Multiple deficiencies were noted during the Inspection of Care (IOC) conducted on 09/09/24. A Corrective Action Plan (CAP) was submitted and approved.
PRLU or OLTC
CAP, IOC Report
Police Report
Elopement, Police Report
Officers were dispatched regarding a missing juvenile. The juvenile left the facility by going over the fence. Staff followed the juvenile, who was still on facility grounds. DHS was contacted so that the juvenile could be moved to another facility.
Police Report
Disturbance, Police Report
Police were called by a facility employee who stated that a patient punched her in the face. The employee stated they were afraid to press charges. No response to the facility was requested. Report only
PRLU or OLTC
Notice of Incident, Self-Harm
On 8/27/24, Resident was upset and tore down posters from facility that were posted on the wall. Resident repeatedly kicked the doors and walls while being redirected by staff. Resident complained about their toe hurting. Nurse assessed resident and OTC medication was given for pain. Resident will be on Assault Precautions for property destruction. The next day there was bruising and he reported pain. APRN ordered an x-ray. X-ray on 9/1/24 showed acute chip/avulsion fracture at the superior tarsometatarsal junction. He will go to Ozark Ortho urgent care today.
PRLU or OLTC
Notice of Incident, Peer Altercation
A resident and a peer got into a physical altercation and were separated by staff. After the separation, the resident began punching the wall with a closed right fist. Later he punched a chair, walls, and doors while on his unit. Afterward, the resident was assessed by the nurse. The resident’s right hand was red and swollen. Resident reported 10/10 pain and was given ice and ibuprofen. The APRN on call was notified and ordered an x-ray of the right hand.
PRLU or OLTC
Elopement, Notice of Incident, Suicidal Ideations
A resident was outside in the courtyard and refused to go back inside. The resident climbed the awning and was threatening to hurt himself or others. Staff continued to process with him, as he walked across the awning and then jumped down from the fence on the other side of the facility grounds. Fayetteville Police Department was notified, but the resident returned to the facility on his own several minutes later. The resident denied wanting to injure himself at the time of assessment. He was placed on elopement precautions and unit restriction to be reassessed 24 hours later.
PRLU or OLTC
Notice of Incident, Peer Altercation
A resident and his peer began to horseplay by pretending to hit one another while outside with their unit. The residents were directed several times to stop. The resident pretended to hit the peer and accidentally hit the peer in the chin. The peer then hit the resident causing a 1-inch laceration above the left eye. A large hematoma with swelling developed. The wound was cleaned and a dressing was applied. The APRN was notified and ordered the resident to be transported to Children’s Hospital for evaluation and treatment. The resident returned to the facility with sutures which will be removed in 7-10 days.
PRLU or OLTC
Accidental Injury, Notice of Incident
A resident reported to nursing that his finger was jammed while catching a football. The resident was assessed by the APRN and an X-ray was ordered. The resident will follow up with Ozark Orthopedics on 8/26/24.
PRLU or OLTC
Accidental Injury, Notice of Incident
A resident reported to nursing that he injured his toe while playing in the gym. He stated that he accidentally kicked the basketball goal pole and had pain in his 3rd toe. The resident was assessed by the APRN and an x-ray was ordered. The APRN will order further treatment as necessary.
PRLU or OLTC
Maltreatment, Notice of Incident, Redacted, Visit Compliance Report
On 8/25/24, resident wrote a grievance stating a staff member called him and a peer a name, shoved them on their beds, and ripped up their papers. After internal review, this was reported to the AR Child Abuse Hotline and accepted for investigation. Staff member was suspended pending the investigation.
Licensing Specialist: Jarred Parnell
Licensing followed up with the facility on the incident. The facility reported that the incident was not reported until 9/3/24 because “the complaint was confusing at first and was reviewed internally.” When asked to provide the witness statements, the facility stated “in most instances these are not released. We will further consult with corporate.” When asked if there was video footage, the facility stated “We tried to download the video but it kept erroring out and would not save.”
