- Elopement
- Residents eloped through the door of the cafeteria and climbed over the fence leaving the facility grounds. Facility notified the police department. No follow-up details.
PRLU or OLTC
Notice of Incident
PRLU or OLTC
Visit Compliance Report
- Specialist reviewed 2 MARs and completed walkthrough. Agency has purchased several new items to be updated including soap dispensers, exit signs, water racks, doorknobs, etc.
- Regs out of compliance –
- R1011.7 – Rooms 400 & 403 have damaged drywall on wall & ceiling from residents hitting/picking at it. Profanity written on a wall of the hall in the South Unit in 2 locations. Agency will have rooms and walls repaired. Room 406 smelled of wet clothes/body odor; Housekeeping was called to clean the room.
PRLU or OLTC
Notice of Incident
- ER Visit (Foreign Object)
- Resident reported she had stuck a rock in her vaginal cavity and it had not come out. Resident reported pain 8/10 so she was taken to ER. No follow-up details.
PRLU or OLTC
Notice of Incident
- Maltreatment (1)
- During interview about a separate matter, Specialist was informed that staff member used inappropriate language and threatened a resident. Additionally, staff did not intervene as the resident was being beat up by his peers.
- Agency stated they are currently doing their own investigation into this matter and conducting interviews with the staff and residents involved. Specialist interviewed 6 residents involved in the altercation that took place; 2 residents reported they did not hear inappropriate comments/language from staff and the other 4 reported that staff “asked nicely”.
PRLU or OLTC
Notice of Incident
- Injury (Self-Inflicted)
- Resident was taken to ER for X-ray of his finger due to punching the wall and window of the seclusion room he was placed into on 9/11/21.
- Specialist received an addendum reporting that both the residents hands were X-rayed at the time of the ER visit and it was determined that he had fractured both pinky fingers.
PRLU or OLTC
Visit Compliance Report
- Specialist received a complaint that staff was out of ratio on 8/30/21. Specialist completed building and grounds walkthrough; All units were currently in ratio, but after shift change between 20:00-20:30 tonight, North and East Units will be out of compliance due to lack of staff availability. (10 staff to 92 residents)
- Regs out of compliance –
- R1012.4 – Bathrooms on South and West Units had paper towels and toilet paper in the floor. Staff stated residents just used restrooms before going to bed. Staff will clean once residents are asleep.
- Regs not correctable –
- R1007.4 – Staff/child ratio was not met on the night of 8/30/21; North Unit was 31 residents to 3 staff, East Unit had 21 residents to 2 staff. Specialist met with CEO who stated the facility was actively trying to fill available positions. Facility has had a high number of call ins and lack of staff availability.
PRLU or OLTC
Visit Compliance Report
No site visit conducted on this day. The specialist spoke with staff to inform them that the complaint received on 7/18/21 has now been completed. Licensing Complaint unfounded.
PRLU or OLTC
Notice of Incident
- Complaint
- Licensing Unit received complaint (from unknown source) stating that the facility is severely understaffed. “On August 30, 2021 one unit had 31 kids and 3 staff during the day. Yesterday there were only 8 staff for 94 kids. The DON and a nurse had to staff the annex building.”
- Specialist visited the facility on 9/7/21 for unannounced visit to conduct walkthrough. The facility was currently in ratio, but the reports from 8/30/21 did show that two units were out of ratio that night as the complaint stated. Additionally, due to call ins, ratio will be out of compliance again tonight (9/7/21).
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client reported to staff that during his first restraint hold at the facility on 8/26/21, staff choked and hit him after the resident spit in his face.
- Staff was placed on suspension on 10/21/21 pending the results of the investigation. Child Abuse Hotline was called and accepted, unsubstantiated. Facility reports there is no video footage of the incident and incident packet has been reviewed. The restraint report shows that resident reported he felt safe with no pain/injuries noted to him by the nurse. Due to no injuries/complaints from resident at the time of the incident, the agency did not have reasonable cause to believe maltreatment occurred so it was not reported.
PRLU or OLTC
Visit Compliance Report
- Facility reported a total of 10 residents and 1 staff member tested positive for Covid-19 this morning. An additional staff member is currently off work with Covid-19. Due to the outbreak, specialist viewed rooms on East and South Units, but not North and West Units as these were where residents were being held on isolation for positive Covid-19. Specialist reviewed 4 residents MARs.
