Inspection Reports for
Seasons Rehab and Healthcare Center
15600 WOODS CHAPEL RD, KANSAS CITY, MO, 64139-1261
Back to Facility Profile4 Reports
Inspection Report — Jan 31, 2025
Routine
Date: Jan 31, 2025
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are six deficiencies: four federal deficiencies addressing Medicare/Medicaid notice requirements, resident activities program, posted nurse staffing information, and psychotropic medication/behavior monitoring; and two Missouri state licensure deficiencies referencing nursing care per resident and the facility activity program.
Deficiencies (2)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F758.
19 CSR 30-85.042(92) Activity Program: Refer to F679.
Report Facts
residents sampled: 3
residents sampled: 18
residents affected: 2
Inspection Report — May 23, 2023
Routine
Date: May 23, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) in one file; the survey type is not stated.
Findings
Five federal health deficiencies addressing staff background checks/abuse policies, medication administration/clinical care, food safety/food preparation, specialized rehabilitative/restorative services, and infection prevention and control; and ten Missouri State Form deficiencies covering policies/procedures, communicable disease/employee screening, nursing care expectations, food safety and equipment/utensils, and employee background check/statute compliance.
Deficiencies (9)
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to F880.
19 CSR 30-85.042(27) Communicable Disease-Employees: Refer to F880.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F658 and F825.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: Refer to F812.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(44) Equipment, Utensils & Single-Service Articles: Refer to F812.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: Refer to F812.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F607.
Report Facts
sampled new staff lacking CBC: 10
sampled new staff lacking NA registry check prior to hire: 7
supplemental residents with missing medication parameters: 3
new employees not screened for TB per policy: 4
sampled residents affected by lack of hand hygiene during medication pass: 1
Inspection Report — Jun 28, 2021
Life Safety
Date: Jun 28, 2021
Visit Reason
CMS-2567 federal Life Safety (K) and Emergency Preparedness (E) survey and Missouri Department of Health and Senior Services State Form licensure survey; life safety survey.
Findings
Thirteen federal deficiencies were cited involving emergency preparedness (EP policies, subsistence needs, contact information) and multiple Life Safety Code topics (hazardous area enclosures, fire alarm out-of-service/fire watch, sprinkler maintenance, portable extinguishers, evacuation/relocation plans, smoking regulations, fire/smoke doors, generator/annunciator, electrical, and oxygen/cylinder handling). Thirteen Missouri state deficiencies were cited referencing many of the federal findings and covering hazardous areas, oxygen storage, fire extinguishers, fire alarm out-of-service, sprinkler testing/maintenance, smoke barriers/doors, fire drills/plans and posted evacuation diagrams, exterior fire safety, electrical wiring, operational policies/procedures, and employee orientation.
Deficiencies (13)
19 CSR 30-85.022(4) Hazardous Areas: Refer to K321.
19 CSR 30-85.022(6) Oxygen Storage: Refer to K929.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: Refer to K355.
19 CSR 30-85.022(10)(H) Fire Alarm System-Out of Service > than 4hrs: Refer to K346.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K761.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: Refer to E015.
19 CSR 30-85.022(33)(B)(1 - 10) Fire Drills - Plan Requirements: Refer to K711.
19 CSR 30-85.022(33)(C) Plan Accessible/Evacuation Diagram Posted: Refer to K711.
19 CSR 30-85.022(40)(B) Exterior Premises-Fire Safety: Refer to K741.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K916, K918.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E0013, E0015, E0031.
19 CSR 30-85.042(20) Employee Orientation/Continuing Ed.: Refer to K929.
Inspection Report — Jun 28, 2019
Life Safety
Date: Jun 28, 2019
Visit Reason
CMS-2567 federal health and Life Safety (K-tag) survey with Emergency Preparedness (E-tag) findings, and accompanying Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not otherwise stated.
Findings
The file contains 24 federal deficiencies (E- and K- tags) addressing emergency preparedness, training and communication, and numerous Life Safety Code topics including sprinkler systems, fire alarm/testing, emergency lighting, egress/doors, kitchen/hood suppression, sprinkler impairments, HVAC and electrical/generator issues; and 18 Missouri State Form deficiencies that largely reference the federal K/E findings for corrective action.
Deficiencies (18)
19 CSR 30-85.012(89) Heating System,Ventilation per Code/NFPA: Refer to K521.
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K324.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Refer to K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(11)(E) Sprinkler System Out Of Service More Than 4hr: Refer to K354.
