Pennsylvania Department of Health
 SENECA PLACE
Patient Care Inspection Results

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SENECA PLACE
Inspection Results For:

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SENECA PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated survey in response to a complaint, completed on February 24, 2026, it was determined that Seneca Place was not in compliance with the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on review of facility policy, review of reports to the local State field office, facility documents, resident clinical records, resident interview and staff interviews, it was determined that the facility failed to report a resident elopement for one of three closed resident records (Closed resident record CR1).

Findings include:

The facility "Wandering and elopement" policy dated 5/1/25, indicated if a resident is missing, to initiate the elopement/ missing resident emergency procedure. The Director of nursing or charge nurse shall complete and file and incident report.

Review of Closed resident record CR1's admission record indicated he was admitted on 2/18/26.

Review of Closed resident record CR1's admission assessment dated 2/18/26, indicated he had diagnoses that included alcohol dependence, hypertension (a condition impacting blood circulation through the heart related to poor pressure), and a history of falls. The assessment indicated he was alert and orientated to person, place, and time. The assessment found he could communicate with clear speech and understand and be understood when speaking.
Mood was pleasant.

Review of Closed resident record CR1's elopement risk assessment dated 2/18/26, indicated a score of "0" meaning he was not an elopement risk.

Review of Closed resident record CR1's clinical nurse progress note dated 2/18/26, indicated that on rounds, Closed resident record CR1 was not located in his room. The unit was searched room to room; facility was searched. He was not located in the facility and 911 call was initiated.

During an interview on 2/24/26, at 9:58 a.m. Registered Nurse (RN) Supervisor Employee E1 stated the following about elopement procedures: "we call code pink. Alert Supervisor and alert administration. Search all the rooms. Upstairs and downstairs. Like an all hands on. We contact the local police while we continue to search. We search outside as well."

During an interview on 2/24/26, at 10:17 a.m. Registered Nurse (RN) Employee E2 stated the following about elopement procedures: "notify everyone to look out for resident. Notify the administration. I know another shift had one. But not mine."

During an interview on 2/24/26, at 10:19 a.m. Registered Nurse (RN) Employee E3 stated 3rd floor "no elopements on this floor. If there is one, the policy is to call code pink. We try to find the missing resident; we make announcement including what room it occurred. We account for all residents. If not found in ten minutes, we contact the police. Notify the supervisor, DON, and department heads."

During a phone interview on 2/24/26, at 10:50 a.m. Nurse aide Employee E4 stated the following: "I was on the other side. He was on the east side on the 4th floor. I went on a lunch break. I saw a few employees outside asking me if I had seen anyone. When I got in the building, the staff said they could not find Closed Resident Record CR1. The police were contacted and the police said Closed Resident Record CR1made it at home safely. I never had a chance to meet Closed Resident Record CR1. I think Nurse Aide Employee E6 was his aide that evening."

During a phone interview on 2/24/26, at10:52 a.m. Licensed Practical Nurse (LPN) Employee E5 stated the following: "I spoke to Closed Resident Record CR1 and greeted him. He was fine. The next minute I know I was told in report Closed Resident Record CR1 was not ambulatory. The aides were looking for an operable lift to weigh him. When I was in the hallway by the nurse station to provide another resident with a breathing treatment, I saw a tall gentleman with gray hair. He looked like he was heading up to the nurse station. I then realized that was Closed Resident Record CR1. About 30 minutes later, I was in a back room, and an aide told me she could not find the Closed Resident Record CR1. We checked the bathrooms and looked at other rooms. I realized it was the resident I saw earlier. I notified the supervisor and we did a room-to-room search. Closed Resident Record CR1 appeared to be alert and oriented. Previously, Closed Resident Record CR1 was very comfortable laying in the bed. We searched whole building and could not find him. Looked outside around the building. One of the nurse aides said she spoke to his roommate, Resident R2. Resident R2 said Closed Resident Record CR1 was on the phone and was asking for a ride. Apparently, he had someone pick him up. I do not know how Closed Resident Record CR1 got out the building. It was after 8 p.m. Closed Resident Record CR1 got a ride. I do not know how. We called the police. The police called me back since I was the only person that had seen him, I gave the police a description and an address and requested the officer go to Closed Resident Record CR1 home. Closed Resident Record CR1 was very close. The police called back and said Closed Resident Record CR1 was fine and he said he was not coming back. That was a little after 9 p.m. He did not sign out AMA (against medical advice). It is my understanding that the Director of Nursing (DON) and unit manager spoke to Closed Resident Record CR1 and see if he would sign out AMA. His shoes and wallet were gone. When he first arrived, he was dressed in a gown."

At 11:46 a.m. Nurse aide Employee E6 was called for her statement and did not respond.

During an interview on 2/24/26, at 11:26 a.m. Resident R2 stated the following: "Yes. It was unusual. Closed Resident Record CR1 had been here. And around 7:30 p.m. or 8:00 p.m. , Closed Resident Record CR1 said he could not walk, and I saw him walk to the bathroom. I was on my phone. Closed Resident Record CR1 asked me if there was a phone available and I showed him how to use the phone in our room. Closed Resident Record CR1 used the phone and gave someone the name of the nursing home. I looked up later and he was gone. A staff person, one of the nurse aides whose name I cannot remember, asked if Closed Resident Record CR1 was in his room. I said Closed Resident Record CR1 was gone. I saw staff searching all over. I asked an aide around 11 p.m. what happened and she said he went home."

During an interview on 2/24/26, at11:54 a.m. Registered Nurse (RN) Supervisor Employee E1 stated the following: "I was at home when this happened. I was notified by the in-house supervisor that they were unable to locate a Closed Resident Record CR1. I was the on-call supervisor. I told staff to start the process of looking for Closed Resident Record CR1 and to notify all the staff. I contacted the Director of Nursing (DON). She called the Nursing Home Administrator (NHA). She contacted Regional administrator. I then got in my car and came to the building."
At any time did you see him on 2/18/26? "I did see Closed Resident Record CR1 later. Around 11 p.m. I saw him at his home."
What was nature of conversation? "As part of our process we contacted the police prior to me making it to the building. The police did a wellness check. They located Closed Resident Record CR1 at his home, and Closed Resident Record CR1 stated he did not want to be in the facility. When I arrived at his home. The DON went with me. Closed Resident Record CR1 was alert/oriented, well-spoken and he wanted to be home. He called his son to pick him up. Closed Resident Record CR1 signed the AMA (against medical advice) paperwork. We educated him that he left the facility without a formal discharge. He was willing to sign the paperwork. I suggested Closed Resident Record CR1 contact his primary care provider (PCP) for any home services."

Review of reports to the state related to elopements and AMA discharges did not include Closed Resident Record CR1 2/18/26 elopement from the facility.

During an interview on 2/24/26, at 2:41 p.m. Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the facility failed to report a Closed Resident Record CR1 elopement as required.





 Plan of Correction - To be completed: 02/27/2026

1. Facility notified the Department of Health of the reportable event that occurred on February 18, 2026 for Closed Record (CR1). Reportable event submitted 2/24/26 and accepted by the Department of Health on 2/25/26.
2. The Administrator and Director of Nursing will be educated by the Regional Director of Clinical Support on notification and timely reporting.
3. The Director of Nursing, or designee, will audit all events for reporting criteria daily for 2 weeks during morning Stand Up and afternoon Stand Down, weekly for 2 weeks, and monthly for 2 months. Audits will be reviewed at monthly QAPI meetings.


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