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The facility failed to provide a building construction type per code. Findings include:

During the survey, the following are examples of what was observed:
The two hour seperation between the Type I (443) structure is not provided on the first floor
1. The Annex Corridor going to the single story building has type II (000) construction
2. The corridor in front of the elevator for the "two story building" has a type II (111) construction on all three floors

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2.

Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain the O.R.s per code. Findings include:

During the survey, the following is an example of what was observed:

The two Second Floor O.R.s could not be verified if they had a smoke venting system or not, the facility staff did not know.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "