Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.
This IOC visit was triggered by a complaint against the facility.
PRLU or OLTC
Complaint Report, IOC
Police Report
Police Report, Sexual Assault
Officers received a report from the Arkansas State Police regarding an abuse investigation. The investigator informed officers that there was nothing of substance for law enforcement to initiate an investigation. The suspect’s attorney declined an interview. At this time there is no evidence of any crime being committed. Case closed.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Redacted, Visit Compliance Report
While being interviewed regarding another referral, client disclosed that approximately 3 months ago a peer had made client finger her and then the peer fingered client. She said it was in the doorway of the room when staff would walk the other way. Client said there was a look out, but she could not remember who. She said this occurred under the clothes and it happened one time. Residents were separated and placed on peer restriction.
Licensing Specialist: Jarred Parnell
10/14/2024 – Licensing Specialist reviewed notes for the maltreatment case.
CACD case unsubstantiated. The complaint has been unfounded by Licensing.
Police Report
Assault, Police Report
Officers received a report from the Arkansas State Police regarding an abuse investigation. Officers reviewed the video of the incident and agreed there was no evidence of a crime and the case could be closed.
PRLU or OLTC
Notice of Incident, Sexual Maltreatment, Visit Compliance Report
A resident spoke to her caseworker and indicated a staff member had acted in an inappropriate manner. The resident wrote a statement for the Director of Risk Management that said the accused staff member asked the resident if she would ever “mess with him”. The resident said no, but one night woke up to find him watching her from the doorway. She stated the staff member entered her bedroom and began touching her. She says she asked him to stop, but he wouldn’t. She reported that afterward, he handed her his vape and told her he’d come to get it in a little bit. The staff member was placed on suspension pending the outcome of the investigation.
Licensing Specialist: Kendra Rice
Program Coordinator discussed the incident with facility leadership. The facility reported that 39 hours of camera footage was reviewed by the CEO. The staff member named in this complaint was not observed entering the resident’s bedroom at any time. The staff member was observed standing outside the resident’s doorway for 30 seconds during room checks. The facility reported after their internal investigation it was determined that the incident did not happen. the staff member is scheduled to return to work and will be re-trained on verbal de-escalation.
PRLU or OLTC
Notice of Incident, Physical Maltreatment, Visit Compliance Report
Complaint received states that a staff member became upset with a resident when she left the day area to sit in her bedroom. The resident stated that when she refused to leave her room, the staff member picked her up and slammed her into the wall. She reported that she was scratched on her neck/shoulder area during the incident.
The resident was medically assessed and treated with topical medication. The Director of Risk and Director of Nursing reviewed camera footage and determined excessive force was not used. The staff member received Handle With Care refresher training on 8/16/24.
Licensing Specialist: Chelsea Vardell
Licensing visited the facility and reviewed camera footage of the incident. Several staff members can be seen going to the resident’s bedroom door. The facility reports that the resident is in her bedroom yelling/making noise that is disrupting the unit at this time. The accused staff member and a nurse enter the resident’s bedroom. The camera does not capture what occurs in the room. Moments later the resident is seen being restrained by the staff member and walked to the seclusion room. Video from the seclusion room shows that the resident is escalated, as she kicks the door and dances. Later, the resident is restrained and the nurse administers a chemical restraint. After she is released, she returns willingly to her unit and goes to bed.
The facility reports that the resident made a grievance report on 8/13/24. Licensing asks facility why the incident wasn’t reported to the child abuse hotline. The facility responded that the nurse who entered the room with the accused staff member reported that she did not witness any maltreatment. Licensing requested copies of all witness statements.
The facility was cited for 110.9.a: Staff shall immediately notify the Child Abuse Hotline if they have reasonable cause to suspect that a child has been subjected to child maltreatment.
This complaint has been Unfounded by Licensing. Suspension for accused staff may be lifted and he may return to normal job duties.
PRLU or OLTC
Notice of Incident, Physical Maltreatment
Three residents were involved in an incident in which they engaged in property damage. Staff intervened and all three residents were restrained. During the debriefing, a nurse raised concerns regarding the level of force deployed by staff. The Director of Nursing reviewed camera footage and noted that actions by three staff members did not align with company policy. Specifically, it appeared that one staff member twice kicked a resident being restrained on the ground. Another staff member was seen swinging her fist at a resident to get her to release a staff’s hair from a hair pull, and later hitting a resident to get them to release another staff member. The third staff member is seen leaning over the resident on the ground with his forearm pressed against her neck.