19 CSR 30-85.022(16) Door Locks: Refer to K222.
19 CSR 30-85.022(24) Exit Sign-Maintain/Illuminate: Refer to K293.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K761.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.022(33)(A) Fire Drills/Emergency Preparedness - Plans: Refer to E007, E015, E022, E026 and E032.
19 CSR 30-85.022(33)(B) Fire Drills - Plan Requirements/Documentation: Refer to K711.
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.022(36) Clothes Dryers Vented, Lint Traps: Refer to K700.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161 and K363.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914, K918 and K919.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E037 and K918.
19 CSR 30-87.020(B) Sufficient Ventilation: Refer to K521.
7 CMS Surveys
Inspection Report — Jan 31, 2025
Routine
Date: Jan 31, 2025
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are six deficiencies: four federal deficiencies addressing Medicare/Medicaid notice requirements, resident activities program, posted nurse staffing information, and psychotropic medication/behavior monitoring; and two Missouri state licensure deficiencies referencing nursing care per resident and the facility activity program.
Deficiencies (4)
F582 Medicaid/Medicare Coverage/Liability Notice: Based on interview and record review, the facility failed to ensure two sampled residents who were notified their Medicare Part A coverage would likely end and had benefit days remaining were provided the Quality Improvement Organization contact name and toll-free phone number on their Notice of Medicare Non-Coverage (CMS-10123).
F679 Activities Meet Interest/Needs Each Resident: Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the needs of sampled residents and failed to ensure easy access to daily activity participation over time.
F732 Posted Nurse Staffing Information: Based on observation, interview and record review, the facility failed to post the actual hours worked for licensed and unlicensed nursing staff per shift in locations throughout the facility and staffing sheets did not show total hours for each eight hour shift as required.
F758 Free from Unnec Psychotropic Meds/PRN Use: Based on interview and record review, the facility failed to document behaviors and develop a care plan that included target behaviors and relevant non-pharmacological approaches for a sampled resident who was prescribed a psychotropic medication.
Report Facts
residents sampled: 3
residents sampled: 18
residents affected: 2
Inspection Report — Jan 31, 2025
Life Safety
Date: Jan 31, 2025
Visit Reason
Federal CMS-2567 Life Safety Code survey (K-tag life safety survey); E 000 initial comments present.
Findings
Three life safety deficiencies were cited addressing fire alarm low-voltage wiring not protected in conduit, deficiencies in sprinkler system maintenance/penetration around a sprinkler head, and exposed nonmetallic sheathed cable lacking required thermal barrier. All deficiencies had the potential to affect the facility residents.
Deficiencies (3)
K341 Fire Alarm System - Installation: Based on observation and interview, the facility failed to ensure low voltage wiring under seven feet was protected in conduit for the fire alarm system door release in the mechanical room. This deficient practice had the potential to affect all 77 residents who resided at the facility.
K353 Sprinkler System - Maintenance and Testing: Based on document review and interview, the facility failed to ensure quarterly sprinkler system inspections were completed and failed to ensure there was no penetration around a sprinkler head in the janitors' closet outside the Pine wing. This deficient practice had the potential to affect all 77 residents who resided at the facility.
K511 Utilities - Gas and Electric: Based on observations and interview, the facility failed to ensure Nonmetallic Sheathed Cable (Romex) was concealed with a required thermal barrier; one mechanical room had exposed 10 AWG nonmetallic sheathed cable coming out of an electrical junction box. This deficient practice had the potential to affect all 77 residents who resided at the facility.
Report Facts
residents potentially affected: 77
Inspection Report — Aug 26, 2024
Routine
Date: Aug 26, 2024
Visit Reason
Federal health survey (CMS-2567); the survey type is not stated.
Findings
One federal health deficiency for failure to assess a resident and to notify emergency medical services in a timely manner after an unwitnessed fall; the finding focuses on fall assessment, staff response and communication.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to assess a resident who had fallen and did not notify Emergency Medical Services in a timely manner, delaying transfer to the hospital.
Report Facts
residents sampled: 4
Inspection Report — May 23, 2023
Routine
Date: May 23, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) in one file; the survey type is not stated.
Findings
Five federal health deficiencies addressing staff background checks/abuse policies, medication administration/clinical care, food safety/food preparation, specialized rehabilitative/restorative services, and infection prevention and control; and ten Missouri State Form deficiencies covering policies/procedures, communicable disease/employee screening, nursing care expectations, food safety and equipment/utensils, and employee background check/statute compliance.
