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This tag not met as observed by the maintenance foreman and this surveyor. It was observed that the clean utility room door in ASU was being blocked open by a storage cart. Storage room doors are only to be held open by approved devices such as a magnetic hold open device that is connected to the fire alarm system so that the door will close automatically when the fire alarm is activated. It was also observed that the Storage room door in ASU does not have a closure device installed on it making it self closing and positive latching.

This tag not met as observed by the maintenance foreman and this surveyor. It was observed that the fire alarm system records did not indicate that smoke detector sensivity tests have not been accomplished as required. This item was identified on the 3/19/2008 survey. After searching the fire alarm records for the tests, this surveyor contacted the fire alarm company that services the system for the unit. The company confirmed to me that the tests have not been done within the last two years.

This tag not met as observed by the maintenance foreman and this surveyor. it was observed that the Laboratory reheat room is requiring the installation of a new reheating unit that is much smaller than the existing unit. When the new and much smaller unit is installed sprinkler and heat/smoke detection will be required for the area. It was also observed that the Nurses Report Room is lacking sprinkler protection. When a new ceiling was installed in the area the sprinkler system was not extended to include this area below the ceiling. NOTE; Because of the small space above the ceiling it will not be required that sprinkler protection be provided for above the ceiling.

The following additional deficiencies were observed by this surveyor duirng the survey: 1) Excessive storage in the electrial room next to material control. 2) DECA building in Machias, the fire alarm system is not being tested annually as required.