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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 |
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
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was taken to the emergency room due to concerns of injury to her right hand. Resident had become escalated on several occasions leading to her punching the wall multiple times. While at the ER, resident was diagnosed with no fractures or breakage. The resident returned to the facility around 1800 with no new orders. Resident placed on self-harm precautions.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact
On 1/18/24, resident told her caseworker that she had been sexually assaulted two Fridays ago by her roommate at the time. Resident refused to write a statement about the situation and also refused to give any more details when asked. Resident does have a history of making allegations and then recanting shortly after. Caseworker is the one who reported the information to us. Roommate when spoken to adamantly denies the allegation with the resident. There is no camera footage in the room so we cannot confirm or dismiss the allegation. Corrective Action: Residents separated and now on different units. Internal investigation being done. Residents placed on sexual misconduct precautions.
Licensing Specialist Jarred Parnell contacted the facility to follow-up with the provider reported incident. The report was not accepted by DCFS and there is no video footage of the incident. Facility staff stated the resident who made the allegation has a history of making false accusations and was not willing to write a statement regarding the incident.
This was not a complaint case, so there is no licensing complaint finding.
Police Report
Assault & Battery
Caller advised she would like to make a report for an assault that happened to her daughter yesterday at this address. Caller advised they are both patients inside the facility.
Officer spoke to mother of child. Some of the staff that was here last night reviewed the video for the officer. The mother and child will not file charges at this time, but officer will be filing an incident report.
PRLU or OLTC
Medical, Notice of Incident
Resident was taken to the ER due to continued complaints of sore throat, nausea, and cramping. Medications had been ordered as nursing already tested for flu, strep, and COVID -19 but the patient was refusing them. Staff was concerned due to the extremeness of patient’s behaviors (crying and yelling) that she was extremely ill. Multiple tests, x-rays, and exams were conducted at the ER and resident was discharged and returned to the facility on 12/27/23 at 2:00 am. She was sent back with a diagnosis of constipation and positive Coronavirus OC43 (this strain is associated with the common cold). Medications were ordered.
Police Report
Citizen Assist
Caller would like to speak to an officer concerning a patient making false allegations of child abuse. Caller was given his options.
Police Report
Disturbance
Officer responded to facility and spoke with the caller and the victim (Resident1), who stated that she and another resident were in a verbal argument when Resident2 grabbed Resident1 by the back of the head and hit her several times. There was no apparent injury and staff separated the two.
The incident is being handled internally.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident reported they had hit their elbow and was in pain. The nurse assessed and wrapped the arm and gave prn Tylenol as ordered without any further interventions needed at the time. It was reported that other residents on the unit started saying this resident was faking which triggered the resident who then banged their arm again on purpose due to this. The nurse was concerned upon assessment that the area was dislocated and wanted to make sure there was no further injury. Resident was taken to the ER and diagnosed with a bruised elbow.
Police Report
Assault
Officer Samuelson responded to Perimeter of the Ozarks to speak with 16 year old patient. Resident1 said there was an incident in which she was assaulted on Dec 4 (23-78333) and on Dec 10 (23-78341). On 12/4/23, Resident1 was in the Day Room Green Unit. Resident2 and Resident3 walked up to Resident1 and pulled her hair. They began hitting her in the back of the head and scratching her. Officer observed a scratch on her arm and took a photo. Resident1 said she was placed in a restraint by staff for fighting, but she was just trying to fight back to get the girls off of her.
Resident1 said she requested to press charges. At the time of incident, staff would not allow her to contact police and said they do not need to get involved. She still lives in the same wing as the other girls and sees them on a regular basis. Resident1 also said she feels like she is being denied her rights to access to contact CPS or her advocate.
Officer Samuelson received an e-mail from Sara Whorton (staff) on December 18 with the following statements: “Results regarding reported incidents: The first incident actually took place on 12/3/23 not 12/4. We do not have audio, but it can be seen on camera that the two other reported residents did walk up and start hitting Resident1 from behind. Staff intervened immediately but both reported residents did get several hits before they were able to be broken up. This took place at 18:28.”
Officer forwarded this case to Washington County Juvenile Prosecutors office for review of the charges of Battery 3rd Degree for Resident2 AND Resident3.
Police Report
Assault
Officer Samuelson responded to Perimeter of the Ozarks to speak with 16 year old patient. Resident1 said there was an incident in which she was assaulted on Dec 4 (23-78333) and on Dec 10 (23-78341). On 12/10/23, Resident1 was in the Day Room Green Unit. Resident2 had assaulted her by going for her hair, and hitting her across the face. She received a black eye, swelling, and a busted lip. Staff came in and both girls fell to the ground. As one resident was being restrained, she kicked the other resident in the mouth.
