The findings of the re-licensure survey, conducted 08/08/22 through 08/12/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the 1st revisit to the re-licensure survey of 08/12/22, conducted 11/16/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Resident 6 was admitted to the facility in  06/2022, with diagnoses including dementia with behavioral disturbance, anxiety disorder and mood disorder.

Resident 6's records were reviewed during survey and indicated the following:

a. A progress note dated 06/07/22 stated Resident 6 called the facility and stated s/he "was walking [his/her] dog and got lost and was at a family location, staff talked to family and got address and went to pick [Resident 6] up across the street from a [local medical center approximately ½ mile from the facility]."  

In an interview on 08/09/22, Staff 1 (Executive Director) and Staff 2 (RN Consultant) stated the location mentioned in the report was not the resident's family, and the family was unknown to the facility and Resident 6, but the resident had previously lived in that area.  

There was no documented evidence the facility investigated or reported the incident to the local SPD office.

b. In an incident report dated 07/24/22, staff documented they "couldn't find [Resident 6] for hour check, looked around building then drove around surrounding streets, found [Resident 6] walking [approximately ½ mile from facility]." A follow-up progress note stated "[Resident 6] was found down [Street Name] with another [Resident 7]." Staff drove Resident 6 back to the facility.

The incident report did not provide information indicating if abuse/neglect had been ruled out, and there was no documented evidence the facility reported the incident to the local SPD office.

The need to ensure resident incidents were investigated to rule out potential abuse and/or neglect and reported to the local SPD office if needed was discussed with Staff 1 and Staff  2 on 08/09/22 and 08/10/22. They acknowledged the findings and reported the incidents to the local SPD per the survey team's request.  Confirmation of the report was provided prior to survey exit.

3. Resident 7 was admitted to the facility in 08/2021 with diagnoses including dementia.

During the acuity interview on 08/08/22, staff identified Resident 7 had an elopement incident with Resident 6. An additional interview on 08/09/22 with Staff 2 (RN Consultant) confirmed that Resident 7 had wandered off the facility grounds with Resident 6 on 07/24/22.

Resident 7's service plan, dated 06/16/22, stated, "[Resident name] is an elopement risk/wanderer as [s/he] is disoriented by place."  

Documentation related to the elopement incident was requested. The facility provided an incident report dated 07/24/22 for Resident 6's elopement which identified Resident 7 was with Resident 6. There was no other documentation in Resident 7's record to indicate the facility investigated the incident or reported it to the local SPD office.

On 08/09/22, Staff 1 (Executive Director) confirmed the incident had not been investigated or reported.

The need to investigate elopements to rule out abuse or neglect of care and to report to the local SPD if needed was discussed with Staff 1 and Staff 2 on 08/09/22. They acknowledged the findings.

The facility was directed to self-report the incident to the local SPD office. Confirmation of the reported was received on 08/10/22, prior to survey exit.

Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect, and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out, and documented for 3 of 3 sampled residents (#3, 6, and 7). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 12/2021 with diagnoses including dementia and anxiety.

Review of the resident's clinical records, including progress notes, incident reports, investigations and temporary service plans, revealed the following:

A service plan update on 12/21/2021 noted Resident 3 had a short-term memory loss, forgot to use his/her call light, and was a fall risk due to unsteady gait and weakness.

* On 05/12/22, Resident 3 experienced an unwitnessed fall and was found on the floor in his/her room with a laceration to the back of the head. The facility failed to complete an investigation to rule out abuse and neglect and failed to report the incident to the local SPD office; and

* On 07/31/22, Resident 3 experienced an unwitnessed fall and was found on the floor in his/her room with a laceration to the back of the head. The facility incident report did not provide documentation as to how they ruled out abuse and neglect. They failed to report the incident to the local SPD office.  

On 08/11/22, the need to immediately investigate unwitnessed falls to rule out abuse and/or neglect was discussed with Staff 2 (RN Consultant) and Staff 3 (Administrative Assistant). They acknowledged the findings.

The surveyor requested Staff 2 and Staff 3 immediately report those incidents to the local SPD office. Confirmation of the report was received from Staff 3, prior to the survey exit.

What actions will be taken to correct the rule violation for each example/resident?

