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Based on observation and interview, the facility failed to ensure that the building fire alarm system functioned as required by NFPA standards.

The findings include:

During the Life Safety Code survey on November 24, 2010, at 10:25 a.m., with the Director of Maintenance (DOM), a test of the fire alarm automatic dialer panel revealed when the panel was placed in trouble from phone line failure the unit did not send a trouble signal to a continuously occupied location within the facility. The main fire alarm control panel showed that all systems were normal. While the dialer panel did emit an audible trouble signal, this signal was not in an area where it was likely to be heard. The monitoring station did receive this signal but did not contact the facility of this phone line failure as required. An interview with the DOM on November 24, 2010, at 10:40 a.m., revealed the DOM was not aware the phone line trouble signal should be in an area where it is likely to be heard. The DOM was not aware the monitoring station should be contacting the facility of this trouble signal in a timely manner.

Reference: NFPA 72 (1999 Edition).

1-5.4.4 Distinctive Signals.
Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

1-5.4.6 Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber

A-5-2.6.1.4(1)
The term immediately in this context is intended to mean "without unreasonable delay." Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.

5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

3-8.1* Fire Alarm Control Units.
Fire alarm systems shall be permitted to be either integrated systems combining all detection, notification, and auxiliary functions in a single system or a combination of component subsystems. Fire alarm system components shall be permitted to share control equipment or shall be able to operate as standalone subsystems, but, in any case, they shall be arranged to function as a single system. All component subsystems shall be capable of simultaneous, full load operation without degradation of the required, overall system performance.

Based on interview and record review, the facility failed to maintain the fire alarm system by NFPA standards.

The findings include:

During the Life Safety Code tour on November 24, 2010, at 11:45 a.m., a record review with the Director of Maintenance (DOM) revealed there were no reports made available regarding the sensitivity testing of the smoke/heat detectors. A sensitivity report entails the testing of components associated with the fire alarm system, e.g., smoke detectors and heat detectors to ensure proper operation. An interview on November 24, 2010, at 11:45 a.m., revealed the DOM was not aware if this required testing was being performed by the fire alarm contractor.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.

7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on observation and interview, the facility failed to ensure emergency stairwell exits were maintained according to NFPA standards.

The findings include:

During the Life Safety Code tour on November 24, 2010, at 11:15 a.m., with the Director of Maintenance (DOM), a bed frame was observed to be stored in the emergency exit stairwell of the facility. These areas must remain free of storage. An interview with the DOM on November 24, 2010, at 11:15 a.m., revealed the Fire Marshal's Office had previously given the facility permission to use the stairwells for noncombustible storage. The DOM stated two other stairwells contained this type of storage.

Reference: NFPA 101 (2000 Edition).

19.2.2.3 Stairs.
Stairs complying with 7.2.2 shall be permitted.

7.2.2.1 General.
Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of this subsection.

7.1.3.2.3*
An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

A.7.1.3.2.3
This provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be "sterile" with respect to fire safety hazards.

7.2.2.5.3* Usable Space.
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on an interview, the facility failed to ensure emergency generators were maintained according to NFPA standards.

The findings include:

During the Life Safety Code survey on November 24, 2010, at 11:00 a.m., an interview with the Director of Maintenance (DOM) revealed the facility had two generators but there were no annunciator panels for the generators at a supervised location as required. A generator annunciator panel warns of potential problems associated with the emergency generator and must be located at a supervised location. An interview with the DOM on November 24, 2010, at 11:00 a.m., revealed the DOM was not aware the generators were required to have an annunciator panel or that the panel(s) was required to be located at a supervised location.

Reference: NFPA 99 (1999 Edition).

3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
a. Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
b. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Based on observation and interview, the facility failed to ensure that the building fire alarm system functioned as required by NFPA standards.

The findings include:

During the Life Safety Code survey on November 24, 2010, at 10:25 a.m., with the Director of Maintenance (DOM), a test of the fire alarm automatic dialer panel revealed when the panel was placed in trouble from phone line failure the unit did not send a trouble signal to a continuously occupied location within the facility. The main fire alarm control panel showed that all systems were normal. While the dialer panel did emit an audible trouble signal, this signal was not in an area where it was likely to be heard. The monitoring station did receive this signal but did not contact the facility of this phone line failure as required. An interview with the DOM on November 24, 2010, at 10:40 a.m., revealed the DOM was not aware the phone line trouble signal should be in an area where it is likely to be heard. The DOM was not aware the monitoring station should be contacting the facility of this trouble signal in a timely manner.

Reference: NFPA 72 (1999 Edition).

1-5.4.4 Distinctive Signals.
Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

1-5.4.6 Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber

A-5-2.6.1.4(1)
The term immediately in this context is intended to mean "without unreasonable delay." Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.

5-5.3.2.1.6.2
The following requirements shall apply to all combinations in 5-5.3.2.1.6.1:
(1) Both channels shall be supervised in a manner approved for the means of transmission employed.
(3) The failure of either channel shall send a trouble signal on the other channel within 4 minutes.
(8) Failure of telephone lines (numbers) or cellular service shall be annunciated locally.

3-8.1* Fire Alarm Control Units.
Fire alarm systems shall be permitted to be either integrated systems combining all detection, notification, and auxiliary functions in a single system or a combination of component subsystems. Fire alarm system components shall be permitted to share control equipment or shall be able to operate as standalone subsystems, but, in any case, they shall be arranged to function as a single system. All component subsystems shall be capable of simultaneous, full load operation without degradation of the required, overall system performance.

Based on interview and record review, the facility failed to maintain the fire alarm system by NFPA standards.

The findings include:

During the Life Safety Code tour on November 24, 2010, at 11:45 a.m., a record review with the Director of Maintenance (DOM) revealed there were no reports made available regarding the sensitivity testing of the smoke/heat detectors. A sensitivity report entails the testing of components associated with the fire alarm system, e.g., smoke detectors and heat detectors to ensure proper operation. An interview on November 24, 2010, at 11:45 a.m., revealed the DOM was not aware if this required testing was being performed by the fire alarm contractor.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.

7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on observation and interview, the facility failed to ensure emergency stairwell exits were maintained according to NFPA standards.

The findings include:

During the Life Safety Code tour on November 24, 2010, at 11:15 a.m., with the Director of Maintenance (DOM), a bed frame was observed to be stored in the emergency exit stairwell of the facility. These areas must remain free of storage. An interview with the DOM on November 24, 2010, at 11:15 a.m., revealed the Fire Marshal's Office had previously given the facility permission to use the stairwells for noncombustible storage. The DOM stated two other stairwells contained this type of storage.

Reference: NFPA 101 (2000 Edition).

19.2.2.3 Stairs.
Stairs complying with 7.2.2 shall be permitted.

7.2.2.1 General.
Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of this subsection.

7.1.3.2.3*
An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

A.7.1.3.2.3
This provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be "sterile" with respect to fire safety hazards.

7.2.2.5.3* Usable Space.
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on an interview, the facility failed to ensure emergency generators were maintained according to NFPA standards.

The findings include:

During the Life Safety Code survey on November 24, 2010, at 11:00 a.m., an interview with the Director of Maintenance (DOM) revealed the facility had two generators but there were no annunciator panels for the generators at a supervised location as required. A generator annunciator panel warns of potential problems associated with the emergency generator and must be located at a supervised location. An interview with the DOM on November 24, 2010, at 11:00 a.m., revealed the DOM was not aware the generators were required to have an annunciator panel or that the panel(s) was required to be located at a supervised location.

Reference: NFPA 99 (1999 Edition).

3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
a. Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
b. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]