HospitalInspections.org

Based on review of Mountain Lakes Medical Center Emergency Preparedness Program and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Hospital 42 CFR 482.15.


The findings include:
During a review of the facilities Emergency Preparedness Program on 07/29/2025 between 10:00 am and 2:00 pm it was noted that there was no documentation available that the Emergency Preparedness plan has not been updated annually.
These findings were confirmed by Staff M at the time of discovery.

Based on observation and staff interviews it was determined the facility failed to provide compliant exit separation.
This affects 1 of 6 smoke compartments.
The findings include:
During a tour of the facility with Staff M on 07/29/2025 between 10:00 am and 2:00 pm observation revealed that the door separating the exit stairwell enclosure on the second floor north stairwell exit does not meet the minimum required fire rating.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, Chapter 19, Section 19.2.2.2.1, 7.2.2.5.1.1, 7.1.2.3.1

Based on observation and staff interviews it was determined the facility failed to provide adequate markings of means of egress.
This affects 3 of 6 smoke compartments.
The findings include:
During a tour of the facility with Staff M on 07/29/2025 between 10:00 am and 2:00 pm observation revealed that 1. Exit signs are missing from the corridor on the third floor north corridor. 2. "No Exit" sign absent to identify door leading from corridor to outdoor patio on the second floor. 3. Exit sign improperly placed over a non exit on the first floor outside of medical room by front entrance.
These findings were confirmed by Staff M at the time of discovery.
Reference: 1. 2012 NFPA 101, 19.2.10.1, 7.10.1.2, 7.10.3, 7.10.8.3.1
2. 2012 NFPA 101, Chapter 19, Section 19.2.10.1 and Chapter 7, Section 7.10.8.3.1
3. 2012 NFPA 101, Chapter 19, Section 19.2.10.1 and Chapter 7, Section 7.10.8.3.1

Based on observation and staff interviews it was determined the facility failed to maintain sprinkler system requirements.
This affects 5 of 5 smoke compartments.
The findings include:
During a tour of the facility with Staff M on 07/29/2025 between 10:00 am and 2:00 pm observation revealed that the total spare sprinkler head(s) count was inadequate for the required stored amount.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, 19.3.5.1, 9.7.1.1, 2010 NFPA 13, 6.2.9.5

Based on observation and staff interviews it was determined the facility failed to maintain doors.
This affects 1 of 6 smoke compartments.
The findings include:
During a tour of the facility with Staff M on 07/29/2025 between 10:00 am and 2:00 pm observation revealed that gaps and a breach of the seal were observed within the door assembly for room 105 and room 107 within the emergency room.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, Chapter 19, Section 19.3.6.3.1 and CMS S&C-07-18

Based on observation and staff interviews it was determined the facility failed to maintain the continuity of compartment separation requirements.
This affects 1 of 6 smoke compartments.
The findings include:
During a tour of the facility with Staff M on 07/29/2025 between 10:00 am and 2:00 pm observation revealed that penetration were observed in rated wall assemblies to the first floor corridor and emergency room wall separation.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1

Based on observation and staff interviews it was determined the facility failed to maintain electrical components.
This affects 1 of 6 smoke compartments
The findings include:
During a tour of the facility with Staff M on 07/29/2025 between 10:00 am and 2:00 pm observation revealed that relocatable power taps were unsecured and located upon the floor subject to damage within the south office space on the first floor and shell space upon the second floor.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, 19.5.1.1, 9.1.2 and 2011 NFPA 70, 380.12 (2)