Mountain Lakes Medical Center

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 50618 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.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 50618 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”

“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: 50618 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”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 50618 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”

“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: 50618 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”

“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: 50618 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”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 50618 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)”