Deficiencies (6)
F607 Develop/Implement Abuse/Neglect Policies: Based on interview and record review, the facility failed to complete Criminal Background Checks for sampled new staff and did not follow policy to check the Nurse Aide Registry for several new hires.
F658 Services Provided Meet Professional Standards: The facility failed to ensure parameters were in place and followed for safely administering digoxin and metoprolol, with nurses administering these medications without checking residents' pulse or blood pressure for multiple residents.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Observations and record review found unsanitary food storage and preparation practices and a failure to properly maintain equipment and document food temperatures, including damaged cutting boards, detached gasket, open/expired food items, and incomplete temperature logs.
F825 Provide/Obtain Specialized Rehab Services: The facility failed to provide restorative nursing services and ensure restorative care orders and follow-through for a sampled resident discharged from therapy.
F880 Infection Prevention & Control: The facility failed to implement a comprehensive infection prevention and control program, including inadequate water management/Legionella controls, incomplete TB screening/testing for new employees, and lapses in hand hygiene during medication administration.
State Statute: Review of State Statute 192.2495.3 showed failures to check the Employee Disqualification List (EDL) and related background-check statute requirements; refer to F607.
Report Facts
sampled new staff lacking CBC: 10
sampled new staff lacking NA registry check prior to hire: 7
supplemental residents with missing medication parameters: 3
new employees not screened for TB per policy: 4
sampled residents affected by lack of hand hygiene during medication pass: 1
Inspection Report — Jun 28, 2021
Life Safety
Date: Jun 28, 2021
Visit Reason
CMS-2567 federal Life Safety (K) and Emergency Preparedness (E) survey and Missouri Department of Health and Senior Services State Form licensure survey; life safety survey.
Findings
Thirteen federal deficiencies were cited involving emergency preparedness (EP policies, subsistence needs, contact information) and multiple Life Safety Code topics (hazardous area enclosures, fire alarm out-of-service/fire watch, sprinkler maintenance, portable extinguishers, evacuation/relocation plans, smoking regulations, fire/smoke doors, generator/annunciator, electrical, and oxygen/cylinder handling). Thirteen Missouri state deficiencies were cited referencing many of the federal findings and covering hazardous areas, oxygen storage, fire extinguishers, fire alarm out-of-service, sprinkler testing/maintenance, smoke barriers/doors, fire drills/plans and posted evacuation diagrams, exterior fire safety, electrical wiring, operational policies/procedures, and employee orientation.
Deficiencies (13)
E013 Development of EP Policies and Procedures: Based on interview and record review, the facility failed to establish and maintain a comprehensive Emergency Preparedness program with required hazard vulnerability and facility needs assessments and community contact information.
E015 Subsistence Needs for Staff and Patients: The facility failed to develop consistent EP policies/procedures to ensure adequate subsistence needs, particularly an adequate, accessible emergency water supply, and observed expired/insufficient water supplies.
E031 Emergency Officials Contact Information: The facility failed to include required state and federal emergency management contact information in its EP plan; required contacts were missing or not clearly identified.
K321 Hazardous Areas - Enclosure: Doors to hazardous areas lacked required visible fire resistance rating (FRR) labels and some doors did not self-close and latch, leaving multiple hazardous areas noncompliant and potentially affecting all residents and staff.
K346 Fire Alarm System - Out of Service: The facility failed to implement a comprehensive, facility-specific Fire Watch policy and procedures when the fire alarm system was out of service, and documentation and implementation of fire watches were inadequate.
K353 Sprinkler System - Maintenance and Testing: A sprinkler head in a storage room was obstructed by HVAC ductwork and the facility failed to ensure sprinkler heads were unobstructed and properly inspected/tested.
K355 Portable Fire Extinguishers: Portable fire extinguishers were obstructed, improperly mounted or hung too high in several locations, and the facility failed to ensure extinguishers were readily accessible and correctly installed.
K711 Evacuation and Relocation Plan: The facility failed to maintain a comprehensive, facility-specific fire safety plan with consistent alert codes, sufficient evacuation maps and staff education on evacuation procedures; evacuation maps were missing or not posted in required areas.
K741 Smoking Regulations: The facility failed to prevent cigarette butts and smoking-related hazards in non-designated areas and lacked adequate signage and receptacles; staff were observed discarding cigarette butts in undesignated locations.