Resident sample #3:

oAPS notified of incident on 8/11/22 by facility Administrator.

o8/11/22 Family member is providing 1:1

o8/11/22 Hospice is notified of need for bed alarm or monitor

o8/14/22 facility staff are now providing 1:1 caregiving until location found for higher level care

o________Resident will be moving to memory care on

Resident sample #6:

oAPS notified of incident on 8/10/22 by facility Administrator.

o8/9/22 facility initiated 1:1 caregiver until memory care facility is found for resident

o8/14/22 resident moved to a memory care facility

Resident sample #7

oAPS notified of incident on 8/11/22 by facility Administrator.

o8/11/22 RN Consultant completed elopement risk assessment and analysis

o8/12/22 Service plan updated to reflect elopement risk with interventions added

The system will be corrected so this violation will not happen again:

oThe facility has developed an Elopement risk assessment tool that will evaluate all potential residents and current residents for elopement risks

oFacility RN Consultant has completed risk assessments on 100% of residents.

o8/24/2022 All facility staff   in-serviced regarding incident reporting/investigation process including definitions of, and mandatory reporting of suspected and/or actual abuse  and re-educated on what  the components of an investigation are, what is an in-depth review of all clinical , environmental and behavioral factors that may be contributing to an event and the importance of the analysis of this information to come to a conclusion  of the event  for known  or unknown cause  by the facility Administrator.

oAll incident investigations will be initiated by staff at time of occurrence and completed by the Administrator or Administrative Assistant with input from the RN Consultant as they occur                                                       

How often will the area needed correction be evaluated?

oMonthly Audits will be done by the Administrator to assure all incident reports are investigated and action plans will be implemented based on their analysis post audit.

oFacility Accident/Incident/investigation policy will be reviewed now and revised if needed and reviewed annually and revised as needed by the Administrator.

Who will be responsible to see that the corrections are completed/monitored

oAdministrator will be responsible for completion of all investigations of accident/incidents to rule out abuse/neglect has occurred and implementation of interventions to prevent future harm to residents.  

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff for 2 of 7 sampled residents (#s 3 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. During the acuity interview on 08/08/22, staff identified Resident 7 had an elopement incident with Resident 6.

On 08/09/22, Staff 2 (RN Consultant) confirmed that on 07/24/22, Resident 7 had wandered off the facility grounds with Resident 6.

Resident 7's current service plan, dated 06/16/22, stated, "[Resident name] is an elopement risk/wanderer as [s/he] is disoriented by place."

There was no evidence the facility had updated the resident's service plan after the 07/24/22 elopement, and there were no clear directions or interventions for staff which addressed the resident's elopement risk.

On 08/09/22 at 3:00 pm, the survey team requested the facility update Resident 7's service plan to reflect the resident's elopement risk. At 4:03 pm, the surveyors received a copy of the updated service plan.

The need to ensure resident service plans were updated and provided clear direction to staff was discussed and reviewed with Staff 2 on 08/12/22. She acknowledged the findings.

2. Resident 3 was admitted to the facility in facility in 12/2021 with diagnoses including dementia and anxiety.

Resident 3's service plan was reviewed, and caregiving staff and the resident were interviewed. The service plan, dated 07/19/22, was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas:

* Transfers;

* Bathing; and

* Laundry.

On 08/10/22, the need to ensure service plans were reflective of the residents' current care needs and included clear direction to staff was discussed with Staff 2 (RN Consultant) and Staff 3 (Administrative Assistant). They acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

Sample Resident # 3:

oAdministrator and RN Consultant reviewed and revised resident #3 service plan to accurately reflect residents' current assistance needed in all areas and educated staff on changes to the service plan.  

Sample Resident # 7:

oService plan was reviewed and updated to be reflective of resident's needs at this time.  

oFacility RN completed elopement risk assessment and updated service plan to reflect elopement risk based on this assessment.

o Elopement risk will be assessed for resident quarterly and more often as needed.

How will the system be corrected so this violation will not happen again?

oAdministrator and Administrative Assistant will review 100% of residents service plans to assure they are reflective of resident individualized needs.

oAdministrator and/or Administrative Assistant will evaluate elopement risk prior to admission.

oFacility RN Consultant will complete elopement risks on 100% of residents, added interventions to service plans and update the resident(s) Elopement risk quarterly and more often as needed.

How often will the area needed correction be evaluated?

oAdministrator or Administrative Assistant will evaluate service plans prior to resident admission, 30 days after admission, quarterly and with significant changes

oFacility RN Consultant will review and update service plan when significant change of condition occurs and will initiate Interim Service Plans at time of significant change of condition

Who will be responsible to see that the corrections are completed/monitored?

oAdministrator will monitor random service plans once monthly to assure that they are reflective of resident care/needs.

2. Resident 3 was admitted to the facility in facility in 12/2021 with diagnoses including dementia and anxiety.

Review of the resident's clinical records, including progress notes, incident reports, investigations and temporary service plans, revealed the following:

A service plan update on 12/21/2021 noted Resident 3 had a short term memory loss, forgot to use his/her call light and was a fall risk due to unsteady gait and weakness.

