Disability Rights Arkansas

Perimeter Behavioral of the Ozarks / Woodridge of the Ozarks

*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 rstanford@disabilityrightsar.org

Location: Springdale, AR                   Population Served: Adolescent girls ages 7-17

# of residents per unit: Up to 12 Residents per room: 2 Capacity: 32

Contact with family (Calls and visit schedule): Weekly calls up to 3x/week for 10 minutes, intervention call available 1x/week for 10 minutes. Visitation available 2x/week for 30 minutes if previously scheduled. Zoom available if in person is not possible.

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

Treatment Components:

Clinical Director: LCSW                    Therapists: 2 full-time therapists (1 LMSW, 1 LAC)

Treatment modalities offered: Facility declined to identify any specific modalities available.

# of individual therapy sessions/week: Varies by client, most clients receive one individual therapy session per month

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

 

DRA Monitoring/Investigations

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PRLU or OLTC

Buildings and Grounds, Visit Compliance Report

  • Licensing Specialist: Michele Sutton.
  • Unannounced buildings and grounds visit completed. Licensing viewed green, blue, and orange units and grounds. Blue unit was recently painted and the unknown black substance around the skylight was removed and painted over. Shower drains have been repaired and tested to ensure they were draining properly. No citations in areas viewed.

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client used fingers to create superficial wound on her left arm. Wound was washed with soap and water. Client was placed on self-harm precautions x 7 days.
    • Licensing follow-up: The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

Police Report

Alarm

Caller requested dispatch. “Got sent to the hotline that is 24/7”; “Building secure.”

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client hit head against wall for a short period resulting in a small circular bump in center of forehead. Client refused treatment for injury. Client placed on self-harm safety precautions.
    • Licensing follow-up: The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).

Medicaid Inspection of Care

  • DMS imposes the following sanctions, based on findings from 10/21/22 Inspection of Care, and monitoring visits on 03/29/22, 07/20/22, and 10/13/22:
    • Placement in high priority monitoring status;
    • Submission of a Corrective Action Plan that addresses the deficiencies related to the missing treatment plans, to be submitted to DMS within 30 days of receipt of this notice;
    • DMS will be reporting the facility to its accrediting agency.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 11:30am – 1:15pm; Census: 26. Licensing inquired about de-escalation training that the CEO was waiting on approval from corporate. Interim CEO reported that the CEO is no longer employed at the facility and that all staff get de-escalation training during their SAMA training and annually. A roster was provided of staff that completed SAMA and annual training. No licensing concerns noted.

PRLU or OLTC

Elopement, Notice of Incident, Visit Compliance Report

  • Elopements
    • At approximately 4:08 pm, Client 1 conspired with peers to pull the fire alarm with a set of keys she had stolen. Client 1 entered the employee breakroom and stole car keys and the wallet of a staff member, then fled facility grounds in staff’s car with Client 2. Client 3 eloped from the facility separately. Police were notified. Clients 1 & 2 were picked up by Conway PD and transported to JDC; Client 1 did not return to the facility and was picked up by AR DHS, and Client 2 returned to the facility and was placed on elopement precautions, line of sight, and placed in paper scrubs. Client 3 was located by Springdale PD 2-3 hours later; She returned to the facility and was placed on elopement precautions and line of sight.
    • Licensing follow-up: Facility visited on 11/29/22 and camera footage reviewed. Licensing was informed that when the resident pulled the fire alarm and ran out of the gym, staff did not follow her but informed other staff and called the police. The resident then entered the breakroom and stole the keys and wallet. The other 2 residents eloped after being escorted outside due to the fire alarm. No licensing concerns noted.

Police Report

Missing Person, Runaway, Theft of Vehicle

At 1614 hours, staff called to report a child missing after the fire alarm was activated and doors unlocked; Shortly after, staff advised all children were accounted for. At 1637 hours, staff advised dispatch a juvenile fled the facility. Upon officer’s arrival, staff stated there were 2 missing juveniles. Staff stated J1 pulled the fire alarm and grabbed a wallet, backpack, cigarettes, and a lighter, then walked outside and left in a staff member’s vehicle. Staff later noticed J2 was missing and were unsure how she left the facility. At 1739 hours, staff called dispatch to advise of another missing juvenile that ran out of the facility when the fire alarm was pulled. J3 was located by police at approximately 8:10pm. At approximately 2319 hours, J1 & J2 were located by State Police near Plumerville.