After the incident, the residents were medically assessed. One resident presented with a bump on the back of the head and a split lip.
All three staff members were suspended pending the investigation outcome.
Licensing Specialist: Kendra Rice
Program Coordinator met with leadership at the facility to discuss the complaint. Program Coordinator sat in on the interview with one of the residents. When asked if she had any bruises, the resident showed a faded bruise and another marking on the inside of her right arm.
Video footage was reviewed by Licensing and confirmed the reported events. All three staff members have been terminated in response to the incident. The residents were placed on assault precautions and increased supervision. The facility was cited for 109.1.g: Unprofessional conduct in the practice of child welfare activities; 905.4.g: Physical injury or threat of injury shall not be used, including as discipline; 905.9: Physical restraints shall be performed using minimal force and time necessary; 110.9.c: Staff in a child welfare agency shall immediately notify the Child Abuse Hotline if they have reasonable cause to suspect that a child has been subjected to conditions or circumstances that would reasonably result in child maltreatment.
This complaint has been Founded by Licensing.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact
The Director of Risk received two Resident Grievance Forms dated 08/11/24. Both forms indicated sexual misconduct occurred between residents, with one resident alleging her peer went into her bathroom and fingered her while she was showering, and her peer stating the resident followed her into the bathroom and told the peer to touch her, which she noted she did. Residents were moved to separate units while investigation was ongoing and placed on sexual acting out precautions..
Licensing Specialist: Kendra Rice
Program Coordinator discussed the provider-reported incident and reviewed the camera footage. It was reported that due to the resident’s shower being inoperable, she was told to use her peer’s shower. Her Peer is observed walking down the hallway and popping in and out of the bedroom a few times. There is no camera in the bedroom, so Program Coordinator was unable to review what took place. Due to the camera angle and distance, Program Coordinator could not determine what the residents were doing while sitting on the floor. It appeared that the residents were face-to-face a few times while sitting on the floor.
Staff members were sitting at the desk with one staff member’s back toward the resident and the other staff member facing a wall in the dayroom. Facility will be cited for 907.2 due to staff not providing adequate supervision. The facility has put a policy in place that was provided to Licensing. The facility stated staff were retrained on hygiene/shower time.
PRLU or OLTC
Accidental Injury, Notice of Incident
A resident reported to staff that her right index finger was swollen and she was experiencing 10/10 pain. The resident stated her finger bent backward when a peer accidentally stepped on her hand. The resident was assessed, and swelling was noted throughout the index finger and hand. She was given a bag of ice and PRN pain medication. The medical provider was notified and ordered the resident to Ozark Orthopedic Urgent Care, where her finger and hand were X-rayed and splinted. The resident will follow up at the Orthopedic office in two weeks.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact Forced
A resident (he/him) reported to staff that while he and a peer were sitting on the floor in the Dayroom with a chair flipped to its side, his peer asked the resident if she could finger him. The resident reported that he didn’t say anything when his peer pulled down his pants and fingered him. He reported feeling very uncomfortable. When asked when this occurred, he reported, “I don’t really know.” He did identify what staff was working. The residents were moved to separate units and an investigation was opened.
Licensing reviewed the provider-reported incident. Licensing followed up with the facility to review supervision concerns.
Police Report
Police Report, Redacted, Sex Offence
Officers received a report of a new investigation of sexual offenses by Arkansas State Police. Officers attended interviews and received statements. Video footage was reviewed.
The video evidence does not support the sequence of events as described by the reporting resident. No sufficient probable cause found.
Police Report
Forcible Fondling, Police Report
On 07/17/24 a Child Abuse report was received from Arkansas State Police Investigator in regards to a new report. On the evening of 07/16/24, Juvenile 1 and Juvenile 2 submitted statements to the Director of Risk (DOR) regarding the alleged sexual misconduct of Juvenile 3 in which J1 reports, “they would bend me over and touch my boobs and butt and flash me and try to see me change like holding my bathroom door open and looking.” The DOR verified that J3 was assigned her own room and staff was in ratio. On the morning of 07/17/24, the DOR interviewed the youth. During J1s interview, she claimed that on multiple occasions over the last few weeks, J3 touched her breast and butt and laughs off her attempts to say no. She also reported that J3 has flashed her breast at J1 a couple of times and has tried to hold her bathroom door open while she is changing. Both J1 and J2 stated they witnessed this behavior. A peer restriction is in place while this is an ongoing investigation.
