Disability Rights Arkansas

Timber Ridge / Neurorestorative Timber Ridge

*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 [email protected]

Location: Benton, AR

Population Served: Youth 4-12 years old

# of residents per unit: 15 Residents per room: 1-2 Capacity: 15

Contact with family (Calls and visit schedule): Families can call daily. Clients can call as long as they have been safe towards themselves and others

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? No

Treatment Modalities:

Clinical Director – MSE, CCC-SLP

Therapists: 3 full-time therapists (1 LPE-I, 1 LAC, 1 PhD Neuropsychologist)

Treatment modalities offered: Play therapy, sand tray therapy, polyvagal, CBT, solution focused, reality therapy

# of individual therapy sessions/week: 1-2/week

# of group therapy sessions led by a licensed mental health professional/week: 1

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PRLU or OLTC

Notice of Incident, Physical Maltreatment, Visit Compliance Report

Resident became aggressive during an intervention. The resident spat in a staff member’s face. The staff member slapped the resident in the back of the head/neck area with an open hand after the resident spat in her face. The staff member was asked to leave the area, and the resident was taken to his room.

Licensing Specialist: Clayton DeBoer

No site visit was conducted. The facility provided Licensing with nursing notes, staff witness statements and case management notes that support the allegation. The staff member was terminated.

Facility was cited for 109.1.g and 404.4.h as a result of the incident.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

Personnel records were reviewed. All items accounted for except one staff member was missing a signed job description.

Facility was cited 105.15g: The agency shall maintain a personnel file for each employee, which shall include: a signed job description.

PRLU or OLTC

Accidental Injury, Notice of Incident

Resident fell while playing ball. He was assessed by nursing and sent to the emergency room for evaluation, where he received two stitches to his ankle.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

Children’s record review completed. All items accounted for. No citations.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was engaged in a behavioral outburst on 5.14.2024, where he kicked the water fountain.

On 5.16.24, client reported pain in foot and the nurse assessed. Order was given to send the resident to an outpatient provider for an x-ray.

X-ray results: Negative for fracture. Staff to client ratio was 5:12.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

Personnel records reviewed. All items accounted for. No citations.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Resident was engaged in a behavioral outburst, during which scratches appeared on his face. Documentation reads that staff were trying to assist him with staying safe and in the midst of it his face was scratched by staff. When he was pulled for therapy he said the staff did it “on purpose”. A report was made to the Child Abuse Hotline and accepted for investigation.

Licensing Specialist: Clayton DeBoer

Program Coordinator inquired about documentation (nursing note, witness statements, and other staff involved). Facility provided documentation. Program Manager requested documentation from facility showing both staff involved in this incident had been trained in de-escalation and restraints. The facility provided CPI training certificates for both staff. The facility stated that the staff did not put the resident in a restraint, but instead used an L2 seated.

Witness Statements from accused staff and witness reviewed. Statements do not indicate that either staff scratched resident during incident. Both witness statements indicate that the resident banged his head against a chair. Resident was interviewed. No observable scratch today. When asked if he could tell what happened when he got his faced scratched he said, “I don’t know”. Resident stated facility staff were nice. When he was given the opportunity again to speak about the incident, he declined. Staff placed on administrative leave pending investigation.

CACD investigation and licensing complaint determined to be unfounded.

PRLU or OLTC

Maltreatment, Notice of Incident

Client’s guardian disclosed during a bi-weekly treatment team meeting that when she picked client up on March 9th for a therapeutic home pass, she noticed redness on his neck. When the guardian asked the client about this, he initially said he did not want to talk about it but later stated he was acting up and a staff was trying to help him, and they had grabbed his jacket and it rubbed his neck. The guardian stated she did not report it when it happened because she did not think anything of it. When the facility was made aware of this today, the therapist asked the client about this situation and he said he was really mad and the staff was trying to help him because he was mad and that he is not hurt, and was not hurt then. Facility looked at notes from that day and client exhibited multiple documented behaviors that morning. A report was made to the AR Child Abuse Hotline (not accepted for investigation).