K761 Maintenance, Inspection & Testing - Doors: Fire/smoke door assemblies lacked legible FRR labels, some labels were painted over, and documentation of door inspections/testing was incomplete, indicating failure to maintain required door assemblies.
K916 Electrical Systems - Essential Electric System Alarm Annunciator: The generator remote annunciator and alarm monitoring were not readily observable or consistently monitored, and alarm panel monitoring practices were changed such that alarms were not consistently monitored.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain sufficient work clearances around generator and electrical panels, had generator exhaust/odor issues, and lacked clear identification of generator-powered receptacles and receptacle coverage.
K929 Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds: Oxygen cylinders and a helium tank in storage were not properly secured or stored and staff lacked training on safe handling and storage, with securing clamps improperly installed.
Inspection Report — Jun 23, 2021
Routine
Date: Jun 23, 2021
Visit Reason
Routine inspection of Seasons Rehab and Healthcare Center to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs for appropriate equipment sizing, incomplete documentation of Do Not Resuscitate (DNR) orders, inadequate privacy and dignity for residents, failure to check Nurse Aide Registry for new hires, failure to prepare a resident properly for surgery, incomplete physician orders follow-up, failure to complete weekly weights and diagnostic testing, inadequate supervision to prevent falls and ensure medication administration, failure to obtain ordered lab tests, medication storage and labeling issues, incomplete tuberculosis screening, failure to wash hands between glove changes during wound care, and lack of a comprehensive Legionella water management program.
Deficiencies (11)
Failed to ensure low air loss mattress settings and appropriate sizing of Broda chair for a resident.
Failed to accurately document wishes of a resident to be Do Not Resuscitate (DNR).
Failed to maintain resident dignity by allowing exposure during cares and inadequate privacy when resident removed clothing.
Failed to check Nurse Aide Registry for two employees to ensure no Federal Indicator prohibiting employment.
Failed to prepare resident for surgery by not ensuring resident was kept NPO resulting in surgery rescheduling.
Failed to complete weekly weights as ordered and to schedule CT scan as ordered for residents.
Failed to provide adequate supervision to prevent near falls and ensure medication administration.
Failed to obtain physician ordered laboratory tests for a resident.
Failed to ensure medications were kept in clean, sanitary, and secured medication carts or rooms; expired medications were discarded; opened medications were dated; no food or cleaning supplies stored with medications; medications removed upon resident discharge; and medications labeled and matched physician orders.
Failed to ensure residents were tested or screened for tuberculosis as required and failed to wash or sanitize hands between glove changes during wound care.
Failed to establish and maintain a comprehensive, facility-specific infection prevention and control program for waterborne pathogens including Legionella, and failed to provide documented assessments for such an outbreak.
Report Facts
Weight: 189
Weight loss percentage: 14
Weight: 107
Weight: 124.6
Weight: 111.2
Weight: 109.8
Weight: 110.6
Weight: 117
Weight: 126.2
Weight: 107
Weight: 107
Height: 64
Medication doses: 10
Expired medication date: May 4, 2021
Expired medication date: Nov 18, 2018
Expired medication date: Nov 24, 2019
Expired medication date: Mar 31, 2020
Expired medication date: Aug 31, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication storage and wound care hand hygiene findings |
| LPN C | Licensed Practical Nurse | Named in resident supervision, wound care, and medication administration findings |
| CNA B | Certified Nursing Assistant | Named in resident supervision and medication administration findings |
| CNA D | Certified Nursing Assistant | Named in medication storage and resident walker inspection |
| LPN A | Licensed Practical Nurse | Named in medication storage and wound care hand hygiene findings |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding deficiencies and facility policies |
| Administrator | Administrator | Named in interviews regarding facility policies and deficiencies |
| Dietary Manager | Dietary Manager | Named in food safety and kitchen inspection findings |
| Restorative Aide | Restorative Aide | Named in weekly weights and resident care findings |
| Human Resources employee | Human Resources employee | Named in Nurse Aide Registry check findings |
Inspection Report — Jun 28, 2019
Life Safety
Date: Jun 28, 2019
Visit Reason
CMS-2567 federal health and Life Safety (K-tag) survey with Emergency Preparedness (E-tag) findings, and accompanying Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not otherwise stated.
Findings
The file contains 24 federal deficiencies (E- and K- tags) addressing emergency preparedness, training and communication, and numerous Life Safety Code topics including sprinkler systems, fire alarm/testing, emergency lighting, egress/doors, kitchen/hood suppression, sprinkler impairments, HVAC and electrical/generator issues; and 18 Missouri State Form deficiencies that largely reference the federal K/E findings for corrective action.
