Licensing Specialist: Clayton DeBoer
Visit conducted 1/3/24. This is to confirm that applicant is not employed by Millcreek of Arkansas.
PRLU or OLTC
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Police Report
Arrest, Battery, Elopement
At approximately 4:45, officers were dispatched to Millcreek of Arkansas for a runaway juvenile. Staff advised the juvenile jumped the back fence and ran into the woods. Officers searched the area and then left the scene to another call.
At approximately 5:45 PM officers were dispatched back to Millcreek because someone had reported they could hear the juvenile in the woods yelling. After locating the juvenile, Ofc. Murry called over the radio that the juvenile was trying to take control of Ofc. Murry’s taser. Ofc. Byrne and Sgt. Hogan ran to Ofc. Murry and found him and a few members of Millcreek staff had the juvenile face down on the ground trying to gain control of his hands. Ofc. Byrne and Sgt. Hogan assisted him in gaining control of the juvenile who refused to give up his hands and continued to pull away and try to fight.
Ofc. Murray and Sgt. Hogan gained control of the juvenile’s hands and placed him into handcuffs, then escorted him to a patrol vehicle. Juvenile refused to get into the vehicle. Once in the vehicle the juvenile kept trying to get out of the vehicle. Ofc. Hogan tried to use the brachial plexus nerve stun with an open hand to gain control of him and missed the target area and caught juvenile in the left side of his face due to him thrashing around while Sgt. Hogan tried to get his seat belt buckled. Still unable to safely buckle him into the vehicle, Sgt. Hogan tried to hit his brachial plexus nerve area two more times and missed. After being held at taser point by Ofc. Murry, Sgt. Hogan got him buckled in the vehicle.
Ofc. Murry then began to transport juvenile to the Dallas County Jail. Juvenile began to kick Ofc. Murry’s windows and doors. At the jail Sgt. Hogan put leg shackles on the juvenile. The jail staff informed us that they could not hold him due to him being a juvenile. Supervisor Lt. Swiger informed officers to take juvenile back to Millcreek and have them keep possession of him. Juvenile was transported back to Millcreek, during which he made several threats to kill officers. Officers removed the handcuffs and leg shackles once Millcreek staff took control of the juvenile.
PRLU or OLTC
Elopement, Notice of Incident
Client became upset and eloped from his living unit, jumped a fence and entered a wooded area. Elopement protocol was initiated, and search efforts began. Fordyce Police Department was called. Client was located on facility grounds and became combative with police and staff. Client alleged to have been injured by police during altercation. Report does not indicate a staff supervision issue. Elopement protocol was followed. Complaint was alleged against Fordyce Police Department.
12/19/23-Phone call made to Chris Butler of Millcreek around 2:30PM. Client had a Dr.’s appt. at 1:00PM. Results are not available yet. Results will be emailed to licensing upon receipt. Client remains at facility. Client was out of supervision of staff for a period of time before being apprehended on facility grounds. Staff were immediately aware of elopement and followed protocol.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was referred to the Dallas County Medical Center for an outpatient x-ray. Resident reported foot pain resulting from a recreational injury that she sustained while playing volleyball. The nursing staff present on-site noted swelling in her right ankle. Upon further examination, the x-ray report indicated that there was no fracture present in her foot.
PRLU or OLTC
Injury Prior to Admission, Notice of Incident
Client was referred to Dallas County Medical Center for outpatient x-ray. He presented with complaints of back pain related to an injury sustained prior to admission to Millcreek. X-ray report indicates that no fracture is present.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was referred by her PCP to Dallas County Medical Center for outpatient x-ray. The x-ray report indicated that no fractures were present, and she was released from the facility without any restrictions.
She had reported experiencing pain in her thumb, following an incident where staff members had to remove rocks from her hand during a de-escalation process while attempting to prevent her from leaving the facility grounds. Resident had become upset and left the school building, and while outside, she picked up rocks and gestured as if she would throw them at the staff members. To prevent any harm, the staff members secured her hand and removed the rocks from it.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer
Buildings and Grounds conducted from 9:30 AM – 10:30 AM. Census: 156
Eagle Hall and Tiger Hall observed to be clean, safe and in good repair. Both Eagle and Tiger Hall have new flooring installed in hallways and have recently been repainted except for door frames, which are scheduled to be painted. Bathrooms clean and sanitary with functioning sinks, showers and toilets. Fire drill log checked today, most recent being completed in November. Outdoor area clean and free of safety hazards.
