Disability Rights Arkansas

Millcreek Behavioral Health / Habilitation Center, Inc.

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at [email protected]

Location: Fordyce, AR                   Population Served: Youth ages 6-17

# of residents per unit: Up to 20 Residents per room: 2-3

Capacity: 162 (111 Arkansas Medicaid PRTF beds, 51 Residential beds used for out-of-state resident PRTF placement or AR contract beds).

Contact with family (Calls and visit schedule): Family visits vary on a case-by-case basis. Phone Calls are allowed on 4 days of each week and are limited to 10 minutes unless otherwise specified.

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? Yes

Treatment Components:

Clinical Director: LPC                    Therapists:8 full-time therapists (LPC-S, 5 LPC, 1 LCSW, 1 LMSW)

Treatment modalities offered: 1 EMDR, TF-CBT

# of individual therapy sessions/week: 1

# of group therapy sessions led by a licensed mental health professional/week: 3

Print this page

PRLU or OLTC

Licensing Follow Up, Notice of Incident, Peer Altercation

  • Licensing (Peer Altercation)
    • Client punched peer during an argument over a basketball. Nurse assessment at the time of the incident revealed no injuries. Client reported continued pain on 10/25/22 and was referred to the ER for assessment. An x-ray revealed a minimally displaced boxer fracture to metacarpal, and a Salter-Harris II fracture cannot be excluded.
    • Licensing follow-up: X-ray was conducted on 10/25/22 and was not reported to licensing until 10/27/22. Facility cited 110.17. Email from facility on 10/28/22 stated client received a splint, and a follow-up will be scheduled with PCP in 4-6 weeks.

PRLU or OLTC

Duplicate Report, Notice of Incident

  • Dual (Duplicate Report)
    • Duplicate report, see case #010389.

PRLU or OLTC

Accidental Injury, Licensing Follow Up, Notice of Incident

  • Licensing (Accidental Injury)
    • During a game of kickball, client ran full force to first base and accidentally ran into a peer’s elbow and was hit in the chest. Client’s chest began swelling, and client was taken to the ER. The initial assessment revealed no injury, and client was released with a sling and activity limitation. X-ray report received on 10/17/22 revealed clavicle fracture. Follow-up appointment scheduled for 10/20/22.
    • Licensing follow-up:Client received medical treatment and remains at facility. Licensing notified timely.

PRLU or OLTC

Accidental Injury, Licensing Follow Up, Notice of Incident

  • Licensing (Accidental Injury)
    • While playing soccer, client kicked the ball and felt as if she dislocated her hip. Client was taken to the ER, and an x-ray revealed a fracture to the iliac wing, lateral margin, involving the apophysis with lateral displacement. Client was released with a referral with ACH Orthopedic Clinic.
    • Licensing follow-up: Client received medical treatment and remains at facility. Licensing notified timely.

Police Report

Third Degree Escape

Officer was dispatched to residence on Highway 79 for female escapee. Upon arrival, Millcreek staff also arrived looking for the juvenile. Officer spoke with owner of residence who stated this has happened approx 6 times. The owner advised Millcreek staff of the juvenile, who then advised the police department. The juvenile had been missing since 1715 hrs, and Millcreek advised police at 1738 hrs.

PRLU or OLTC

Accidental Injury, Licensing Follow Up, Notice of Incident

  • Licensing (Accidental Injury)
    • Client complained of thumb pain, stating he hurt it while playing with a peer on 10/1/22. Nurse noted swelling and bruising to the palm area, and client was sent to the ER. On 10/4/22, facility received client’s diagnosis: Subtle salter mid diaphyseal fracture of the proximal phalanx.
    • Licensing follow-up: Client x-rayed and remains at facility.

PRLU or OLTC

Complaint, Notice of Incident

  • Complaint
    • Received complaint that the following incident was not reported: On 8/13/21, peer threw an aerosol can and struck client on the head. Client was taken to the ER. 
    • Licensing follow-up: Licensing received notification of incident from other entity on 9/21/22, that the incident was not reported to licensing. After further review, it was determined the incident occurred on 8/13/21 (Friday) and licensing was notified on 8/16/21 (next business day). Complaint unfounded.

PRLU or OLTC

Accidental Injury, Licensing Follow Up, Notice of Incident, Self-Harm

  • Licensing (Self-harm, Accidental Injury)
    • Client became agitated and began banging on walls and attempted to pull out a light socket. As client pulled against the plug, the metal backing cut her finger. Nurse assessment: Deep laceration to finger. Injury was cleaned and wrapped before client was sent to the ER. Client received stitches at ER and returned to the facility.
    • Licensing follow-up: Client received treatment and remains at facility. Licensing notified of incident the next business day.