- Regs not correctable –
- R908.8 – After reviewing MARs for 4 residents on West Unit, it was discovered that all medications for today were labeled as administered to the patients for the full day including night medications. Nurse reports she has a “bad habit” of pre-filling medication logs when she knows she will be the one to administering them in the evening. Additionally, two medications were not initiated or marked as administered to resident on 8/18/21.
PRLU or OLTC
Notice of Incident
- Suicidal Statement
- Resident reported to staff that he wanted to kill himself.
- Physician was notified and ordered the resident to be assessed for acute placement. He was assessed late afternoon/evening and was admitted late in the evening to Vantage Point for acute care.
PRLU or OLTC
Notice of Incident
- Injury (Accidental)
- Resident attempted to do a back flip during recreation and landed on his hand. Nurse noted swelling/bruising. Resident was taken to ER. No follow-up details.
PRLU or OLTC
Notice of Incident
- Injury (Peer Altercation)
- Two residents were in an altercation in the cafeteria.
- Both residents were placed on precautions and assessed by the nurse. Resident 1 stated his pinky finger hurt and was swollen. He received an X-ray that showed an acute oblique nondisplaced fracture of the base of the distal phalanx of the fifth finger. Staff emailed the specialist to report that the staff/child ratio at the time of the incident was 3/17 and there is no video footage of the incident.
Police Report
Assist Agency
Smoke coming from room; Smoke coming from mechanical room, no fire. CEMS and PD canceled.
PRLU or OLTC
Notice of Incident
- Maltreatment – Sexual Abuse
- A former resident made a report that during his stay in 2018/2019 that an unknown staff member pulled him from class and took him to the nurse’s station. While at the nurse’s station the unknown female staff fingered his private parts. The former resident reported that this only happened one time.
- Due to their not being a staff member named in the investigation and the alleged abuse happened 2-3 years ago, there is not enough information for an interim corrective action. Child Abuse Hotline was called and accepted.
PRLU or OLTC
Notice of Incident
- Other – Restraint
- Resident was refusing to go inside the facility after it began to rain/lightning. Resident was placed in a restraint hold for kicking/hitting staff by two nursing staff. Resident claimed nurse bent her thumb backwards during the restraint but does not believe it was done on purpose.
- Facility interviewed both nurses on the incident/restraint hold.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.15.f – Cords found on shorts in rooms of 201 and 408. Strings were removed from shorts on site. Correction date 7/9/21.
- R907.3 – Staff was out of ratio with residents in Sprout Day Room 1:12. Additional staff were called to the day room to ensure ratio compliance before walkthrough continued. Correction date 7/9/21.
Medicaid Inspection of Care
On-Site Inspection
- Included: IOC, CAP
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Resident reported that staff member pushed him. Resident states he first pushed staff several times and was upset at staff member for taking his ball and dice. Staff member then pushed resident about 6ft towards the nurse’s station.
- Staff member was immediately taken off his shift and sent home. Staff member was placed on suspension. Child Abuse Hotline was called and accepted.
PRLU or OLTC
Visit Compliance Report
- Scheduled meeting with CEO/Administrators and supporting staff to discuss operations at the facility and to participate in a tour of the facility.
PRLU or OLTC
Visit Compliance Report
- No regs noted out of compliance. Census: 92 minors.
- TA –
- R1009.2 – Ensure that minors are encouraged to tidy their bedrooms.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R1011.7 – Hole observed in wall above light switch in bathroom of room 102 (West). Due date 6.18.21.
- R1012.4 – Water was observed to have been collected on the floors of room 301 (girl’s unit) and room 102 (West). Due date 7.12.21.
Police Report
Assist Agency
Caller (staff) can smell smoke in the building and white smoke is coming from the ceiling in the bathroom. Officer advised caller they need to evacuate even though her manager said not to. Nothing found.
PRLU or OLTC
Notice of Incident
- Injury
- Client was outside playing catch with football; While attempting to catch the football along with another resident, he jammed his middle finger on left hand. X-ray showed acute nondisplaced fracture. Client went to Ozark Ortho and was treated with a finger splint. No follow-up details.
PRLU or OLTC
Visit Compliance Report
- Reviewed 2 children’s records. No regs noted out of compliance.
- TA –
- Room 201 missing baseboard, repaired during visit.