MAR checked. All but PM meds initialed and up to date. PM meds were not marked for 12/5/23. Facility cited 908.8. DON will consult with nursing staff on the importance of timely medication administration documentation.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer
Annual Reviews/Policies PRTF completed. All items on checklist accounted for.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Resident was in the laundry room and [staff member] told her to get out. When she did not listen, staff went to physically remove her and client hit staff. Staff then hit client in the head with a closed fist multiple times. The reporter stated that there was no bruising or blood anywhere. Staff was placed on administrative leave pending investigation.
Licensing Specialist: Clayton DeBoer
Client interviewed in response to complaint that A/O physically assaulted client. Client stated that she was aware of an incident in which “all but 2 staff showed up” in which her and staff were “playing…but we never touched each other”. Client stated that staff has never hit her or been mean to her. Client stated that staff at Millcreek were nice and that she felt comfortable talking to staff at Millcreek if she felt she needed to. Video reviewed of Flamingo Hall from 11/15/23 from 6:30AM-12:00PM. No altercation outside or around the laundry area is seen in this review of video.
CACD investigation and Licensing complaint unfounded.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer
Personnel Records Review conducted. All items required per minimum licensing standards observed.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was sent for an outpatient x-ray at Dallas County Medical Center. She was assessed by on-site nursing after an episode of self-injury where she kicked a door. X-ray report indicates there were no fractures present. She was released to return to the facility.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was sent for an outpatient x-ray at Dallas County Medical Center. She was assessed by on-site nursing after an episode of self-injury where she punched a wall. X-ray report indicates a minimally displaced fracture of the fifth digit. Dallas County ER provided a splint, and she was released to return to the facility. PCP will oversee her recovery from the injury.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident opened a fence gate that led to the outdoor walking trail and received an injury from metal found on the gate. Following onsite nursing assessment, she was referred to Dallas County Medical Center ER for assessment and treatment. Surgical stitches were used to close the laceration on her 3rd digit, and Dermabond was used to close a minor laceration on her 5th digit. She was released to return to the facility. Her PCP will oversee any further medical care needs. The fence gate has been secured to prevent any future injuries similar to this incident.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer.
Facility visited from 10:00AM-11:00AM. Video reviewed of the late night/early morning hours of October 25th, 27th and 29th for Tiger Hall, Flamingo Hall and Zebra Hall. All staff/client ratios viewed within licensing standard of staff/client ratio for sleeping hours 1:8.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted from 9:30AM-10:30AM. Census: 160. Outdoor play area staff/client ratio: 2:12. Rock Hill observed to be clean, safe and in good repair except for previously identified worn down spots in laminate tile. Millcreek is having tile replaced throughout facility, Rock Hill in line for the future. MAR checked for 5 residents. No licensing concerns noted during visit.
PRLU or OLTC
Notice of Incident, Self-Harm
On the evening of 10.11.23, client became upset and punched a wall. The swelling was noted initially but could also be a result of a previous injury sustained prior to admission that presented continued tissue swelling without the presence of a fracture. She was seen by her PCP on 10.13.23 and referred for x-ray at Dallas County Medical Center. X-ray report reflects moderate soft tissue swelling about the ulnar wrist without acute fracture or dislocation.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Client reported that on 10/05/23, a peer made him “suck him off.” Client stated he “tried to say no, but the kid said he would give me clothes, so I said OK, to make him shut up.” Clothes were exchanged between the two peers. Peer was moved to a different living unit and placed on Close Observation to prevent future occurrences. Child Abuse Hotline was called but not accepted due to a duplicate entry. On 10/11/23, Millcreek received notification that a report was made by an outside entity and accepted for investigation by CACD. The report alleged that client woke from sleep to find a penis in his mouth. He was forced to continue to perform oral sex until the peer ejaculated in his mouth. The report also alleged concerns with patient supervision by direct care staff at Millcreek.