Resident1 said she requested to press charges. At the time of incident, staff would not allow her to contact police and said they do not need to get involved. She still lives in the same wing as Resident2 and sees her on a regular basis. Resident1 also said she feels like she is being denied her rights to access to contact CPS or her advocate.
Officer Samuelson received an e-mail from Sara Whorton (staff) on December 18 with the following statements: “The second incident took place on 12/9/23 at 15:47 not on 12/10. Resident1 antagonized several residents one after the other for about 10 minutes. The other four did not respond as staff were able to intervene. The reported resident did fight with Resident1 after verbal exchange was seen being made on camera. Again, we do not have audio, but the reported resident got up from her chair and hit Resident1 which began the fight. Staff were there and broke it up immediately.”
Officer forwarded this case to Washington County Juvenile Prosecutors office for review of the charges of Battery 3rd Degree.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Resident1 went into her room and wrapped material around her neck. Staff were present and responded immediately. While staff was trying to respond a resident from across the hall tried to start hitting Resident1 who began trying to fight, so staff assisted her off the unit for safety. Once off the unit, Resident1 became verbally and physically aggressive. She was placed in a hold until she was calm and could verbalize her plan for safety. She was released at 21:52. Afterwards she went to bed with no further issues.
Corrective Action: Resident placed on suicide precautions including removing all linens. Treatment team to discuss potentially moving resident to a different unit.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
The lead on duty reported that on 12/16/23 (Saturday) a staff member reported to her that one of the residents said a peer told them that the MHT had shown her a picture of his penis on his phone. This was reported to have happened on 12/10/23 (the previous Sunday) on the second shift after med pass. Cameras were reviewed and there was no evidence of this taking place. Staff never showed the resident his phone. Cameras were reviewed for the entire shift. Corrective Action: Staff suspended immediately until internal investigation is complete. Staff placed on restriction from this resident upon return. Child Abuse Hotline was called, not accepted.
Licensing Specialist: Jarred Parnell
12/19/2023 – A visit was conducted to review camera footage for provider reported incident for 12/10/2023 from 15:15 – 20:20. Video footage was reviewed for contact between the staff person and residents on the green unit. Staff person can be seen with his cell phone but never shows the residents anything on his phone. Whenever the staff uses his phone it’s for approximately 10-20 seconds and the phone is either in his pocket or left on the table. In light of the allegation, the staff person has been placed on a different unit and is currently on restriction from the resident as a precaution.
Licensing investigation is unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Jarred Parnell
A building and grounds walkthrough was completed of the building. All units, the classrooms, the cafeteria and outdoor recreation area were inspected for cleanliness, structural maintenance issues, sleeping arrangements. Ratios were evaluated during the walkthrough. The M.A.R was reviewed for 6 residents while at the facility. The M.A.R. is up-to-date for the days medication distribution.
Medicaid Inspection of Care
Corrective Action Plan, Inspection of Care Report
Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility on 12/06/23.
A Corrective Action Plan was submitted and approved.
Police Report
Welfare Check
Caller checking on his daughter. Caller said he got a call from her and heard loud music in the background and that made him worry. He said she shouldn’t even have a phone. He wants contact after she is checked on. Officer responded. She’s fine.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident reported to staff on 12/6/23 that on 12/2/23 after returning from her pass and taking her meds she went to her room and that her roommate at the time kept taking her blanket and smacking her on the butt. She reported her roommate proceeded to escalate and that she then began to touch her vagina and eventually inserted her fingers inside her and was licking her vagina as well. Resident stated she did not tell her to stop because she is scared of her roommate, but it was not consensual. Resident stated she eventually told her roommate she wanted to go to bed and her roommate told her she would let her sleep and then went back to her own bed. Resident reported that her roommate began masturbating after she went back to her own bed. Corrective Action: Residents separated and placed on sexual misconduct precautions.
Licensing Specialist: Jarred Parnell
Facility visited and video footage was reviewed for 12/2/2023 from 22:00 – 6:30 to evaluate supervision for nightly bed checks every 30 minutes. Video footage shows the staff checking the residents room around the time of the alleged incident.
While viewing the footage between the hours of 5:00 AM and 6:00 AM, the staff person did not do a bed check. The facility was cited for this 907.6. Staff to be retrained on bed checks and a system of reminder will be instituted in order to meet the standards for bed checks.
CACD investigation was unsubstantiated. Licensing founded complaint.