PRLU or OLTC

Licensing Follow Up, Maltreatment, Notice of Incident

  • Dual (Maltreatment)
    • Client reported he was choked by a staff member. Client became upset, kicked a door open and attempted to elope. Client was stopped and brought back by a peer. Staff stopped the other patient from trying to assist and client became physically aggressive towards staff. Nurse assessment revealed no injuries to indicate he was choked. Alleged staff member stated he did not choke client, and was defending himself from client attempting to bite, hit, kick, and spit on him. Four patient witnesses were interviewed and indicated client was not choked by staff. Staff placed on leave pending investigation.
    • Licensing follow-up on 9/16/22: Facility visited, and Specialist interviewed client and witnesses. Three patient witnesses report at no time did they see staff choke client, and one patient reported he heard client yelling “quit choking me” but did not witness the incident. All statements were collected. Outcome: Unfounded.

PRLU or OLTC

Visit Compliance Report

  • Program Coordinator: Chelsea Vardell.
  • Program Coordinator and Program Manager conducted visit from 9:25am – 12:00pm. Census: 162. Flamingo Hall, Tiger Hall, Magnolia Hall, Eagle Hall, Pebble Creek, Rock Hill, Pine Ridge, and Deerfield viewed. MARs reviewed for 5 clients.
  • Regs out of compliance –
    • 9.911.6 – Shower curtain torn in Tiger Hall (replace by 9/16/22). Light was not functioning in the “time away room” in Deerfield; Staff reported the light has not been working for an extended period (replace by 9/16/22). Base of door frames in the cottages were seen to be eroding and in need of repair to prevent injuries (repair or cover by 10/12/22). Roach seen crawling out of clothing in closet of resident in Rock Hill (treat cottage for pests by 10/12/22). Outlet cover in Pine Ridge dayroom was broken (replace by 9/16/22). Shower head needs repaired or replaced in Pine Ridge bathroom (by 9/16/22). Shelf in Pebble Creek was broken and could easily be removed (repair or remove by 9/16/22).
    • 9.912.4 – Mold was seen above the sink on the ceiling in Eagle Hall (treat area by 9/16/22). Rock Hill bathrooms smelled strong of urine (clean by 9/13/22). Pebble Creek toilet had a leak with a sheet on the ground around the base of the toilet, and a strong urine smell (clean by 9/13/22).
    • 9.911.15.f – Strings were found in clothing items in 3 rooms of Flamingo Hall (corrected on-site). Shoestrings were found in shoes in Pine Ridge room (corrected on-site). Walmart bag removed from a resident’s closet in Rock Hill.
  • TA –
    • 9.910.1 – Ant hill was seen by the entrance sidewalk. Please have ant hill removed.
    • 9.913.5 – Room 5 in Pebble Creek needs new comforter on the bed.

PRLU or OLTC

Accidental Injury, Licensing, Notice of Incident

  • Licensing (Accidental Injury)
    • Client was leaning backwards while swinging and fell from swing. Nurse assessed and noted swelling to client’s wrist. Client was taken to the ER, and x-rays revealed 2 fractures to the right wrist.
    • Licensing follow-up: No licensing concerns noted.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Building & Grounds conducted; Pine Ridge, Rock Hill, and Magnolia Hall observed. Census: 167. Pine Ridge: Some mold observed in bathroom and a bedroom had 2 sections of missing baseboards. Rock Hill: A copy of client rights could not be located. Magnolia Hall: Some mold observed in bathroom.
  • Regs out of compliance –
    • 9.901.3 – The agency shall establish and post a written list of children’s rights.
    • 9.911.6 – All buildings and furnishings shall be safe, clean, and in good repair.

Police Report

Radio Log, Unusual Activity

Staff reported a suspicious vehicle that had been parked in the lot for 2 hours. Upon arrival, officer spoke with CPS staff member who stated he arrived early to transport juvenile back to Texas. Officer confirmed this with staff.

Police Report

Disorderly Conduct, Radio Log

Officer was dispatched in reference to a fight. Upon arrival, staff member was arguing with a juvenile. Staff stated juvenile was upset due to a fight that happened involving other residents. The physical fighting had dispersed by the time officers arrived.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Program Coordinator: Chelsea Vardell.
  • Visit conducted from 9:45am – 12:00pm. Census: 161. Licensing Specialist and Program Coordinator completed walkthrough of Flamingo Unit, Deerfield, the cafeteria, and the school building. Licensing discussed the progress the facility is making on correcting issues with their regulatory checks noted by the DHS regulatory check unit. The facility reported they are approx. 30% completed on all checks and are on track to have all completed by 8/31/22. MARs reviewed.
  • Regs out of compliance –
    • 9.908.8 – The administering of all medications, including over-the-counter, shall be logged at the time the medication is given, by the person administering the medication.
    • 9.911.15.d – Areas used by children shall be designed, constructed, and furnished to reduce risk of suicide and assault.
    • 9.911.15.f – Areas used by children shall be designed, constructed, and furnished to reduce risk of suicide and assault.
    • 9.912.4 – The bathroom shall be clean and sanitary.
  • TA –
    • 9.914.6 – There shall be an emergency evacuation plan diagramed and posted in each building used by children.

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client’s face collided with the back of a peer while playing basketball. Nurse assessed and noted bleeding to nose and small knot to side of nose. On 7/29/22, the client was transported to the ER for an x-ray. X-ray revealed a non-displaced fracture of the distal tip of the nasal bone. No follow-up details.