PRLU or OLTC

Complaint Visit, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 10:15am – 12:30pm; Census: 24. Licensing inquired about boundary training, and the CEO reported that all staff have completed boundary training (Maintaining Healthy Boundaries) except for 3 PRN staff members. CEO stated those staff will not be able to work until they have completed the training. Copies of the sign-in sheets were provided. No licensing concerns noted.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

  • Maltreatment
    • It was reported by residents and staff that 2 residents were allowed to use a vape by a staff member while on transportation to an outside medical facility. The staff member was terminated from the facility on 11/22/22, and the staff member who reported it received a verbal and final written warning. Residents and their belongings were searched and nothing was found.
    • Licensing follow-up: Licensing spoke with staff, who stated the 2 residents were being taken to the ER for a stomachache and strep throat. The alleged staff member transported them, along with a new staff member who reported the incident. When asked about the incident by management, the alleged staff member stated “something like that may have happened” and refused to discuss it further. The staff member was immediately terminated. A sweep of the facility was conducted and no vape pen was recovered. Child Abuse Hotline call was screened out. Licensing was provided with the discharge papers for the ER visits, witness statement from staff, phone numbers of the staff members, and corrective action plan. Facility was cited for 907.2 (staff failed to provide the level of supervision to ensure the safety and well-being of the residents).

PRLU or OLTC

Notice of Incident, Suicide Attempt, Visit Compliance Report

  • Suicide Attempt
    • Client was sleeping in the dayroom due to safety precautions. When staff approached to do a safety check, client had 2 socks tied together and was making gestures to put it around their neck. Staff removed the socks and client was assessed. Suicide precautions were extended. 
    • Licensing follow-up: Licensing viewed camera footage on 11/23/22 and observed 4 residents sleeping in the dayroom due to being on precautions. Due to the camera angle, licensing was only able to observe client’s lower extremities under the covers, moving around on her mattress. No licensing concerns noted.

Police Report

Disorderly Conduct

Caller stated they needed an officer “right now”, stating a client was fighting staff (at approximately 1945 hours). Yelling could be heard in the background of the call. Officers responded to facility. A juvenile was transported to ER after complaining of stomach pain.

PRLU or OLTC

Complaint, Notice of Incident, Visit Compliance Report

  • Complaint
    • During a buildings and grounds walkthrough, multiple residents expressed concerns about the facility.
    • Licensing follow-up: On 11/17/22, Licensing interviewed residents and staff, and reviewed camera footage. Complaints:
      • 1) Client reported she doesn’t feel safe, and stated a staff member called her and her mother “nasty.” Client alleges the staff member stated “get the girl away from me because if she comes over here, she’ll have to fight me” (Video reviewed, Licensing couldn’t determine what was said; Unfounded).
      • 2) Client stated staff member is “always” telling one resident what another resident is saying about them, and stated a staff member can corroborate this. She also reported safety concerns (founded, cited 911.6), 2 residents self-harming with staples, and not having a hairbrush or conditioner.
      • 3) Client concerned about “black mold” on unit and lack of soap (citation & TA provided), and a sexual assault report not followed up on (Licensing verified report was investigated by state police).
    • Regs out of compliance –
      • 911.6 – Showers not draining properly (correct by 12/17/22), black substance around skylight feature on blue unit (repair by 11/25/22), exposed outlet with wire and screws behind a chair in the orange unit dayroom (repaired on-site).
    • TA –
      • 912.6 – No soap found in any bathroom on the unit or day areas.
      • 914.8 – Ensure severe weather drills are completed quarterly (facility reported they believed they were required every 6 months).
    • Revisit on 11/23/22: Drains in the process of being repaired (partially completed), wall plate was replaced, black substance cleaned and painted. Staff informed Licensing that residents are allowed a hairbrush and conditioner only during hygiene, and that upon request, residents are provided a small cup of liquid soap to wash their hands. MARs reviewed for 5 residents. No licensing concerns noted. 

PRLU or OLTC

Attempted Assault, Notice of Incident, Visit Compliance Report

  • Attempted Assault
    • Client began threatening to attack a staff member who she had a verbal disagreement with earlier, as well as peers. Client jumped on the nurse’s station and began throwing items, then picked up the phone and dialed 911, stating she “wants to go to jail.” Police were dispatched due to the call, and client was placed in handcuffs after attempting to push past officers. Once client was able to calm down, handcuffs were removed. Minimal redness noted to client’s wrists. Assault precaution safety plan was extended.
    • Licensing follow-up: Facility visited on 11/23/22 and camera footage reviewed (no audio). At no time was staff observed arguing with the client. Staff reported the telephone was moved to the YCC office and is brought out for telephone time, and all papers/notebooks will be kept in the nurse’s office. No licensing concerns noted.