PRLU or OLTC
Maltreatment, Notice of Incident
Resident told staff on 12/1/23 that on the previous night 11/30/23 after showers but before bedtime that a staff member went into her room and raped her. She stated that the staff member entered her room and when she told him no, that he pushed her down on the bed and forced himself on her. The staff was suspended immediately. Later on during the day the resident called the milieu supervisor over to talk and stated that she had lied about the incident. She stated that nothing had ever happened and she was not sure why she had said that. Corrective Action: Staff suspended immediately. Internal investigation being done. Resident placed in high acuity room (has only one bed) due to recent multiple allegations and then her recanting.
The report was screened out for the maltreatment hotline. Licensing stated “This was not a licensing complaint investigation.” Facility investigation found untrue. Staff cleared to return to work.
Police Report
General Information
Fire Testing until 10:30 AM. Alarm company advised as well.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Resident took a washcloth from a staff table and ripped it up, then tried to tie it around her neck. Staff responded immediately and took the washcloth from her. Nurse reported that resident was sitting in the floor smiling and refused to process. Once the material was taken, resident became assaultive to staff.
There was no loss of airway and no injury or bruising to area. Resident’s breathing was not affected as staff intervened before she could get it tightly around her neck. Corrective Action: Patient placed on Suicide precautions. Units are no longer allowed to use washcloths or towels to clean up spills.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Within the past few days, Resident1 had made allegations towards another peer regarding the same types of situations as these. Today while therapist was speaking with her about the allegations, Resident1 admitted that she lied about previously accused peer, that those allegations were false. She then stated that she had been sexually assaulted by her roommate. She could not give dates. She stated that it has happened multiple times around bedtime/3rd shift. She said that Resident2 would lay on top of her and often insert fingers into her vagina. Resident1 also stated that Resident2 would force her to perform oral sex on them. Those were the only details she would provide at this time. Corrective Action: Residents separated and placed on sexual misconduct precautions.
Licensing Specialist: Jarred Parnell
A visit was conducted to review supervision for bed checks for dates 11/22/2023 – 11/25/2023, 15:00 – 7:00 AM. Specific times of the incident are not clear in the report. Supervision was reviewed by Licensing Specialist to ensure staff were doing regular bed checks within the 30 minute time frame.
Licensing and CACD unsubstantiated the complaint.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident1 reported on 11/24/23 that on 11/22/23 at 08:52 in the morning, Resident2 sexually assaulted her. Resident1 reported that the other resident entered her bedroom and demanded her to take off her pants. Resident1 states that after this Resident2 placed two fingers in her vagina and made her bleed. She also reports that Resident2 performed oral sex on her. Upon review of camera footage residents were not alone in a room together. They both were in the dayroom with staff and peers at the time surrounding and of the reported incident.
The next day on 11/25/23 Resident1 reported another incident to staff that was said to have taken place in October. The statement said that Resident2 came into her bathroom while she was there and made her do poses in front of her. She then stated that Resident2 put her vagina on hers and ejaculated. Resident1 continued her statement saying that two weeks ago while in her room Resident2 came in and humped her while kissing her on the lips. After Shower time on 11/25/23 Resident1 also came and showed the nurse fresh hickeys on her arms that had not been there previously. This was confirmed with the nurse who took initial report on the 24th as Resident1 was in paper scrubs and they would have been visible. Hickeys line up where mouth meets arm when raised.
On 11/26/23 Resident1 recants all statements stating that she lied and that it was a different resident (her roommate) who did these same type of activities to her. She refuses to write that statement. Resident2 denies all allegations completely and was not admitted when some of the allegations were alleged to take place. She was not admitted until 11/2/23. Corrective Action: Residents separated. Residents placed on sexual misconduct precautions.
Licensing Specialist: Jarred Parnell
Documentation for routine bed checks was requested around the time of the incident. S. Whorton will provide a log after the video footage has been reviewed and provide to licensing. 11/29/23 – A visit was conducted to review supervision for bed checks for dates 11/22/2023 – 11/25/2023. 15:00 – 7:00 AM.
Licensing and CACD unsubstantiated the complaint.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident1 reported that on 11/23/23 during second shift, Resident2 sexually assaulted her by climbing on top of her and sucking on her neck and breasts leaving hickeys. She also reported that she was kissed on the lips and that none of it was consensual. Resident2 refuses to talk about the situation or write a statement. Hickeys were noted by the nurse upon assessment. Corrective Action: Residents separated and placed on sexual misconduct precautions.
Licensing Specialist: Jarred Parnell
A visit was conducted to review supervision for bed checks for dates 11/22/2023 – 11/25/2023. 15:00 – 7:00 AM. Video footage reviewed did not show the alleged incident and it is unclear if the allegations are founded. Sleeping time supervision and nighttime bed checks was evaluated as part of the visit as the allegation states the incident happened in the bedrooms where camera footage is not available.