9/6/24 – Licensing visited facility to address concerns for the complaint, obtain staff and resident witness statements, and obtain a copy of the resident grievance report. Staff interviewed.
Citation issued for 110.9.a: A maltreatment report was made by a resident on 8/25/24. A maltreatment hotline report was not made until 8/27/24.
CACD case was unsubstantiated. Licensing complaint was unfounded.
Police Report
Elopement, Police Report
Officers were dispatched to the facility in response to two missing juveniles. Officers patrolled the area and issued a BOLO. At approximately 2120 hours, officers were dispatched to the facility for a recovery report. The juveniles returned to the facility on their own.
PRLU or OLTC
Elopement, Notice of Incident
While outside, two residents refused to go back inside. They climbed the fence and left facility grounds. Two nurses followed the residents but were not able to keep up. Fayetteville Police Department was notified. The residents returned on their own approximately two hours later. They were searched and assessed by nurses. No injuries were noted. Both residents were placed on Unit Restriction with Elopement Precautions to be reassessed 24 hours later.
PRLU or OLTC
Accidental Injury, Notice of Incident
A resident reported that he had accidentally swallowed a marble while he and a peer were playing a game. He was evaluated by the APRN, who ordered an X-ray. No bowel obstructions were visible. Resident will have Miralax, MOM, and Colace. Nurses will process safety concerns with residents.
PRLU or OLTC
Notice of Incident, Peer Altercation
Resident complained of pain and swelling to the left side of his face after being hit by a peer with a hard plastic item. Resident was assessed by the nurse and then taken to Arkansas Children’s Hospital for further assessment. Resident returned to the facility with an order for Tylenol or ibuprofen for pain. The peer was placed on assault precautions.
PRLU or OLTC
Maltreatment, Notice of Incident, Redacted, Visit Compliance Report
Resident reported that a staff member had let her and a peer use her nicotine vape on more than one occasion. Staff member was suspended. A report was made to the AR Child Abuse Hotline and accepted. Resident reported these incidents occurred in an area of the facility that does not have cameras.
Licensing Specialist: Jarred Parnell
Licensing spoke with staff concerning the residents having access to employee’s personal belongings. The facility has implemented new policies concerning personal belongings being placed in a secure location while on the floor.
CACD case was found unsubstantiated.
Facility reported to Licensing that the staff member would receive additional training on boundaries and zero tolerance for any type of abuse. 10/9/24 – Licensing followed up regarding retraining for staff, and the facility reported that the employee was not retrained as they are no longer working at the facility. This complaint has been unfounded by Licensing.
PRLU or OLTC
Complaint, Notice of Incident, Redacted, Visit Compliance Report
Licensing received complaint that a resident at the facility did not receive appropriate medical care on numerous occasions, such as: taking his blood pressure as directed by his Neurologist, didn’t provide his special diet, did not ask guardian for ID when resident was discharged, and that the resident has escaped numerous times.
Reporter stated the resident reported that while being transported to Fostering Change, the facility transporter allowed him to use his vape and play games on his phone, and he saw pornography on his phone and that he was a pedophile. This reportedly occurred on 6/5/24.
Licensing Specialist: Jarred Parnell
Licensing inquired if the facility was aware of the facility transporter allegation, and facility staff stated that the allegation “was shared by his therapist supposedly to another therapist that he stated something pertaining to a vape and/or phone access. This was brought up verbally days after the fact, but was still not documented by the person who received it which questioned the validity of reported topic.”
Facility was informed of the allegation on 7/2/24 when an investigator visited the facility. CACD investigated this complaint and it was unsubstantiated (07/02/24 Notice of Incident).
Complaint unfounded by Licensing.
PRLU or OLTC
Notice of Incident, Redacted, Sexual Maltreatment, Visit Compliance Report
Resident reported to staff that a staff member took pictures and videos of him, showed him nude pictures of herself, allowed the resident to speak with her sister on the phone, has been bringing him food and candy and that staff member asked the resident if he was a virgin and made an inappropriate comment about oral sex.