3/21/24 – Per phone call with Kenleigh Bennett of Timber Ridge, staff mentioned by client will be retrained on proper restraints. 3/25/24 – Sign in sheet for staff training provided to licensing.

This was not an accepted investigation for maltreatment therefore there are no findings for maltreatment or licensing.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

As the therapist was processing the journals with the client in session 2/28/24, she came across an entry that stated that staff “let me hit her THC pen and I am high as f, she’s in there laughing her ass off.” The therapist asked the client about this after they read it and the client confirmed that the staff “let me hit her weed pen.” Client stated this happened on 12/14/23 and stated it happened again in January 2024 but did not have a specific date. The client also reported that this staff bought her a nicotine vape, but that she does not have the vape anymore. The staff did complete room sweeps on 2/27/24 to ensure there was no nicotine in the room and nothing was found. To ensure safety of this client, she was placed on safety and intensive supervision. Staff has been suspended and we called this into the child maltreatment hotline.

Licensing Specialist: Clayton DeBoer.

Staff informed Licensing Specialist that the hotline call was not accepted for investigation, and that staff will be terminated subsequent current suspension. Facility visited 2/29/24. Journal entry reviewed. It is the opinion of facility and licensing that this incident did occur.

  • Facility cited 109.1.g: Staff gave 17 y/o client vape pen access which may have contained marijuana and/or nicotine.

This complaint has been founded by Licensing.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Background checks review conducted for all staff.

  • FBI background checks missing for 18 staff. Facility cited 103.6: The following persons in a Child Welfare Agency shall be checked with the Identification Bureau of the Arkansas State Police for convictions of offenses listed in Arkansas Code Annotated 9-28-409.
  • Child Maltreatment Check missing in file for 6 staff. Facility cited 103.2: The following persons in a child welfare agency shall be checked with the Child Maltreatment Central Registry in his state of residence, and any state of residence in which the person as lived for the past 5 years, and in the person’s state of employment, if different for reports of child maltreatment.

PRLU or OLTC

Medical, Notice of Incident

Nursing provided treatment to client struggling with bowel movements, but client still did not release bowels. Medical Director ordered client to go to Arkansas Children’s Hospital for bowel care due to constipation. Client was provided enema in the ER. Client was not admitted and was sent back to Timber Ridge due to releasing bowel in the ER after treatment.

PRLU or OLTC

Notice of Incident, Suicide Threat

Client sent to Methodist Behavioral Health Hospital for acute admission due to suicidal and homicidal threats with a plan. Client was returned to facility 1/22/24.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

Buildings & Grounds conducted. Census 13. Clients in school today. 6 staff present at PRTF Buildings. School client/staff ratios: 2:4, 2:2, 3:5.

Grounds clean and free of safety hazards. PRTF building clean, safe, and in good repair except for some rooms being worked on during today’s visit (installing puncture resistant white lining). Bathrooms clean and sanitary with functioning sinks, showers, and toilets. Emergency diagrams, fire extinguisher and client rights observed. MARs checked. All initialed and up to date.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

PRTF Buildings & Grounds attempted 1/4/23. Due to multiple clients and staff being Covid positive, no visit could be conducted. Buildings & Grounds will be rescheduled. Neurorestorative Timber Ridge will notify Licensing when PRTF building is Covid free.

