Heritage Green Nursing Home

Based on observation, record review and staff and resident interview, the facility did not ensure that menus met the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board during one of one meal observed during food preparation. The issue involved the addition of fillers (bread) to pureed meat and pureed vegetables diluting the flavor and altering the texture of the food items. The protein content of the meat served (breaded pork cutlet) did not meet the planned amount of protein for the meal for all diets receiving the item, and residents on puree diets did not receive adequate vegetable portions. Residents #239 and 249 were involved. This was a pattern of no actual harm with potential for minimal harm that is not immediate jeopardy.

The finding is:

1. Review of the Week 2 cycle menu dated 1/30/12 revealed the Thursday lunch meal consisted of Honey Dijon Pork Cutlet, whip potato, and Capri vegetables (cauliflower, broccoli, carrot medley). Meal preparation for the puree diets was observed on 2/2/12 at 10:00 AM. The cook was observed combining 24 pork cutlets, 12 pieces of wheat bread and an unmeasured amount of water to produce 24 puree meat portions. The cook was then observed making the puree vegetables by combining Capri vegetables, wheat bread and water then blending until pureed.

A test tray was completed on 2/2/12 at approximately 12:45 PM for palatability and texture. The meat product had an undistinguishable taste (questionably meat or potato) and the pureed vegetable could not be specifically identified as what vegetable it was.

Resident #239 has diagnoses which include hypertension, osteoarthritis, and failure to thrive. Interview with the Dietary Clerk on 2/12/12 at approximately 11:15 AM revealed the resident receives a puree diet and interviewable. Interview with the resident on 2/12/12 at 12:55 PM revealed "I don't know what I'm eating, but I don't like it".

Resident #249 has diagnoses which include cerebral vascular accident (CVA - stroke), ocular nerve palsy, and depression. Interview with the Dietary Clerk on 2/12/12 at approximately 11:15 AM revealed the resident receives a puree diet and is interviewable. The resident was observed during the lunch meal on 2/2/12 being fed a spoonful of the meat product by a certified nurse aide (CNA). Interview with the resident on 2/2/12 at approximately 12:58 PM revealed "It taste like potato. I don't like it".

Review of the posted Kitchen recipe revised 5/25/11 revealed a serving size for pureed meat with 1/2 slice of bread blended in when the meat is already breaded is a #10 scoop or 3.2 ounces (oz). The vegetable portion with a 1/2 slice of bread blended in, use a #8 scoop which is 4 ounces.

Review of the Week Thursday Extension Sheet-3 revealed residents on pureed diets received #10 scoops (3.2 ounces) of breaded pork cutlet and wheat bread mixture, and 4 ounces of puree vegetable with wheat bread mixture. Residents on Regular diets received 1 breaded pork cutlet and 4 ounces of vegetable.

Interview with the Registered Dietitian (RD) on 2/2/12 at 3:00 PM revealed the meal plan exchange for protein utilized at the facility is 2 oz of protein at breakfast, 2 oz at lunch, and 2 oz of protein at dinner. The vegetable serving is 4 oz at lunch and 4 oz at dinner.

Review of the Nutrition Facts from the box of Breaded Pork Patties revealed 1 patty equaled 3 oz and contained 10 grams of protein or 1.4 ounces of protein. The breaded pork patty did not meet the facility meal plan exchange of 2 oz of protein. Based on the recipe used to puree the breaded pork chops, residents on puree diets received less protein than residents on regular diets as the pureed breaded pork patties had additional bread and water blended in with it.

Interview with the RD on 2/2/12 at 3:00 PM revealed she didn't know the breaded pork cutlets ordered by the Food Service Director did not have the right amount of protein in them.

The meal preparation observation on 2/2/12 at 10:00 AM also revealed that residents on a pureed diet received the same portion size of vegetable as the regular diet even though they had bread blended in with the vegetable.

Interview with the RD on 2/3/12 at 1:00 PM revealed a #6 scoop (5.3 oz) should have been used for the pureed vegetables. The RD stated the posted recipe for pureed diets that the cook followed on 2/2/12 was incorrect.

