Gothenburg Health

“42 CFR 482.41 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, “Existing Health Care Occupancies” of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Gothenburg Memorial Hospital is a Type II (000) facility that was built in 2003 and 2015. The facility is 1 story, fully fire sprinkler protected, and has smoke detection in the corridors and areas open to the corridors. The facility is attached to a clinic and YMCA activities center that are separated by a 2-hour fire rated barrier. The facility is comprised of 4 smoke compartments (Patient Wing, Emergency/Surgery, Mechanical/Imaging, and Administration). Gothenburg Memorial Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41 Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“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: 38544 Based on record review and interview, the facility failed to maintain emergency lighting appliances by not providing documentation of the monthly and annual inspection and testing of the devices. This deficient practice did not ensure emergency lighting was functional in 1 of 4 smoke compartments (Surgery) and would affect all occupants within the affected smoke compartment. Findings are: Record review on 6-4-2026 at 10:42 AM revealed the following: 1) Facility failed to provide documentation of the inspection and testing of the emergency lighting in the Operating Room. During an interview on 6-4-2026 at 10:42 AM, Maintenance Staff confirmed the finding.”

“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: 38544 Based on observation and interview, the facility failed to separate hazardous areas from the remainder of the building by allowing unsealed penetrations in the walls and ceilings. This deficient practice could cause smoke and hot gases to migrate into the corridor affecting all occupants in 2 of 4 smoke compartments (Emergency/Surgery, and Mechanical/Imaging). Findings are: Observations on 6-4-2026 between 11:03 AM and 11:08 AM revealed the following: 1) The sprinkler riser room had an unsealed conduit penetration in the north wall. 2) Radiology electrical room had an unsealed conduit penetration in the north wall. During interviews on 6-4-2026 between 11:03 AM and 11:08 AM, Maintenance Staff confirmed the findings.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 38544 Based on record review and staff interview, the facility failed to conduct fire drills or emergency orientation training quarterly on each shift at varied times under varying conditions and staffing levels. This deficient practice would not provide simulated training for staff response in the event of a fire. This deficient practice affected all occupants throughout the facility. Findings are: Record review on 6-4-2026 at 10:35 AM revealed the following: 1) Facility conducted 5 of 5 drills on 1st shift at 3:00 PM, 1:00 PM, 1:00 PM, 2:15 PM, and 11:15 AM. 2) Facility conducted 4 of 4 drills on second shift at 8:09 PM, 8:00 PM, 8:10 PM, and 7:58 PM. 3) Facility failed to conduct a documented drill for the 4th quarter (October - December) 2025 on 2nd shift. During an interview on 6-4-2026 at 10:35 AM, Maintenance Staff confirmed the findings.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 38544 Based on record review and interview, the facility failed to maintain the building construction and fire/smoke rated assembly construction by not documenting maintenance, inspection, and testing of fire door assemblies throughout the facility. This deficient practice does not ensure the required fire/smoke rated assemblies are maintained, which could cause smoke, hot gases, and fire to migrate through the facility. The deficient practice would affect all occupants in 4 of 4 smoke compartments. Findings are: Record review on 6-4-2026 at 10:45 AM revealed the following: Facility failed to provide documentation of the maintenance, inspection, and testing of fire door assemblies throughout the facility. During an interview on 6-4-2026 at 10:45 AM, Maintenance Staff confirmed the finding.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 38544 Based on record review and interview, the facility failed to maintain the facility electrical system by not conducting documented electrical receptacle inspection and testing for hospital grade electrical receptacles. This deficient practice does not ensure the electrical receptacles are wired correctly and free of any damages or defects which may cause fire or operational failure. The deficient practice would affect all occupants in 4 of 4 smoke compartments Findings are: Record review on 6-4-2026 at 10:38 AM revealed the following: Facility failed to provide documentation of the inspection and testing of hospital grade electrical receptacles throughout the facility. During an interview on 6-4-2026 at 10:38 AM, Maintenance Staff confirmed the finding.”