Licensing Specialist: Jarred Parnell
8/13/24 – Licensing visited the facility to review video footage of 3 separate timeframes on 8/8/24.
23:00-23:18, Staff can be seen on her phone regularly and showing the resident things on her phone periodically.
23:37-23:56, Staff and resident can be seen sitting in the hallway and exchanging a sticky note, staff was seen getting an earbud from her pocket that the resident had given to her, and staff can be seen giving resident what appeared to be bags of snacks.
13:06-13:09, Staff and resident can be seen entering the laundry room which is not on camera. It is unknown what took place in the laundry room.
Facility stated staff are not supposed to be on their phones for extended periods of time or have personal belongings while working, nor was the resident supposed to be out of his room during sleeping hours. Licensing requested all staff be retrained. Licensing reviewed witness statements.
8/15/24 – The staff member was arrested for Sexual Indecency with a Child and is no longer employed with the facility.
CACD case found true. Complaint was founded by Licensing. Citation issued for 109.1.g: A staff person engaged in unprofessional conduct with a resident.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Facility received a complaint that involved a former resident. The complaint alleged that staff would give vapes, dap bens with cannabis, cigarettes, lighters, and cell phones to the residents. The contraband was hidden along the fence line.
Also alleged was that staff would allow residents to fight in areas with no cameras, that staff showed inappropriate videos to the residents, and that staff would threaten to write residents up, falsifying restraint papers, to get residents in trouble.
Licensing Specialist: Jarred Parnell
Licensing Specialist visited the facility to complete a full walkthrough of the facility’s outdoor area, inspecting areas along the fence and outdoor areas accessible to the residents. No contraband was found during the inspection.
This complaint has been Unfounded by Licensing.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident complained of pain in his groin after falling on the steps of the playground area. Resident was assessed, then sent to the emergency hospital for further evaluation.
Diagnosis: Perineal/groin hematoma
Resident was discharged with orders for rest, ice, Tylenol, and ibuprofen.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident reported that his roommate told him their other roommate licked the resident’s penis while he was sleeping. The accused roommate denied the incident but was placed in a single room while the investigation was pending.
Licensing Specialist: Jarred Parnell
Licensing Specialist (LS) visited the facility in response to the incident. LS spoke with facility staff to discuss the complaint and safety plan implemented by the facility. The resident was interviewed. The resident does not know if the incident occurred, because he was told by the witness that the incident happened while he was asleep.
This complaint has been Unfounded by Licensing.
PRLU or OLTC
Elopement, Notice of Incident
Resident walked away from staff while outside with her unit. She ignored staff directions to return and squeezed through the gate into the parking lot and made her way to the main road. Staff continued to walk with her, urging her to return. The resident returned to the facility 28 minutes later.
Resident was placed on elopement precautions.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident rolled off the top bunk while sleeping, resulting in a laceration to his left eyelid. He was transported to the emergency room due to dizziness after the fall, where he was treated.
Resident will follow up with the facility APRN as needed.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was injured while playing football. Resident tripped, hitting his head on a pole. The incident resulted in a laceration above his left eyebrow and a chipped tooth.
The resident was transported to the emergency room for treatment. Afterward, he returned to the facility. An appointment with a dentist is being scheduled.
PRLU or OLTC
Notice of Incident, Peer Altercation
Resident was involved in an altercation with his peer, in which he was hit in the face. Resident was assessed for injuries by nursing. The altercation resulted in the resident receiving a chipped tooth. A follow-up appointment with the dentist will be scheduled.
Residents were separated and placed on assault precautions.
PRLU or OLTC
Elopement, Notice of Incident
Resident being admitted to the facility eloped from the facility before admission was completed. Police were immediately notified. A nurse driving home later that evening saw the resident on the side of the highway.
Police were contacted, and they were able to retrieve the resident and return him to the facility unharmed. The resident was placed on elopement precautions.