Police Report

Assault

Officer responded to facility after dispatch received a 911 hang up, in which a male and female were heard yelling at each other. Upon arrival, officer observed juvenile banging on a locked door, yelling at people on the other side of the door. Juvenile was detained in handcuffs after being noncompliant and threatening to “kill all the hoes”. Juvenile stated she had called the police and advised an employee threw a chair at her earlier. Officer spoke with staff member, who stated the girls had been allowed to put makeup on themselves and after wipes were left out with makeup on them, staff stated it was “nasty”. Staff stated juvenile took it as staff calling her nasty, and juvenile threw a binder at her and spit on her before police arrived. Officer issued juvenile a citation for Assault 2nd.

PRLU or OLTC

Notice of Incident, Self-Injury, Suicide Attempt, Visit Compliance Report

  • Suicide Attempt, Self-inflicted Injury
    • Client attempted to scratch arm on door frame and get to outlets in the dayroom. Once taken to the comfort room, client attempted to choke herself with her hands, and began digging her nails into her skin to “get to the vein.” Upon assessment, small circular breaks in the skin were noted from client’s fingernails, with redness and minimal bleeding. Client was placed on suicide and self-harm precautions and placed in paper scrubs.
    • Licensing follow-up: Facility visited on 11/23/22 and camera footage reviewed. Licensing also checked the door frame and felt no rough edges when rubbing hand and wrist across the rounded screws. No licensing concerns noted. 

PRLU or OLTC

Licensing, Notice of Incident, Self-Harm, Suicide Attempt

  • Licensing (Suicide Attempt, Self-harm)
    • Client attempted to scratch arm on a door frame and get to outlets in the dayroom. Once in the comfort room, client attempted to choke herself by putting her hands around her neck and began digging her nails in her skin. Nurse assessed client and noted small circular breaks in the skin and redness with minimal bleeding; No first aid required. Client was able to self-regulate and per the C-SSRS results, client was high-risk and placed on suicide and self-harm precautions and in paper scrubs for safety. No follow-up details.

PRLU or OLTC

Licensing Follow Up, Notice of Incident, Suicide Attempt

  • Licensing (Suicide Attempt)
    • Client wrapped a towel around her neck after a verbal altercation with peer. Staff removed the towel, and no marks or redness was noted. Per the C-SSRS results, client was high-risk and will remain on suicide precautions for 7 days. Client placed on Constant LOS and took PRN medication.
    • Licensing follow-up: Specialist was informed that the PRN medication is documented on the MARs and is set up as needed medication and PRNs are already prescribed and available as needed. No licensing concerns noted.

PRLU or OLTC

Children's Records Review, Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Kendra Rice.
  • Facility visited from 11:20am – 3:30pm; Census: 26. Licensing reviewed 1 personnel file and 5 children’s charts with no licensing concerns noted. Licensing was informed that the facility’s boundary training started on 11/09/22 and the completion date to have all personnel trained is 11/11/22.

PRLU or OLTC

Licensing Follow Up, Notice of Incident

  • Licensing (JDC)
    • Client stated she intended to “kick-punch everyone until I get to leave with the police.” Client was placed in a restraint after attempting to destroy the fire extinguisher and threw a walkie talkie at staff. During restraint, an emergency call was heard for Green Unit and 2 staff left the restraint to address the issue w/o nurse directive. Another hold was initiated after client attempted to trigger fire alarm and punched staff who intervened. Shortly after restraint, client attempted to break into the med room, resulting in a hold. Client assaulted staff during restraints, and after attempting to assault officer, was taken into police custody. As of 11/9/22, client remains at Washington County JDC.
    • Licensing follow-up: Specialist viewed camera footage of incident and reviewed the incident report log and restraint documentation. No licensing concerns noted.

Police Report

Assault, Disturbance

At 0849 hours, officer responded after caller advised juvenile was aggressive and fighting with staff, and had to be held down. Officer left the facility, as juvenile had not committed a crime. At 0924 hours, officer responded again after staff reported the juvenile had set off the fire alarm and forced her way into the medicine room. While staff were removing her from the med room, juvenile bit staff member on the back, leaving a red mark. Officer charged juvenile with battery 2nd felony and transported juvenile to JDC.

PRLU or OLTC

Licensing Follow Up, Notice of Incident, Self-Harm

  • Licensing (Self-harm)
    • Client used a toothbrush she broke to make superficial cuts on her forearm. The scratches were cleaned, and a self-harm safety plan was initiated for 7 days.
    • Licensing follow-up: DON informed Specialist that the incident took place in the client’s bedroom bathroom, where there are no cameras. On 11/17/22, the Specialist was informed the client was doing better with no further incidents reported.

PRLU or OLTC

Complaint Survey with POC, Revisit Survey

  • 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.