On 7/19/24, [redacted] was interviewed by State Police Investigator. J1 denied any type of unwanted sexual contact or battery, and described most of the activity as playful conduct that most of the girls in the behavioral unit do. State Police closed this case as unfounded.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact Forced, Visit Compliance Report
Residents submitted statements to the Director of Risk regarding allegations of sexual misconduct by a peer. Reports stated, “They would bend me over and touch my boobs and butt and flash me and try to see me change, like holding my bathroom door open and looking.”
The Director of Risk verified room assignments and that staff was in ratio, then interviewed the reporting resident. The incident was reported to Licensing and the residents were placed on peer restriction and alternate unit programming.
Licensing Specialist: Jarred Parnell
Licensing Specialist visited the facility to review the video footage. Video footage shows resident “twerking” and receiving a kiss from another resident. Licensing Specialist reviewed the incident with facility staff and discussed the need for increased supervision during hygiene time. Documentation of new hygiene time routine received.
This complaint has been Unfounded by Licensing.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact Forced, Visit Compliance Report
Resident reported that a peer kissed her twice and forced her to lick her peer’s vagina. The resident reported she and her peers were playing Truth or Dare and another peer dared the resident’s peer to kiss her. The resident reported her peer had turned her around and kissed her, then followed her into the bathroom where her peer forced her to lick her vagina.
Licensing Specialist: Jarred Parnell
7/19/24: Licensing Specialist visited the facility to review camera footage and discuss the incident with facility staff. Video shows residents in the day room. When a staff member leaves the day room, the two residents enter the first bedroom door where residents use the restroom. The two residents are out of view for approximately 20 seconds, then re-enter the day room.
Licensing specialist reviewed the incident with staff and discussed implementations for increased supervision during hygiene time and providing more structure. The facility will provide documentation of the implementation by 7/26/24.
This complaint has been Unfounded by Licensing.
PRLU or OLTC
Notice of Incident, Self-Harm, Visit Compliance Report
Resident used a piece of plastic from a deodorant bottle to self-harm her right forearm. The resident was assessed and sent to Arkansas Children’s Hospital for evaluation. The resident received 6 sutures to close the wound and was discharged with orders to apply antibiotic ointment on the laceration until the stitches were removed. The resident returned to the facility, where she was placed on Self-Harm precautions. Staff performed a contraband sweep of all units.
Licensing Specialist: Jarred Parnell
Licensing Specialist visited the facility to review video footage of the incident. Resident used a cap from a stick of deodorant, which she was able to break and sharpen to cause the lacerations. Facility staff are implementing a plan to ensure hygiene products are accounted for after hygiene time. Facility staff will provide documentation of the implementation when completed.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
Complaint received by Placement and Residential Licensing Unit (PRLU) alleges that a resident arrived at the facility in April, but did not have an adequate master treatment plan. The complaint also alleges that there have been multiple “unit against unit” brawls at the facility.
7/10/24: The complaint was reviewed by Licensing.
8/7/24 Program Manager and Licensing Specialist visited the facility to review children’s records.
Licensing Specialist: Chelsea Vardell
Licensing reviewed two resident’s records. Resident 1’s file contained a master treatment plan that included no reviews since May 2024. A restraint packet was found in the records that did not contain a physician’s orders for the restraint. Additionally, four other restraints were documented, but no corresponding restraint packets could be found. Resident 2’s file contained a master treatment plan dated 7/25/24, but the resident had been admitted on 4/24/24. The facility could not produce the original treatment plan for this resident. Additionally, a review of the physician’s orders showed that the resident had been placed in restraints on two occasions, but there was no restraint documentation accompanying those orders. The resident has only received family therapy with her guardian one time since her admission, although she is supposed to receive family therapy twice a month.
Facility cited as follows:
903.4 – Treatment plans were found not to have been developed within 30 days of admission
903.8 – Treatment plan reviews were not present in files
905.11 – Physician’s orders were not found regarding chemical restraints given to resident.
905.12 – Physician’s orders were not found regarding physical restraints performed on resident.
905.17 – Documentation of restraints were not found in resident’s records.
PRLU or OLTC
Accidental Injury, Notice of Incident, Visit Compliance Report
Resident injured her toe by climbing on the metal part of a volleyball net. The resident was sent to Arkansas Children’s Hospital (ACH) Emergency Room per physician’s orders after nursing assessed a cut to the bottom of the resident’s left toe.