415.14(c)(1)(d)(1)(2)

Based on record review and staff interview, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. One (Resident #118) of 16 residents reviewed for care plans did not have a Comprehensive Care Plan (CCP) developed for Hydration Risk. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #118 has diagnoses of congestive heart failure and recurrent Clostridium difficile (C-diff bacterial infection in the stool). Review of the Minimum Data Set (MDS) dated 1/25/12 revealed the resident is cognitively intact, usually understands, and is understood.

Review of a nursing Interdisciplinary note dated 7/1/11 revealed the resident was admitted to the hospital with dehydration. An Admission H&P (History and Physical) documented in the Interdisciplinary Notes dated 8/11/11 documented the resident was readmitted to the facility on 7/19/11.

Review of the Care Plan, last updated on 1/30/12, revealed there were no interventions or identification of the resident's risk for dehydration.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 2/2/12 at 12:21 PM revealed the last quarterly review of the care plan was on 1/25/12 and he thought the resident had a care plan for Hydration. The RN UM had no explanation why it was omitted.

415.11(c)(1)

Based on staff interviews and record review the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. One (Residents #118) of two residents reviewed for hydration had issues with lack of ongoing monitoring of a resident's suboptimal fluid intake, lack of Nurse Practitioner notification of fluid consumption less than 1000 cubic centimeters (cc) per hour in accordance with a physician's order, and lack of evaluating an order for 80 milligrams (mg) Lasix daily while administering 75 cc fluid via IV (intravenous). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #118 has diagnoses of congestive heart failure and recurrent Clostridium difficile (C-diff bacterial infection in the stool). Review of the Minimum Data Set (MDS) dated 6/7/11 revealed the resident is cognitively intact, usually understands and is understood.

Review of a Hospital Discharge Summary dated 5/31/11 revealed the resident was discharged with diagnoses of C-diff colitis and compensated congestive heart failure and is on Lasix (diuretic medication used to promote the excretion of urine) 40 milligram (mg) daily.

Review of Admission Physician orders dated 5/31/11 revealed an order for Lasix 40 mg daily.

Review of the Comprehensive Care Plan (CCP) dated 6/1/11 revealed the resident was identified at risk for impaired hydration related to diuretic use, loose stool, elevated blood urea nitrogen (BUN - blood test to determine kidney function and hydration status) and meal intakes of less than 75 percent (%). Planned interventions include keeping the resident free from signs and symptoms of dehydration, providing medications as ordered, providing fluids per the dietary care plan and monitoring the resident's labs (laboratory results).

Review of an Admission Dietary Interdisciplinary Note dated 6/1/11 noted the resident's C-diff and chronic obstructive pulmonary disease (COPD) and documented that the resident had loose stools and edema upon admission. Review of hospital laboratory reports noted in the 6/1/11 Dietary note revealed the resident had a BUN of 34 (normal 7 to 27 mg/dl) and a creatinine (blood test to determine kidney function) level of 1.4 (normal .6 to 1.1 mg/dl). The Dietary note documented that the resident weighed 172 pounds, had a BMI (basal metabolic index - relationship between weight and height that is associated with body fat and health risk) of 29 and an estimated daily fluid need of 2340 cubic centimeter (cc) fluid.

Review of a Physician Interdisciplinary Note dated 6/13/11 revealed the resident was seen by the physician on 6/6/11, and on 6/6/11 the physician increased the Lasix to 40 mg twice a day for increased lower extremity edema with plans to obtain blood tests including a complete blood count (CBC), basic metabolic profile (BMP - blood test including basic chemistry studies of the blood).

Review of a Nurse Practitioner (NP) order dated 6/13/11 revealed an order to notify the NP if the resident consumes less than 1000 cc fluid intake in 24 hours via the fluid report in the communication book.

Review of a Registered Dietitian (RD) Note dated 6/16/11 revealed the resident is alert and able to make needs known. There was no evaluation of the resident's fluid intake.

