report by the state stated that a majority of the deficiencies noted in the April report had been corrected, but Gracedale still failed to meet minimum nurse aide ratios and struggled to consistently provide the minimum amount of direct care hours to patients, and on one day, patients received 25 minutes less care than mandated. According to Northampton County, Gracedale was cited again during the first week of 2026; however, the state has not yet made this report publicly available. After each citation, Gracedale issued corrective plans, which included varying measures such as contracting a staffing company, performance audits, staff reeducation, new staff education, risk meetings and policy reviews. According to a release from the county, the county created a plan, overseen by Zrinski and Susan Wandalowski, county director of human services.Under this plan: - The administrator of Gracedale will provide a written report every two weeks to Zrinski and Wandalowski. - The director of administration will attend the facility’s quality assurance committee meetings to exercise oversight over quality issues before they become deficiencies. - A review will be undertaken of nursing services contractors and their staff, on-site training and the scheduling of nursing staff. - Efforts will be put in place to improve and retain county employees at Gracedale. - Employee training will be improved. Other steps have also been taken, including the facility’s declining admittance to potential residents who put other residents and staff at high risk.