The resident received stitches and a Tetanus shot. She was discharged with a topical cream to apply twice daily.
7/3/3024 – A visit was conducted at the facility to inspect the volleyball netting equipment. Licensing discussed adding some padding to the base where the metal knob is exposed or increasing supervision when the residents are in the gym with facility staff.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident reported that her peer touched her on her lower front. Her peer reported that the resident touched her on her butt.
Licensing Specialist: Jarred Parnell
A visit to the facility was conducted to discuss the incident and review supervision. Video footage was reviewed for supervision and bed checks.
Complaint was UNFOUNDED by Licensing.
Police Report
Police Report, Sex Offence
Officers were dispatched to the facility regarding a complaint of sexual assault made by a resident. The resident reported that she had been assaulted by one of her peers.
The incident was investigated. Findings suggest the incident occurred but was consensual.
Open case was moved to inactive.
Police Report
Fire Alarm, Police Report
Officers were notified that the facility was performing a fire alarm test.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
Complaint received: We received a report about a resident being arrested and charged with second degree battery for hitting a staff member. After reviewing video of the incident, we realized the description of the event was misleading and did not match the events described in the report. The situation could have been prevented if staff had left the resident in the seclusion room instead of dragging her to the unit. Staff failed to de-escalate the situation and used police and a behavior management tool. We are seeing too many facilities using police as behavior management, resulting in children being charged with crimes. Another issue observed in the video was the child getting a chemical restraint after she was calm for 10 minutes. In summary: Before the assault on the nurse occurs, the resident is sitting calmly in the seclusion room. She does not becom dysregulated until staff pick her up and drag her out of the room and back to the unit. In between the time the resident hit staff and was separated from her peers until the nurses enter to give her a shot (16 minutes), she sat still and didn’t move.The report says that after police left, the resident assaulted staff again. No evidence of a second attack was seen on the video of the incident. After asking the facility risk manager to identify the second assault, she stated that it was not cooperating when staff tried to remove her from the seclusion room, where she was sitting calmly and quietly. Considering these facts, we do not feel this incident should’ve resulted in a second call to the police and the arrest of the resident.
Licensing Specialist: Chelsea Vardell
Licensing visited the facility with OLTC (Office of Long Term Care) in response to the complaint. Licensing reviewed the facility restraint log, the resident’s file, staff personnel file, and the facility restraint policy, along with video footage, the police report and 911 call.
The following were issues and concerns identified during the review: No physician’s orders for 7 physical restraints and 1 seclusion; No restraint justification packet for two physical restraints and two seclusions; One physical restraint and seclusion order not listed on the facility restraint log; Staff member’s last training on the facility’s restraint policy was on 12/6/2023 while she was a contract nurse. She was hired as a full time staff member in July 2024. The facility policy is to train staff at the time of hire and every six months afterward; Review of video shows resident sitting calmly for 17 minutes before receiving a chemical restraint.
The facility will be cited for: 905.12: Physical restraint and Seclusion can only be used if ordered by a physician; 905.17: Documentation of all restraints shall be maintained; 905.10: Physical restraint was conducted on a resident who was in a seclusion room and not a danger to themselves, others, or property.
All staff should be retrained on the facility restraint policy. Staff must be retrained on Handle With Care by 9/6/24.
PRLU or OLTC
Aggressive Behavior, JDC, Notice of Incident
Resident was escorted to the Juvenile Detention Center (JDC) by Springdale Police Department for assaulting a Nurse.
On 6/22/24, the resident was uncooperative and aggressive during a transition back to her unit. She tried to elope off the unit and attacked a nurse, punching her with a closed fist in the face, back, and chest. The nurse went to the Springdale Police Department to press charges. Three officers from the Police Department arrived and issued a warning to the resident. Shortly after officers left, the resident assaulted staff again. Officers were called back and escorted the resident to JDC
Police Report
Disturbance, Police Report
Officers were dispatched to the facility in regards to a 911 hang-up call. No signs of disturbance at the facility. False alarm.
Police Report
Disturbance, Police Report
Officers were called to Perimeter Ozarks in regards to a resident assaulting staff members.
Police Report
Assault, Police Report
Officers responded to Perimeter Ozarks regarding a report that a staff member had been attacked by a resident. Officers issued a citation and a warning to the resident about her behavior.
Approximately 15 minutes after leaving the facility, officers were called back to Perimeter Ozarks regarding the same resident assaulting more staff members. Officers arrested the resident and transported her to the Juvenile Detention Center (JDC).