Deficiencies (24)
E007 Emergency Preparedness Population: The facility's Emergency Preparedness documentation did not identify and address the resident population and the procedures to meet the special needs of residents during an emergency as evidenced by record review and interview.
E015 Subsistence Needs for Staff and Patients: The facility failed to include or implement policies and procedures to ensure subsistence needs (food, water, supplies, alternate energy) for residents and staff in the emergency preparedness plan as evidenced by record review and interview.
E022 Policies/Procedures for Sheltering in Place: The facility failed to develop and/or maintain policies and procedures addressing sheltering in place and related planning in its Emergency Preparedness documentation as evidenced by record review and interview.
E026 Policies and procedures: The facility failed to include required emergency preparedness policies and procedures consistent with federal requirements, as evidenced by record review and staff interviews.
E032 Primary/Alternate Means for Communication: The facility did not develop and maintain a current communication plan, including primary and alternate means for communicating with staff, residents, and external authorities, as evidenced by record review and interview.
E037 Training Program: The facility failed to provide evidence of required emergency preparedness training and documentation for staff, volunteers and others, including maintenance of training records and demonstration of staff knowledge, as evidenced by record review and interview.
K161 Building Construction Type and Height: The facility failed to ensure required construction features and smoke barriers were maintained (including missing escutcheons, compromised barriers and related issues) as evidenced by observations, interviews and record review.
K222 Egress Doors: Door assemblies and egress arrangements were not maintained in accordance with code, including issues with required hardware and locking/egress arrangements, as evidenced by observation and record review.
K291 Emergency Lighting: Emergency lighting was not provided or maintained in required locations and documentation of required testing/maintenance was lacking, as evidenced by observation and record review.
K293 Exit Signage: Exit and directional signage was not installed or maintained to provide required guidance, and some signage pointed the wrong direction, as evidenced by observation and record review.
K324 Cooking Facilities: Cooking equipment, exhaust hoods and related fire-extinguishing systems were not properly maintained (including grease build-up, missing components and other deficiencies) as evidenced by observation and interview.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to provide complete documentation and evidence of required fire alarm system inspections, testing and maintenance, as evidenced by record review and interview.
K353 Sprinkler System - Maintenance and Inspection: Sprinkler system components were obstructed, missing or otherwise not maintained and complete inspection/testing documentation was not provided, as evidenced by observations and record review.
K354 Sprinkler System - Out Of Service/Impairments: The facility did not properly manage impaired sprinkler conditions or provide required impairment program documentation, and sprinklers were found impaired or obstructed, as evidenced by observation and record review.
K363 Corridor Doors: Corridor doors and smoke barrier door assemblies were not maintained to code (gaps, missing gasketing/thresholds, or other conditions affecting smoke containment), as evidenced by observation and record review.
K521 HVAC: Heating, ventilation and air conditioning systems and related life-safety components (including dampers and required documentation) were not properly maintained or documented, as evidenced by observation and record review.
K700 Operating Features - Other: Housekeeping and operational features presented fire hazards (including lint accumulation and dryer/laundry issues) and required procedures/controls were not in place, as evidenced by observation and interview.
K711 Evacuation and Relocation Plan: The facility's evacuation and relocation planning and documentation (maps, procedures and assigned responsibilities) were incomplete or not current, as evidenced by record review and interview.
K712 Fire Drills: The facility's fire drill records and evidence of transmission/monitoring of fire alarm signals and drill notifications were incomplete or inadequate, as evidenced by record review and interview.
K741 Smoking Regulations: Smoking devices/ashtrays and related procedures were not maintained or managed to comply with code requirements, as evidenced by observation and record review.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to provide required documentation and performance of door inspections and required maintenance/testing per standards, as evidenced by record review and interview.
K914 Electrical Systems - Maintenance and Testing: The facility failed to maintain electrical receptacles/bedside outlets and associated records as required and documentation of repairs/inspections was inadequate, as evidenced by observation and record review.
K918 Electrical Systems - Essential Electric System/Generator: The essential electrical systems and on-site generator were not properly maintained, tested or documented (including evidence of maintenance and safe operation), as evidenced by observation and record review.
K919 Electrical Equipment - Other: Related electrical equipment and junction box/covers/associated components were found missing, unsecured or in need of repair and documentation of corrective actions was lacking, as evidenced by observation and record review.
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