Review of the Resident I/O (intake and output) documented in the Day Chart (computerized report that tabulates the resident's daily fluid consumption) revealed the resident's total daily fluid intake ranged from 420 cc to 1530 cc, with an average daily intake of 844 cc from 6/6/11 to 6/27/11. After 6/13/11, the resident's intake was below 1000 cc from 6/16/11 to 6/21/11, 6/24/11 and 6/27/11. Review of Interdisciplinary Nurses' Notes from 6/13/11 to 6/27/11 revealed no notification to the NP/MD regarding the decreased fluid intake.

Review of the CCP dated 6/1/11 revealed there were no changes to the hydration care plan after 6/1/11 to indicate the diuretic therapy was increased, to notify NP/MD if fluids were less than 1000 cc, nor indication that the resident was consuming less than 1000 cc at times.

Review of the Medication Administration Record (MAR) dated 6/11 revealed the resident received Lasix 40 mg twice a day from 6/6/11 to 6/30/11.

Review of a Dietary Interdisciplinary Note dated 6/28/11 at 11:45 AM revealed the resident lost 20 pounds. The Dietary note noted that the resident was on diuretic therapy and has loose stools from C-diff. The note indicates the dietician, nurse and nurse practitioner held a meeting and planned for weekly weights and a caloric intake review and suggests 60 cc of two cal HN twice a day. The resident's fluid needs were re-calculated at 2040 cc fluid. There was no documented evidence that the resident's daily fluid intake was not met from 6/13/11 to 6/28/11.

Review of a Physician Order, written by the NP, dated 6/29/11 at 12:35 PM revealed an order for IV (intravenous) Normal Saline at 75 cc/hr continuous. The Lasix order was not discontinued on this date.

Interview with the Physician on 2/3/12 at approximately 12:30 PM revealed when he placed the resident on 80 mg of Lasix per day, he was monitoring the resident with labs and weekly weights. The Physician stated on 6/28/11 the resident had blood work results which were consistent with C-diff colitis. The Physician stated he called the gastroenterologist on 6/29/11, informed him of the resident's clinical condition and discussed transfer to the hospital. The Physician stated, in retrospect he should have held (not given) the resident's Lasix on 6/29/11. The Physician stated the resident was very ill and initially refused to go to the hospital so they started an IV in the nursing home.

Interview with the RN UM on 2/3/12 at 10:39 AM revealed the resident was admitted to the facility with C diff and loose stools. The RN UM stated the facility practice is to monitor a resident for hydration, care plans are put in place by dietary staff. The RN UM explained that the certified nurse aides (CNAs) notify nursing staff if a resident has low urine output, and staff look for changes in mentation. The RN UM stated that nursing staff review all residents' 24 hour fluid intake daily and for residents with an intake under 1000 cc, the RN will talk to the resident and assess them for signs of dehydration. If the nurses find any issues, the NP is immediately notified. The RN UM could not recall that Resident #118 consumed less than 1000 cc a day until right before the resident was transferred to the hospital on 7/1/11.

Interview with the NP on 2/3/11 at approximately 10:00 AM revealed Resident #118's fluid status was very important because of her C-diff colitis. The NP stated that the nurses are supposed to inform her when a resident's fluid intake is low, "less than 1000 cc". The NP stated nursing staff never informed her that the resident consumed less than 1000 cc per day.

Interview with the Registered Dietitian on 2/3/12 at 3:15 PM revealed she could not recall noting the resident's low daily fluid intake of less than 1000 cc and they were not documented on her 6/28/11 assessment because "it was an oversight; she should have". The RD stated it is the responsibility of both Dietary and Nursing staff to monitor the resident's daily fluid status. The RD stated she would have reviewed and updated a resident's care plan if they were on a diuretic and consumed less than 1000 cc of fluid daily.

Interview with the Director of Nursing (DON) on 2/3/2012 at 12:00 PM revealed the facility has no formal policy for dehydration.

415.12(j)

Based on observation, record review and staff and resident interview, the facility did not ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. One (Resident #125) of three residents reviewed for pressure sores had issues involving lack of a pressure relief cushion and air mattress for a resident as planned. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #125 has diagnoses of paraplegia (paralysis of lower extremities) following spinal cord injury and a Stage 4 pressure sore of the buttock. Review of the Minimum Data Set (MDS) dated 11/25/11 revealed the resident has intact cognitive abilities, understands and is understood. The MDS documented that the resident has a Stage 4 pressure sore and skin/ulcer treatments include the use of pressure relieving devices for the chair and bed; a turn and positioning (T&P) program; and the application of nonsurgical dressings.

