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Based on observation and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the fire alarm control panel (FACP) displaying trouble and supervisory signals. This affected 26 of 26 patients and 12 of 12 smoke compartments.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1 * General.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72 National Fire Alarm, 2010 edition
26.3.7.3 * Supervisory Signals.
Upon receipt of a supervisory signal from a sprinkler system, other fire suppression system(s), or other equipment, the central station shall perform the following actions:
(1)* Communicate immediately with the persons designated by the subscriber and notify the fire department or law enforcement agency, or both, when required by the authority having jurisdiction
(2) Dispatch a runner or maintenance person to arrive within 2 hours to investigate
Exception: Where the supervisory signal is cleared in accordance with a scheduled procedure determined by 26.3.7.3(1).
(3) Notify the authority having jurisdiction when sprinkler systems or other fire suppression systems or equipment have been wholly or partially out of service for 8 hours
(4) When service has been restored, provide notice, if required, to the subscriber or the authority having jurisdiction, or both, as to the nature of the signal, the time of occurrence, and the restoration of service when equipment has been out of service for 8 hours or more
Exception: If the supervisory signal results from a prearranged test, the actions specified by 26.3.7.3(1), (3), and (4) shall not be required.

26.3.7.4 Trouble Signals. Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber.
(2) Dispatch personnel to arrive within 4 hours to initiate maintenance, if necessary.
(3) When the interruption is more than 8 hours, provide notice to the subscriber and the fire department if so required by the authority having jurisdiction as to the nature of the interruption, the time of occurrence, and the restoration of service.


Findings:

During a tour of the facility, and interview with the staff on 7/5/23, the FAS was observed.

At 11:42 a.m., the Fire Alarm Control Panel Room in the smoke compartment identified as "1L" was observed with a Fire Alarm Control Panel labeled (FACP 1). FACP 1 had flashing red and yellow LEDs indicating a trouble signal with the FAS. The Fire Alarm Control Panel labeled (FACP 2) located in the Penthouse was observed with 25 fire alarm, 173 trouble, one supervisory, and one "other" signal on the display. During a concurrent interview, Staff 1 stated that FACP 1 was installed when the facility was first built, and that FACP 2 was installed when a new wing to the facility was added, approximately four years prior. FACP 2 was programmed to communicate with FACP 1 rather than communicating directly to the initiating devices found throughout the facility, and that the motherboard of FACP 1 was causing a miscommunication between the two panels. And the miscommunication between FACP 1 and FACP 2 made false alarms appear on FACP 2, causing the fire department to arrive on 6/12/23. Staff 1 stated that the facility had been on fire watch since 6/12/23. The annual FAS report was unable to be provided. The facility was given until 10 a.m. on 7/6/23 to submit the requested documentation. The facility failed to submit the requested documentation.