Record review indicated Resident 3 experienced multiple injury and non-injury falls:

* On 04/29/22, incident reports and progress notes indicated the resident experienced two separate non-injury falls. There was no documented evidence he facility developed or monitored new interventions to address the residents ongoing fall risk; and

* On 05/12/22, the resident experienced three separate unwitnessed falls, with the third fall resulting in a laceration on the back of the head. The resident was sent to the hospital via emergency medical services. The resident was admitted to the hospital and was readmitted to the facility on 06/03/22 after a skilled nursing facility stay related to the fall.

Resident 3 experienced multiple unwitnessed falls between 04/29/22 and 05/12/22, the last of which resulted in a laceration to the back his/her head, hospitalization and a stay in a skilled nursing facility. There was no documented evidence the facility identified or determined interventions, monitored interventions for effectiveness or provided staff with clear instruction on how to minimize falls.

On 08/11/22, the need to ensure changes of condition had resident-specific interventions, interventions were monitored for effectiveness weekly until resolved and provided clear, resident-specific directions for staff was discussed with Staff 2 (RN Consultant) and Staff 3 (Administrative Assistant). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition were evaluated and necessary resident-specific actions or interventions were determined, documented, and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through resolution for 3 of 7 sampled residents (#s 3, 6 and 7) who had documented changes of condition. Resident 3 had multiple unwitnessed falls, one of which resulted in injury, and Resident 6 experienced three episodes of wandering away from the facility and had to be located and/or brought back to the facility by staff and/or emergency medical services. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2022, with diagnoses including dementia with behavioral disturbance, anxiety disorder and mood disorder.

Resident 6's records were reviewed during survey and indicated the following:

Resident 6's service plan documented the following care areas and/or interventions were initiated on 06/06/22:

* Resident was living in independent living and "needed to move into assisted living due to confusion and wandering";

* Resident had some confusion and had recently left [his/her] home and became lost. The service plan instructed staff to redirect as needed; and

* Resident's judgment and memory were not always good, s/he had some confusion which staff were to monitor and provide guidance and redirection as needed.

In an interview with Resident 6 on 08/09/22, s/he displayed confusion and disorientation to place and time.

A progress note dated 06/07/22 stated the resident called the facility and stated s/he "was walking [his/her] dog and got lost and was at a family location, staff talked to family and got address and went to pick [Resident 6] up across the street from a [local medical center approximately ½ mile from the facility]."  In an interview on 08/09/22, Staff 1 (Executive Director) and Staff 2 (RN Consultant) stated the location mentioned in the report was not the resident's family and the family was unknown to the facility and Resident 6, but the resident had previously lived in that area.  

During an interview on 08/09/22, Staff 2 stated staff were instructed to provide 30 minute safety checks starting on 06/09/22. The facility provided documentation of staff completing the 30 minute safety checks.

An RN progress note dated 7/12/22 stated the resident displayed increasing agitation, crying and attempting to leave the facility. The RN advised staff to continue 30 minute checks, if the resident attempted to leave to try to redirect him/her back in the building and if not able to redirect call 911. The RN contacted the resident's physician and family to request assistance with 1:1 care, but the family had not responded. Staff 2 documented she notified Staff 1 the resident was not appropriate for this facility's level of care and probably needed a secured facility if s/he continued to attempt to exit the campus.

In an incident report dated 07/24/22, staff documented they "couldn't find [Resident 6] for hour check, looked around building then drove around surrounding streets, found [Resident 6] walking [approximately ½ mile from facility]." A follow-up progress note stated "[Resident 6] was found down [Street Name] with [Resident 7]." Staff drove Resident 6 back to the facility.

On 07/25/22, an RN progress note stated the resident needed a secure unit given the level of dementia, and this was the 3rd time the resident had wandered off campus. There was no documented evidence the facility developed new interventions related to the resident's ongoing wandering behaviors.

On 08/01/22, an incident report stated the resident continued to have exit-seeking and wandering behaviors and left the facility. Staff 1 followed the resident and called 911 when the resident refused to return. The resident was transported to the hospital for further evaluation for possible infection. The resident returned to the facility the same day. No new interventions were developed to address the resident's ongoing wandering behaviors.

On 06/06/22, the facility identified Resident 6 had a history of wandering away from home and becoming lost and was at risk for wandering behaviors. On 06/07/22, the resident left the facility, became lost and was not able to find their way back to the facility; the facility initiated 30 minute checks. The resident continued to display wandering behaviors, documented on 07/12/22, 07/24/22 and 08/01/22. The facility failed to develop and monitor new interventions to address the immediate safety risk related to the resident's wandering behaviors, which placed the resident at risk of harm.

