Danville State Hospital

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors within this component. Findings include: 1. Observation on August 18, 2026, between 10:00 am, and 11:45 am, revealed this component exceeded the maximum allowable story height for this type of construction. Exit interview with the Facility CEO, the Facility Executive Director, and the Facilities Manager, on August 18, 2026, at 12:00 pm, confirmed this component exceeded the maximum allowable story height for this type of construction.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined that the facility failed to maintain emergency lighting in one location, affecting one of two floors. Findings include: 1. Observation on August 18, 2026, at 10:10 am, 1st floor, revealed the emergency lights on the exit sign, inside the exit enclosure behind door 1100B, failed to illuminate when tested. Exit interview with the Facility CEO, the Facility Executive Director, and the Facilities Manager, on August 18, 2026, at 12:00 pm, confirmed this the emergency lights failed to illuminate when tested.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of three floors. Findings include: 1. Observation on August 18, 2026, at 11:11 a.m., revealed the undercut of the 212, (Room 21-C) Housekeeping Closet, exceeded one inch. Exit interview with the Facility CEO, the Facility Executive Director, and the Facilities Manager, on August 18, 2026, at 12:00 pm, confirmed the hazardous area enclosure deficiency.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting one of three floors. Findings include: 1. Observation on August 18, 2026, between 9:57 a.m., and 10:02 a.m., revealed the following: a. 9:57 a.m., the first floor, 211 Medication Room door required adjustment to fully close and latch. b. 10:02 a.m., the 211 Day Room door required adjustment to fully latch. Exit interview with the Facility CEO, the Facility Executive Director, and the Facilities Manager, on August 18, 2026, at 12:00 pm, confirmed the corridor opening deficiencies.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls in one location, affecting one of four floors. Findings include: 1. Observation on August 18, 2026, at 10:21 am, Unit 310, revealed two penetrations of the smoke barrier wall, one unsealed penetration around two blue data wires and a yellow data wire. A second unsealed penetration next to the first, above smoke doors 1200A on the 1st floor. Exit interview with the Facility CEO, the Facility Executive Director, and the Facilities Manager, on August 18, 2026, at 12:00 pm, confirmed this the unsealed penetrations.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of four floors. Findings include: 1. Observation on December 14, 2023, at 11:40 a.m., revealed the Unit 311, Visiting Room door required adjustment to fully latch within the door frame assembly. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the common wall door deficiency.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors within this component. Findings include: 1. Observation on December 14, 2023, between 11:30 a.m., and 1:15 p.m., revealed this component exceeded the maximum allowable story height for this type of construction. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed this component exceeded the maximum allowable story height for this type of construction.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one stair tower enclosure, affecting three of three floors. Findings include: 1. Observation on December 14, 2023, at 12:44 p.m., revealed the Unit 214, door 2055, stair tower enclosure door was not fire-tight. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the stair tower deficiency.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain exit signage in one location, affecting one of four floors. Findings include: 1. Observation on December 14, 2023, at 9:14 a.m., revealed exit signage had been removed from the second floor, Unit 214 construction area. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the exit signage deficiency.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain vertical openings in three locations, affecting three of three floors. Findings include: 1. Observation on December 14, 2023, between 10:23 a.m., and 10:42 a.m., revealed the following: a. 10:23 a.m., a penetration of the floor slab assembly, located within the third floor room, closest to stair tower door 3072. b. 10:40 a.m., at the floor slab assembly, located within the Unit 209 Shower Room. c. 10:42 a.m., an unprotected, three story, vertical opening, located within the Unit 209 Shower Room. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the vertical opening deficiencies.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of four floors. Findings include: 1. Observation on December 14, 2023, at 9:02 a.m., revealed the Unit 211, Room 1100F, Janitor’s Closet door lacked a self-closing device. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the hazardous area enclosure deficiency.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to install automatic sprinkler protection in one location, affecting one of four floors. Findings include: 1. Observation on December 14, 2023, at 8:37 a.m., revealed the Unit 211, electrical closet, lacked automatic sprinkler protection. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed automatic sprinkler protection deficiency.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in two locations, affecting two of four floors. Findings include: 1. Observation on December 14, 2023, between 9:31 a.m., and 10:10 a.m., revealed penetrations of the smoke barrier separation walls in the following locations: a. 9:31 a.m., within the second floor, Unit 213, above the 2016 door. b. 10:10 a.m., above third floor, smoke barrier door 3300. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation wall deficiencies.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting one of four floors. Findings include: 1. Observation on December 14, 2023, at 9:22 a.m., revealed the 2200A, smoke barrier separation door, was lacking a portion of the self-closing assembly. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation door deficiency.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain the heating, ventilation, and air conditioning system in one location, affecting two of four floors. Findings include: 1. Observation on December 14, 2023, at 8:45 a.m., revealed a fresh air duct penetration of the floor slab assembly, located within the first floor, Unit 211, Room 1100C, lacked retaining angles and a fire damper. Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the HVAC deficiency.”