Licensing and CACD unsubstantiated the complaint.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident1 reported to staff that on 11/23/23 Resident2 had touched her inappropriately without consent. Resident1 stated that Resident2 told her to put her hand on Resident2’s thigh and that when she did in return Resident2 put her hand on Resident1’s thigh and then moved up to her vagina against her wishes. Residents report that it was over clothes and Resident2 stated that the activities were consensual. This took place in the dayroom while the residents were sitting next to each other under separate blankets that were overlapping. There was no sign of distress or fighting/arguing. Residents were sitting in the back of the dayroom with all of the peers from that unit and staff in front of them. Both residents can be seen watching staff and stopping movement under blankets when they think he is going to see them. Corrective Action: Residents separated. Residents placed on sexual misconduct precautions. Staff will be re-educated on blankets not being allowed in the dayroom unless therapeutically approved and meeting the criteria to be allowed (can not cover half of the body).
Licensing Specialist: Jarred Parnell
Video footage for the incident was reviewed at the facility. Times reviewed for date 11/23/23 at 18:00 – 18:30. The two residents can be seen in the day room sitting in chairs with separate blankets. The blankets are overlapping and movement can be seen near the residents pelvic areas. Staff are present in the room and supervising the residents, and at one point appear to be engaging in conversation with the residents from across the day room. The two residents can be seen watching staff while seated in their chairs. After approximately two minutes, the residents stand and walk towards the door for meal time. It is unclear if the alleged victim is distressed or upset after she stands from her chair and walks to the door.
Licensing and CACD unsubstantiated the complaint.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Resident1 was escalated and trying to fight another resident. Staff tried to remove the other resident, and Resident1 tried to follow and run off the unit. The accused staff grabbed Resident1 and pushed her back on the unit, knocking her to the floor. This was discovered while reviewing camera footage of a second incident. The second incident was reported by staff to Licensing, DON, and CEO. A Staff member reported that during the second incident occurring 20 minutes after the first, the accused staff hit Resident1 in the back. Accused staff reported that Resident1 bit her while staff was trying to separate Resident1 and another resident who were fighting. Both incidents were reported to the child abuse hotline. Corrective Action: Accused staff was suspended immediately. Resident1 and the other resident who were fighting have been separated.
Licensing Specialist: Jarred Parnell
Video footage was reviewed by Licensing for the two incidents. Incident 1 – The accused staff bumps the alleged victim with her shoulder and then pushes her to the floor. Incident 2 – Resident1 can be seen with staff’s right arm around her face. Resident1 bites staff. Staff hits Resident1 in the center of her back with a fist because she was not releasing the bite.
Facility is being cited 109.1g for unprofessional conduct for engaging in behavior that could be dangerous, and physically harmful to children. The facility has terminated the accused staff. Residents have been moved to different units and staff have been retrained on resident/staff interaction.
CACD accepted for the hit, documented only for the push. CACD unsubstantiated. Licensing founded.
Police Report
Criminal Mischief
Staff advised dispatch that she wanted to file a report due to 2 residents putting things in her water. Staff advised one juvenile spit in her water and the other put a green squishy in her water. Staff requested an officer respond to the facility as soon as possible. Officer spoke with the staff member and she was given her options.
Police Report
Sex Offenses
A report was received from Arkansas State Police Investigator. The report stated that a resident at the facility reported that 2 staff members have been sexually assaulting her. “On Thursday, 10/19/23, Alleged Victim was in the shower when [staff 1] and [staff 2] came in and held her arms. Alleged Victim advised that [staff 1] put his penis in her front (vagina) and [staff 2] put his penis in her back (anal), after ejaculating they switched places and did it again. They both took pictures of Alleged Victim. Alleged Victim stated that [staff 1] and [staff 2] put their penis in her mouth and ejaculated. Alleged Victim advised she was bleeding from her front and back. It was reported that Alleged Victim has been sexually assaulted orally and penetration by [staff 1] and [staff 2] with the last time being 10/24/2023.” The resident alleged there have been verbal threats to not tell anyone but on the 24th [staff] put a knife to her throat saying he would kill her if she told someone.
CACD investigator interviewed resident, during which more details were provided. Both staff members were interviewed who denied the allegations.
Facility internal investigation: After video review, neither staff member was with the resident alone or off camera. Due to being on self-harm precautions, the resident sleeps in the dayroom and does not have access to her room for most of the day. The only time the resident was in their room was for showers. Camera footage shows they were in their room alone, no staff went into the room. On multiple occasions the resident reported allegations while in the shower but the resident didn’t take showers on those days. Multiple staff and residents have reported that this resident has made comments that they are trying to get these staff members fired and also made statements that these allegations are false.
At this time, there is no evidence that a crime has been committed. This case will be submitted for Inactive Case Status Review pending further information upon the examination of the SA kit.