Review of the Care Plan for Pressure Ulcers (sores) / Skin Problems dated 11/18/11 revealed the resident has a Stage 4 pressure ulcer on the left ischium (lower and back part of the hip bone) and the sacrum (area above the tail bone on right and left buttocks) related to paraplegia with approaches for an air mattress on the bed and a trapeze to assist with positioning. The care plan documented that the resident preferred not to be turned and positioned during the night unless she rings for assistance.

Observation on 2/2/12 at 1:04 PM revealed two certified nurse aides (CNAs) provided personal care to the resident in bed and informed the surveyor when they were done they were transferring the resident to a Geri chair. There was no air mattress on the bed, the air mattress was sitting on the floor in the corner of the room. Observation on 2/2/12 at 3:30 PM revealed the resident was sitting in the Geri chair without a pressure relieving device in place.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 2/2/12 at approximately 4:00 PM revealed she thought the resident was using an air mattress on the bed.

During an interview on 2/2/12 at 3:30 PM, the resident stated she was uncomfortable in the bed and chair and did not like sitting in the Geri chair without a pressure relieving device. The resident added that the air mattress she brought to the facility when returning from the hospital was uncomfortable.

When interviewed on 2/2/12 at 5:10 PM, the RN UM stated she believed the pressure relieving cushion was issued for the resident's wheelchair and stated she knows the resident prefers to sit in the Geri chair.

Interview with the Director of Rehabilitation on 2/3/12 at approximately 9:00 AM revealed the department issued a gel cushion for Resident #125's wheelchair. During the same interview, it was learned that the resident requests to sit in a geri chair which the Rehabilitation staff has not recommended and added since her pressure ulcers are healing he is not concerned clinically about the lack of a pressure relieving cushion when the resident sits in a Geri chair.

415.12(c)(2)

Based on record review, resident and staff interviews it was determined that the facility did not provide an ongoing program of activities to enhance the well being of each resident. Three (Residents A, C, D) of 20 residents interviewed regarding activities had an issue with the lack of structured activity programs in the evening. This was a pattern of no actual harm with potential for minimal harm.

The findings are:

1. During resident interviews on 1/31/12 and 2/1/12, 4 of 20 residents stated that there was a lack of activities in the facility in the evening. When asked "Are there activities available in the evenings?", the residents responded as follows:

- On 1/31/12 at 1:39 PM, Resident A answered "No, not too much, they have movies".
- On 1/31/12 at 10:54 AM, Resident C answered "No, not that I know of".
- On 2/1/12 at 9:50 AM, Resident D answered "No, not very often and I would like more".

Review of the activity calendar for 9/11 through 2/12 two or less evening activities were scheduled during four of the six months.

Interview with the Activity Director on 2/2/12 at 1:50 PM revealed they used to have 2 to 3 activities in the evening but not many residents would come. The movies are available a couple of times a month in the evening, if the residents want something to do. If the resident is interested in watching the movie, they have to go to maintenance, let them know they want to watch a movie, and maintenance will open the room and set the movie up for the resident. The Activity Director stated she did not have an attendance record indicating how many residents were attending the movies but would check with maintenance. Review of an attendance document provided by the Activity Director on 2/3/12 at 8:50 AM, per the maintenance department, revealed no one attended the movies scheduled for 9/7/11, 9/14/11, 9/21/11, 10/13/11, 10/27/11, or 11/16/11.

During an interview on 2/2/12 at 1:30 PM, Resident A stated "if they had bingo or yahtzee at night I would go. The residents have complained there is not much to do in the evening. A lot of residents do like bingo".

Interview with Resident D on 2/3/12 at 4:55 PM revealed "I like music and bingo and I would go to that in the evening. I don't really like movies so I don't go to them. I like to go to bed between 8:30 PM and 9:30 PM but I would stay up later if there was something I would like to go to. Activities has asked me what I like to do, but I don't remember them asking me about having more things to do in the evening. I think my friends (other residents) would go to activities in the evenings. I go to the resident council meetings, and I don't remember them asking about evening activities there".