Licensing Specialist: Clayton DeBoer.
Facility visited 10/12/23. Peer was interviewed and denied this incident ever took place. Peer stated client is saying this because he is afraid peer is going to beat him up over some necklaces and also to be moved closer to his girlfriend who resides at Millcreek. Peer repeated that this incident never took place adding that he has a girlfriend at home and is not homosexual. Peer stated that he has never seen all 3 staff (17 clients at Pine Ridge) leave Pine Ridge at any given time. He stated that staff do take breaks but other staff relieve them. Client was interviewed and stated that staff were absent from his living area when this incident occurred. Client stated “[staff 1] said he was going to the smoke shack”, “[staff 2] went out back to vape” and “[staff 3] went to get Taco Bell…I know because I saw the big Taco Bell sack”. Client stated the incident took around 3-4 minutes.
CACD investigation was unsubstantiated. This complaint is unfounded by Licensing.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted for Penguin Hall from 10:30AM-11:30AM. Census: 12. Penguin Hall recently painted, new floors installed. Day area, bedrooms, hallway, and bathrooms viewed. MARs checked for 5 residents. No licensing concerns noted during visit.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
Client was sent to Dallas County Medical Center ER for assessment following a physical confrontation. On-site nursing indicated bruising and swelling to the facial area. The CT scan indicates no fractures were present. Upon his return, he was reassigned to an alternate living unit to provide safety and reduce the chance of future incidents.
Licensing Specialist: Clayton DeBoer.
Staff reported there is no camera footage of incident. Facility visited 10/3/23. Client was interviewed and stated that there were two staff assigned to Magnolia Hall at the time of the incident but that one staff member had “gone to get trays”. Chris Butler of Millcreek indicated that this would typically take 8-10 minutes. Client stated that the other staff member present did not intervene after he was “jumped” by peers. Client presented today with swollen and bruised face. Staff, present and absent from Magnolia, if even for a brief period, failed to ensure the safety and well-being of client during this incident. Facility will conduct in-service training for staff involved in this incident that staff/client ratio will be ensured at all times.
Facility cited 907. 2: Staff did not ensure the safety and well-being of client during this incident resulting in the swelling/bruising of face.
Facility cited 907. 3: One staff left Magnolia Hall resulting in staff/client ratio 1:8.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was sent to the hospital for outpatient x-ray after reassessment from an injury the previous day. Client had punched a wall when he was instructed by staff members to give up a basketball. X-ray report indicates that no fractures are present.
PRLU or OLTC
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Licensing Specialist: Clayton DeBoer.
Facility visited and random video reviewed of cottages during evening hours. No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was sent out for an outpatient X-ray after complaining of pain to her hand after punching on the punching bag during recreation time the previous evening. No fractures were found. Client was returned to Millcreek without any restrictions. No licensing concerns noted from this report.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
Client was sent out for an emergency dental appointment after a physical confrontation with a peer, resulting in one tooth being knocked out. During the dental visit, it was determined that a second tooth was damaged and needed to be removed (completed during visit). Client returned to the facility. Millcreek is developing a follow up plan to address the missing teeth.
Licensing Specialist: Clayton DeBoer.
Facility visited and client interviewed. Client stated that staff immediately prevented him and peer from continuing to fight. Staff present during the incident stated she and other staff were deescalating an argument with client and other peers, when peer snuck up and punched client. Staff immediately intervened and client was taken to the nurse.
PRLU or OLTC
Accidental Injury, Notice of Incident
During recreational time in the gym, client slipped on the bleachers and obtained a laceration to her leg. Client was transported to the ER for treatment per PCP. Client returned to the facility and will follow up with her PCP. No licensing concerns noted from this report.
PRLU or OLTC
Accidental Injury, Notice of Incident
While playing basketball during recreational therapy, client went up for a rebound and came down and fell in between two other players and injured his ankle. Upon assessment, the nurse noted swelling to the right ankle. Client was transferred to the ER for treatment per PCP. Client will follow up with his PCP. No licensing concerns noted from this report.