On 08/09/22 the survey team discussed the need for the facility to develop and monitor new interventions when residents experienced changes of conditions with Staff 1 and Staff 2. The facility provided an updated service plan and implemented new interventions of 1:1 care on 08/09/22.

3. Resident 7 was admitted to the facility in 08/2021 with diagnoses including dementia.

During the acuity interview on 08/08/22, staff identified Resident 7 had an elopement incident with Resident 6. On 08/09/22, Staff 2 (RN Consultant) confirmed Resident 7 had wandered off the facility grounds with Resident 6 on 07/24/22.

Resident 7's 06/16/22 service plan described the resident as an elopement risk and wanderer, as s/he was disoriented by place. There was no documented evidence the facility had determined actions or interventions to address the resident's elopement risk prior to the incident on 07/24/22, and no evidence the facility evaluated the resident after the elopement incident, determined and documented what actions and interventions were needed for the resident, communicated them to staff on all shifts, updated the service plan or monitored the resident.

On 08/10/22, The need to ensure the resident was evaluated when s/he experienced a short-term change of condition related to elopement, was discussed with Staff 1(Executive Director) and Staff 2. They acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

Sample resident # 3:

o8/11/22 APS notified of incidents 7/31/22, 5/12/22 and 4/29/22 by facility Administrator.

o8/11/22 Implemented 1:1 caregiving by daughter and continued 30-minute checks by facility until 1:1 facility/agency caregiver arranged. Requested bed monitor from Hospice for resident

o8/14/22 - initiated for 1:1 caregiver by facility/agency staff by Administrator and ISP put into place

o8/15/22 RN met with Hospice RN and daughter explaining need for higher level of care.

o8/19/22 Daughter advised facility that they have secured a room in a memory care facility and resident will be moving as soon as room is ready.

Sample resident # 6:

oAPS notified of incident on 8/10/22 by facility Administrator.

o8/10/22 facility initiated 1:1 caregiver until memory care facility is found for resident

o8/14/22 resident moved to a memory care facility

Sample resident # 7:

oAPS notified of incident on 8/11/22 by facility Administrator.

o8/11/22 RN Consultant completed elopement risk assessment and analysis

o8/12/22 Service plan updated to reflect elopement risk with interventions added

How will the system be corrected so this violation will not happen again?

oThe facility has developed an Elopement risk assessment tool to assess resident(s) elopement risk.

oFacility RN Consultant has completed risk assessments on 100% of residents.

oElopement risk will be assessed for resident quarterly and more often as needed.

o8/24/2022 All facility staff in-serviced regarding changes of condition, implementation of interventions to assure resident safety and requirement for monitoring change in condition was conducted by the facility Administrator.

o8/24/2022 Facility RN Consultant will have a MA Meeting on educating Med Aides on notification to the RN of changes of conditions, educated on their role in short term change in condition monitoring vs significant change in condition and OAR requirements for changes of condition and monitoring and significance of notifying Facility RN and the need for weekly monitoring note to determine if short term change in condition is improving or if there is need for additional interventions.

How often will the area needed correction be evaluated?

oFacility RN Consultant  and Administrator will do weekly audits of 24 hours shift reports for change of conditions to assure interventions are implemented

oAdministrator will review and revise facility Change of Condition policy will be reviewed annually and as needed with rule changes.

Who will be responsible to see that the corrections are completed/monitored?

oAdministrator will be responsible for assuring that residents change in conditions are monitored and interventions are implemented and documented in service plan or interim service plan with date of documentation included.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with a diagnosis of  pancreatic cancer and received hospice care.

Resident 1's 08/04/22 through 08/09/22 MAR was reviewed and identified the following:

* Morphine 2 ml every hour for pain was ordered. The MAR instructed staff to document the resident's respirations each time the medication was administered and to hold  if the resident was somnolen or respirations were less than ten. There were numerous blanks on the MAR where the resident's respirations should have been documented.

On 08/12/22, Staff 2 (RN Consultant) reported staff had been checking the resident's respirations, but failed to document these on the MAR.

The need to ensure MARs were accurate was discussed with Staff 2 on 08/12/22. She acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2018 with diagnoses including weakness and hypertension.

Review of Resident 4's 07/01/2022 through 08/08/2022 MARs identified the following PRN medications lacked clear parameters:

a. PRN medications for pain:

* Acetaminophen 325 mg tablet; and

* Morphine 20 mg/ml solution.

b. PRN medications for fever:

* Acetaminophen 325 mg tablet; and

* Acetaminophen 650 mg suppository.