Interview with the Activity Director on 2/3/12 at 8:50 AM stated she was "kind of aware" that residents were not going to the movie but was not aware they wanted more activities in the evening. The Activity Director stated they have not offered structured activities in the evening in over a year and stopped because of poor attendance.

415.5(f)(1)

Based on record review and staff interview, the facility did not inform each resident or the resident's representative during the resident's stay, of charges for services not covered under Medicare. Three (Residents #68, 173, 186) of three residents reviewed for notification of Medicare Non-Coverage and Liability did not receive Liability Notices when payment for skilled services ended and the resident remained in the facility. This was a pattern of no actual harm with potential for minimal harm.

The findings are:

1. Resident #68 has diagnoses which includes prostate cancer, severe anemia, and chronic atrial fibrillation (irregular heart rhythm). Review of the Minimum Data Set (MDS) dated 12/12/11 revealed the resident is cognitively intact

Review of a Notice of Medicare Provider Non-Coverage form dated 12/13/11 revealed Medicare coverage for skilled services would end on 12/15/11. Review of the medical record Profile Face Sheet on 2/2/11 revealed the resident remained in the facility after the Notice of Medicare Provider Non-Coverage was sent to the resident.

During an interview on 2/2/12 at approximately 10:15 AM, the Registered Nurse (RN) Clinical Reimbursement Case Manager, stated the Notice of Medicare Provider Non-Coverage form was provided to the resident's representative on 12/13/11, however the resident's representative was not provided with a Liability Notice which is included in the facility's Skilled Nursing Facility (SNF) Determination of Continued Stay form. The RN Clinical Reimbursement Case Manager said she thought that the facility was using the SNF Determination on Continued Stay form, but learned on 2/2/12 that the facility was not sending this form which explains liability for costs of services.

During an interview on 2/2/12 at approximately 10:15 AM, the Medical Records Secretary confirmed that the resident stayed in the facility until 2/2/12.

Interview with the RN Charge Nurse on 2/2/12 at approximately 11:00 AM revealed the resident was admitted to a hospital on 2/2/12.

2. Resident #173 has diagnoses which include hypertension, anxiety disorder, and iron-deficiency anemia. Review of the Minimum Data Set (MDS) dated 12/2/11 revealed the resident is cognitively intact.

Review of a Notice of Medicare Provider Non-Coverage form dated 11/29/11 revealed the resident's representative was notified that Medicare coverage for skilled services would end on 12/1/11. Review of the medical record Profile Face Sheet on 2/3/12 revealed the resident currently remains in the facility.

During an interview on 2/2/12 at approximately 10:15 AM, the Registered Nurse (RN) Clinical Reimbursement Case Manager stated the Notice of Medicare Provider Non-Coverage form was provided to the resident's representative on 11/29/11, but the resident's representative was not provided with a Liability Notice which is included on the facility's Skilled Nursing Facility (SNF) Determination on Continued Stay form.

3. Resident #186 has diagnoses which include renal failure, atrial fibrillation (irregular heart rhythm), and hypertension. Review of the Minimum Data Set (MDS) dated 11/28/11 revealed the resident has severe cognitive impairment.

Review of a Notice of Medicare Provider Non- Coverage form dated 12/21/11 revealed Medicare coverage for skilled services would end on 12/23/11. Interview with the Medical Records Secretary on 2/2/12 at approximately 10:15 AM, revealed the resident remained in the facility after the Medicare Provider Non-Coverage was sent, until 1/15/12, when the resident was discharged to another residential health care facility.

During an interview on 2/2/12 at approximately 10:15 AM, the Registered Nurse (RN) Clinical Reimbursement Case Manager, stated the Notice of Medicare Provider Non-Coverage form was provided to the resident's representative on 12/21/11, but the resident's representative was not provided with a Liability Notice which is on the facility's Skilled Nursing Facility (SNF) Determination on Continued Stay form.

