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SENECA REHABILITATION HOSPITAL
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based on observation, record review, and staff interview it was determined the facility failed to ensure compliance with National Fire Protection Association (NFPA) 101, and 80. This deficient practice could affect all patients, staff, and visitors in the areas referenced.
Findings include:
a) Observation during the facility inspection tour conducted on 07/08/25 at 10:20 a.m., revealed the B-2 Wing Fire Doors not latching and six penetrations to the doors from missing hardware screws.
b) Observation during the facility inspection tour conducted on 07/08/25 at 10:21 a.m., revealed the frame of the B-3 Wing Fire Doors to have penetrations due to missing hardware screws.
c) Interview on 07/08/25 at approximately 10:45 a.m., with the Facility Maintenance Supervisor verified these findings. The findings were were also acknowledged by the Director of Nursing at the exit interview on 07/08/25.