Missing Circuit Breaker Locking Device for Fire Alarm Booster Module
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation in the Mechanical Room (Memory Care), it was found that the required circuit breaker locking device was not provided in the circuit breaker panel for the installed fire alarm booster module. This omission was confirmed through an interview with the facility Maintenance Director at the time of observation. The lack of the locking device could potentially allow for unauthorized tampering with the fire alarm system, and this deficiency could affect all 64 residents in the facility.
Plan Of Correction
ELEMENT 1 The circuit breaker locking device has been placed on in the circuit breaker panel in the Mechanical room on Orchard View. ELEMENT 2 The Maintenance Director and/or designee did an audit on all circuit breaker panels in the facility to ensure there is a locking device present. Any areas of noncompliance were addressed immediately. ELEMENT 3 The Maintenance Director has been reeducated to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 2 months to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.