415.3(g)(2)(iii)

Based on observation, record review and staff interview during a Life Safety Code survey, smoke barrier doors were not designed to limit the transfer of smoke. This affected two (Lakeside, Parkside) of three resident units. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the Parkside Unit on 1/31/12 at approximately 12:04 PM revealed that there was an approximate one inch gap between the smoke barrier doors located near resident rooms #216 and #232 when they were allowed to close. Also at this time, observation revealed that the door located closest to resident room #216 was observed to be hung up on its frame when it was released from its magnetic hold open device and allowed to close. Further observation at this time revealed that this same door had several gouges in it and that one of the gouges located near the base of the door was approximately two foot long by at least one quarter inch wide. Interview with the Director of Environmental Services and the Maintenance Supervisor at this time revealed that they were not aware of the gouges and that it appeared that the door had been hit by something.

Review of the facility's architectural drawings on 2/2/12 at approximately 10:55 AM confirmed that these doors were smoke barrier doors.

2. Observation on 1/31/12 at approximately 12:21 PM above the smoke barrier doors on the Parkside Unit located near resident room #224 and the Laundry Soiled Linen room located on the Lakeside Unit revealed that there was an approximate one inch gap between the doors when they were allowed to close. Also at this time observation revealed that the door located closest to the Laundry Soiled Linen room was observed to be hung up on its frame when it was released from its magnetic hold open device and allowed to close. Interview with the Director of Environmental Services at this time revealed that these doors were smoke barrier doors and that they separated the Lakeside Unit from the Parkside Unit.

Review of the facility's architectural drawings on 2/2/12 at approximately 10:55 AM confirmed that these doors were smoke barrier doors and that they separated the Lakeside Unit from the Parkside Unit.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.7.6, 8.3.4, 8.3.4.1

Based on observation, record review and staff interview during a Life Safety Code survey, smoke barrier walls were not complete from floor to roof deck. This affected three (Lakeside, Parkside, Woodside) of three resident units. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Observation in the Laundry Soiled Linen room on 1/31/12 at approximately 12:25 PM revealed that there was a greater than one quarter inch open, unsealed penetration around a sprinkler pipe that ran through the wall that separated the Laundry Soiled Linen room from the Parkside Unit corridor near resident rooms #224, #225 and #226. Also at this time observation revealed that the Laundry Soiled Linen room was located on the Lakeside Unit. Interview with the Director of Environmental Services at this time revealed that the sprinkler pipe was installed through this wall approximately one week ago and that the penetration had been open and unsealed since then.

Review of facility's architectural drawings on 2/2/12 at approximately 10:55 AM confirmed that the wall that separated the Laundry Soiled Linen room from the Parkside Unit corridor near resident rooms #224, #225 and #226 was a smoke barrier wall and that it separated the Lakeside Unit from the Parkside Unit.

2. Observation above the ceiling tiles on 2/1/12 at approximately 9:30 AM revealed an approximate four inch long by three inch wide area of the Lakeside Unit smoke barrier wall was missing gypsum board. Also at this time observation revealed that a sprinkler pipe was running through this same wall to the right of the area that was missing the gypsum board. Further observation at this time revealed that this area that lacked gypsum board was located above the smoke barrier doors that separated the Lakeside Unit near the Laundry Soiled Linen room from the Parkside Unit near resident room #224.

Interview with the Director of Environmental Services on 2/1/12 at approximately 10:14 AM revealed that this sprinkler pipe was installed through this smoke barrier wall approximately one week ago and that the area had been open and unsealed since then.

Review of facility's architectural drawings on 2/2/12 at approximately 10:55 AM confirmed that the wall that had the area that was missing gypsum board was a smoke barrier wall and that it was part of the smoke barrier wall that separated the Lakeside Unit from the Parkside Unit.

3. Observation above the ceiling tiles on 2/1/12 at approximately 10:15 AM revealed an approximate four inch long by one half inch wide open, unsealed penetration around a sprinkler pipe that ran through the Woodside Unit smoke barrier wall. Also at this time observation revealed that this open, unsealed penetration was located above the smoke barrier doors near the Kitchen.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.7.3, 8.3.1, 8.3.2