Kaiser Foundation Hospital Manteca

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 48963 Based on observation, record review and interview, the facility failed to maintain the interior wall and ceiling finishes. This was evidenced by open walls, ceiling and unfinished flooring. This affected the main Hospital (Intensive Care Unit and Medical Surge on the first floor), and could result in the spread of fire and smoke in the event of a fire. Findings: During a tour of the facility, document review and interview with staff on 6/2/26, the walls, ceilings and floors were observed, and records were requested and reviewed. At 1:02 p.m., the first floor tower in the main Hospital was observed with white tarps blocking off the Intensive Care Unit (ICU) and Medical Surgery (Med Surge). In ICU Room #1920, three of four walls were observed to be open with exposed insulation and piping. The ceiling was open, exposing tubes, piping and the floors were stripped. During record review, the document titled, “Situation Summary for Room #1920 ICU” indicated “16:35 Sprinklers activated.” Upon interview, Staff 1 stated that the sprinkler in Room 1920 was activated on 5/31/26 and caused damage to the walls and ceiling of the ICU, and mainly Room 1920. Staff 1 further stated that out of caution, all the first floor was closed off due to water damage and residual smoke in the ICU and Med Surge.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 48963 Based on observation, record review and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by trouble signals on the fire alarm control panel (FACP). This affected the main Hospital and could result in the delay of notification in the event of a fire. Findings: During a tour of the facility, document review and interview with staff on 6/2/26, the FACP was observed. At 2:45 p.m., the FACP located on the first floor in the Control Room #954 was observed with several trouble signals. The FACP had three amber lights on (supervisory, trouble, and partial system disabled). During record review, the facility provided a panel report that indicated 51 trouble signals on the first floor, two on the second floor and two on the third floor. The first floor has an intensive care unit (ICU), Medical Surgery (Med Surge), Post-Anesthesia Care Unit (PACU), offices, Emergency Department, and Pharmacy. The second floor has offices, and the third floor has Med Surge. The fire alarm panel generated a report that showed trouble signals on first floor for the following locations: “patient rooms 1900 Smoke detector (SD), patient room 1901 SD, patient room 1902 SD, patient room 1903 SD, patient room 1904 SD, patient room 1905 SD, patient room 1906 SD, med 1 clean utility SD , med surg 1 SD, tower pantry SD , clean utility room 1515 SD, med surg center SD, tower clean room 1530 SD, tower tub room 1531 SD, med surg 3 SD, break room 1536 SD, break rest room 1538 SD, tower EVS closet 1539 SD, med surg 1 SD, ICU corridor SD, patient room 1921 SD, patient room 1922 SD, patient room 1923 SD, patient room 1924 SD, boiler room 930 SD, patient room 1943 SD, tower clinical tech room 1315 SD, patient room 1944 SD, patient room 1945 SD, med surg 3 corridor SD, elevator lobby SD, tower sprinkler riser SD, med surg center 1610 SD, patient room 1925 SD, patient room 1940 SD, patient restroom 1941 heat detector, patient room 1941 SD, patient room 1942 SD, ICU nurse vestibule SD, med surg 3 corridor SD, ICU corridor SD, med surg 1 corridor SD, med surg 3 SD, med surg 1 SD, radiology sprinkler riser SD, operating room sprinkler riser 801, radiology sprinkler 51.” On the same report, the fire alarm panel showed trouble signals on the second floor and third floor for “waterflow and tamper switch.” The last FAS annual report was dated 7/18/25 and passed. Upon interview, Staff 1 stated that the trouble signals on the first floor were due to the system being disabled while construction was being done to repair water and smoke damage to walls, ceilings and floors. Staff 1 further stated that the supervisory signals on the second and third floors were due to vendors being on site to do fire sprinkler tie-ins.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 48963 Based on record review and interview, the facility failed to maintain the electrical equipment. This was evidenced by missing information on preventative maintenance records. This could result in a malfunction equipment and affected the main Hospital. Findings: During record review and interview with staff, the patient related electrical equipment maintenance records were requested and reviewed. On 6/2/26 at 2 p.m., the facility provided the annual maintenance record for a Hamilton-G5 ventilator (equipment # CWKD4540639) titled, “Clinical Work Order Details” dated 11/20/25 that was missing test/ inspection information. The annual preventative maintenance indicated “Replaced battery, installed pm kit, completed pm and calibrations, tested, passed, released for clinical use.” On 6/23/26 at 12:17 p.m., the manufacturer maintenance requirements titled, “Test Mode Units Include” provided by the facility has a total of 23 requirements. The facility did not include Test mode unit calibrations for “6. zero & full-scale calibration, 7. O2 sensor or paramagnetic oxygen sensor Calibration and Checks, 8. Mixer calibration & Checks, 13. Exp. Valve Calibration, 21. Checks and Touchscreen Calibration.” The type of calibrations done by the facility could not be confirmed based on facility’s documentation. Also included in tested mode unit were “22. Event log and Technical Status, 23. Update Software” which could not be confirmed was completed based on facility’s documentation. On 6/23/26 at 4:57 p.m., upon interview, Staff 4 stated that they believe Biomed staff who perform the preventative maintenance on the ventilators do not record all items that are tested. Staff 4 stated that if any test fail, the equipment will be given a failed report.”