Skip to content
- Complaint #AR00028965 was not in compliance, all or in part, with deficiencies cited at N132, N215, and N216.
- Complaint #AR00029061 was in compliance.
- Regs out of compliance –
- N132 – Failed to ensure a physical hold of Client #1 was performed in a safe manner.
- N215 – Failed to ensure a Certified Nursing Assistant, hired through an agency, had received Satori Alternatives to Manage Aggression (SAMA) training for the safe use of restraints prior to placing Client #1 in a restraint.
- N216 – Failed to ensure a Certified Nursing Assistant, hired through an agency, had received training on de-escalation techniques prior to placing Client #1 in a restraint.
- POC – All direct care staff will complete a full SAMA class and refresher course by a certified instructor regarding de-escalation and holding techniques. DON will complete camera review of all safety interventions to ensure physical holds are completed in a safe manner. HR will schedule any staff hired through an agency to attend a new hire orientation prior to being placed in the milieu. HR has audited all personnel files to ensure training compliance and will report training compliance weekly to CEO, DON, and Corporate Risk Manager.
- A revisit was conducted on 12/21/22 for all deficiencies cited on 11/04/22. All deficiencies have been corrected, and no new noncompliance was found.