The MAR failed to include clear parameters and instructions to unlicensed staff when and in what order PRN pain and fever medications should be administered.

On 08/11/22, the need to ensure PRN medications included resident-specific parameters was discussed with Staff 2 (RN Consultant) and Staff 3 (Administrative Assistant). They acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

oResident sample #1: Parameter for respirations was added to MAR on 8/8/22 by RN Consultant.

oResident sample #4: Parameter for multiple pain medications was added to MAR on 8/12/22 by RN Consultant.

How will the system be corrected so this violation will not happen again?

oRN will complete 100% audit on all residents to assure parameters on MAR's are activated in drop down boxes.

o8/24/2022 RN Consultant will hold MA Meeting educating Med Aides on reviewing double signing off of orders which includes adding from the drop-down boxes the parameter that the physician has ordered and are supposed to be monitoring and the purpose of the parameters.

How often will the area needed correction be evaluated?

oFacility RN Consulted will complete audit medication orders once weekly to assure parameters are in place as specified by MD or RN Consultant   and thereafter audit once quarterly during physician's order review and submit audits to Administrator.

o

Who will be responsible to see that the corrections are completed/monitored?

o Administrator will be responsible for assuring that parameters are in place on medication records and are being followed by facility medication aides as ordered.  

Based on interview and record review, it was determined the facility failed to ensure all employees completed the infectious disease training for 6 of 6 employee records reviewed (#s 7, 9, 13, 14, 15 and 16). Findings include, but are not limited to:

On 8/11/22, employee training records were reviewed. There was no documented evidence the following employees had completed infectious disease training:

Staff 7 (CG), hired 03/28/16; Staff 9 (MA), hired 03/17/17; Staff 13 (Housekeeping), hired 01/11/22; Staff 14 (CG), hired 02/21/22; Staff 15 (CG), hired 12/28/20; and Staff 16 (CG//MA), hired 02/22/17.

The need to ensure all employees completed a department-approved  infectious disease training was discussed with Staff 3 (Administrative Assistant) on 08/12/22. She acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

oAll facility staff will be in-serviced on 9/9/2022 regarding infection control by the facility Administrator.  

How will the system be corrected so this violation will not happen again?

oAdministrator will review and update infection control policy to reflect hours needed per OARs for staff training requirement on infection control.

How often will the area needed correction be evaluated?

oAdministrator will audit trainings once monthly to ensure that staff have OAR required trainings.

Who will be responsible to see that the corrections are completed/monitored?

oAdministrator will be responsible to all corrections are completed.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair and pathway edges did not have drop-offs which could cause tripping hazards for residents. Findings include, but are not limited to:

The facility's grounds were toured on 08/09/22 and 08/12/22. The facility's exterior pathways had areas of raised and uneven concrete and multiple areas with drop-offs of 2-4 inches near pathway edges.

The need to ensure exterior pathways were maintained in good repair and pathway edges did not have drop-offs which could cause tripping hazards for residents was discussed with Staff 1 (Executive Director) on 08/10/22 and Staff 3 (Administrative Assistant) on 08/12/22. They acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

oAdministrator replaced batteries in all doors and verified all exit doors were alarmed and working.

oAdministrator met with head of maintenance and went over new system for checking/assuring that exit door alarms are working and batteries are replaced.

How will the system be corrected so this violation will not happen again?

oMaintenance will check that all exit door alarms to assure they are working and replace batteries as needed.

How often will the area needed correction be evaluated?

oAdministrator will audit if doors are alarmed monthly and randomly.

Who will be responsible to see that the corrections are completed/monitored?

oAdministrator will be responsible to all corrections are completed.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with functional alarms or other acceptable systems to alert staff when residents exited the facility. Findings include, but are not limited to:

On 08/09/22, observations of the facility's eight exit doors showed there were no functional door alarms, either audible or which reported to the facility's pager system.

During an interview on 08/09/22, Staff 11 (CG), stated the doors had audible alarms but they were never on, and they had only heard the alarms on twice since working at the facility.

The need to ensure exit doors were equipped with functional door alarms to alert staff when residents exited the facility was discussed with Staff 1 (Executive Director). Staff 1 acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

oSide walk drop off will be completed on 8/19/2022, original date was scheduled for 9/2/22; facility was able to have another vendor come out and fix immediately.  Facility had rock filled in around sidewalks.

How will the system be corrected so this violation will not happen again?

oMaintenance will do monthly exterior checks.  Maintenance will notify administrator and vendor if any repairs are needed.

How often will the area needed correction be evaluated?

oMonthly

Who will be responsible to see that the corrections are completed/monitored?

oMaintenance will complete any corrections needed and Administrator will monitor.