PRLU or OLTC

Maltreatment, Notice of Incident

  • Maltreatment
    • Client reported that during restraint, staff member dropped client, causing them to hit their head on the ground. Nurse noted knot to back of client’s head. Staff member denied allegation, and stated the restraint was necessary to prevent self-injurious behavior and escalation of peers. Six resident witnesses were interviewed, and each reported that client was punching staff member and struggling against staff as the restraint was initiated. Three residents indicated they saw client’s head hit the ground, but that staff member was not attempting to harm client. Staff member was placed on administrative leave pending the investigation.
    • Child Abuse Hotline called and accepted. Licensing follow-up on 8/18/22: Specialist visited facility and conducted interviews. Staff members involved stated that at no time did client’s head hit the ground. Two residents who witnessed the incident stated they did not see client’s head hit the floor, and one resident stated the alleged staff member lifted client and slammed him into the floor headfirst. Facility was cited 110.9 (Risk Management was made aware of the incident on 8/10 but did not report to the hotline or Licensing Unit until 08/11). CACD investigation was unsubstantiated. Licensing complaint unfounded. 

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Not listed.
    • Facility visited from 11:00am – 12:30pm regarding incident reported to Licensing on 7/10/22, in which client alleged that multiple staff members tried to have a peer fight him and allowed him to drink Lysol. Witness statement reviewed and client interviewed. When asked about issues with staff, client stated that the 3 staff members, on separate occasions, all approached client with their fists balled up and other staff stopped them. During interview, client made a complaint to Risk Management regarding another staff member. No definitive evidence of licensing concerns voiced during this complaint. No definitive evidence from witness statements or interview yield licensing concerns.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment (1)
    • Client reported that while being placed in a restraint, client was kicked in the face by staff. The staff member was immediately removed from the vicinity by another staff member. Facility Investigation: Staff member denied allegation. Three staff members confirm the events as reported by the client. Nurse assessment revealed no injury, but noted prior to the restraint, facial redness and petechia to lips. On 7/11/22, client reported pain in nose area. X-ray at ER revealed no fracture. Staff was terminated on 7/12/22.
    • Child Abuse Hotline was called and accepted, unsubstantiated. Licensing follow-up on 7/12/22: Facility level investigation determined the allegation to be founded. Facility cited 109.1.g, 907.2, and 905.4.g (staff struck client in face). 

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment (2)
    • Client stated that 3 staff members tried to have peer fight client. Client stated they were kicked in the head by peer and the staff were aware the fight was happening. Client stated no one broke up the fight until the end. Client also stated staff told them to kill their self and wouldn’t remove Lysol from room when client asked them to. Client then said he drank the Lysol and is now stuttering and has an upset stomach and has not received medical treatment. All 3 staff members were placed on administrative leave pending investigation.
    • Child Abuse Hotline was called and accepted, unsubstantiated. Licensing follow-up on 7/11/22: Witness statement from Direct Care Staff stated that client was upset after receiving directive from staff, and client walked to nightstand that staff was using and sprayed cleaning product in their mouth while staff attended to another resident. Witness statement from nurse indicates client was assessed after spraying Lysol in mouth. Client interviewed: When asked about issues with staff, client stated that the 3 staff members, on separate occasions, all approached client with their fists balled up and other staff stopped them. During interview, client made a complaint to Risk Management regarding another staff member. No definitive evidence of licensing concerns voiced during this complaint.

PRLU or OLTC

Licensing Compliance Record, Self Report Incident Response

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 9am – 11am regarding 06/25/22 incident, in which client eloped from facility by pushing unit door open and jumping the fence. The client was located by Magnolia PD on 6/26/22 and was returned to the facility.
  • Licensing observed door that client eloped from to be locked from both inside and outside, requiring a key, but noted the door did have “a little give” when pushed and/or pulled. Licensing interviewed client, who stated that previously, the door was able to be opened by pushing on it, even when locked. Client stated after eloping, he walked about “15 miles” which took him about 2 hours, then he got on a stationary train which shortly began to move. Client stated he jumped from the moving train (no injuries reported) and a guy helped him to get to Magnolia (by hitch-hiking) where he was recognized by police and returned to Millcreek. When given the opportunity to voice issues or concerns, client voiced complaints about staff. Licensing confirmed client was aware of how to follow protocol for reporting facility complaints. Staff contacted maintenance, who stated that a replacement door is being ordered. No deficiencies in minimum licensing standards noted regarding this incident.

PRLU or OLTC

Elopement, Notice of Incident

  • Elopement
    • At approximately 1156, client pushed the unit door open and eloped from Magnolia Hall. The client jumped the fence and ran into a wooded area. Staff followed but were unable to locate client. On 6/26/22, Fordyce PD informed facility that client was in the custody of Magnolia PD. Millcreek obtained custody of client and client was returned to facility at 1417. Client was placed on elopement precautions. No follow-up details.

Police Report

Second Degree Escape

At approximately 12:15pm, Nurse provided officers with description of missing juvenile and advised that the last time staff saw him, he was running into a wooded area. On 06/26/22 at approximately 8:38am, officer was advised that the juvenile was located. The juvenile was transported to the police department and the facility made arrangements to pick him up.