Annual Review/Policies PRTF conducted. All items on checklist accounted for. Incident Report Log for 2023 reviewed during today’s visit.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Client was sent for an x-ray today due to reported thumb pain. X-ray showed irregularity with possibility of small avulsion fracture. On 11/24/23, client began attacking staff by punching and hitting them. Staff used their body as a barrier and blocked to maintain safety. When trying to intervene and help client calm, he lost his balance and caught himself with his hand on the ground and continued to attempt to attack staff. Staff worked with him to try to calm, but he continued to be aggressive towards staff and then was placed in an NCI approved therapeutic hold to maintain safety of himself and others. Client was assessed by nursing and was treated and monitored accordingly. On 11/27/23, nursing assessed and informed the medical director of symptoms, and the medical director ordered the x-ray. Client accused staff of bending his thumb during the incident and this was called into the Child Abuse Hotline on 11/25/23 (not accepted, documented only). There is no camera footage of this incident.

Licensing Specialist: Clayton DeBoer

Licensing reviewed nursing notes and 6 witness statements. No documentation reviewed mention staff bending client’s thumb or indicate any inappropriate hold. Client was interviewed, who stated that staff member “bent my thumb and finger back on purpose”. When asked how he knew staff did this on purpose, client stated “because I punched her in the face”. Client indicated that this happened during the hold on the ground with staff . Staff Tylyn was interviewed who was involved in the ground supine hold and stated they did not observe the accused staff who had ahold of the other arm. Staff Anna interviewed and stated she was present for the entirety of the ground supine hold. Staff Anna stated that she observed staff holding client ‘s wrist during hold, and at no time did she witness staff grab or grab near client’s hand. Staff Anna stated that after the incident, she was present for and aided in deescalating when client disclosed that staff bent his thumb. Staff Anna stated that she did not report this to the hotline because she did not have reasonable cause to suspect that maltreatment occurred. Upon receiving this report the next morning, Timber Ridge PRTF Director Kenleigh Bennett advised staff Anna to call the Child Abuse Hotline.

T/A given for 110.9.a: Any owner, operator, employee, foster parent, or volunteer 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 child maltreatment. All staff will be retrained on mandated reporter policy and sense of urgency for making reports. Staff sign in sheet will be provided to licensing by 12/28.23

Licensing unfounded complaint.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

Buildings & Grounds conducted for PRTF building and Americana House. PRTF Census: 13, Americana Census: 4.

PRTF Building clients in line for school. Staff/client ratio: 6:12. One client was disrupting and in room 1 with 1 staff present. Grounds, bedrooms, and bathroom areas viewed. Kenleigh Bennett of Timber Ridge explained that single room walls are having puncture resistant white lining installed. One single room observed to have this today.

T/A given for 911.6: Room 3 had torn baseboard and room 5 had baseboards completely missing. Maintenance confirmed these issues are currently being addressed.

MAR checked. All initialed and up to date.

Americana House observed to be clean, safe, and in good repair. Bathrooms clean and sanitary with functioning sinks, showers, and toilets. Grounds clean and free of hazards.

Annual Review/Policies PRTF review conducted. All items on checklist observed during today’s visit.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Personnel Record Review conducted for 6 staff members. All items missing from review on 8/31/23 have been sent via email or viewed during today’s visit.

PRLU or OLTC

Notice of Incident, Peer Sexual Contact

Two clients were horse playing together and were cued multiple times to stop. Client then came running out of his room and told the staff that the peer touched his butt. The peer confirmed that he did briefly touch his butt over the clothes. CACD was called and initially accepted, but screened out.

Safety plan and incident information: At the time of the incident the ratio was 6 staff to 14 kids. Client was immediately removed, placed on intensive supervision, and he is sleeping in the common area now. He is also on safety and has been moved rooms away from peer.

No licensing findings as this was not a licensing complaint investigation.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Buildings & Grounds conducted from 8:30am – 9:30am. Census: 14. Areas viewed: Living areas, dayroom, kitchen, sleeping areas, bathrooms, and grounds. MARs checked for 5 residents. No licensing concerns noted.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Personnel records review conducted for 4 staff members. Several missing items noted in today’s visit. Personnel files will be audited by facility for items listed in the checklist for minimum licensing standards and progress will be reviewed by 9/30/23.

Regulations out of compliance:

  • 103.1: No FBI check in files for 2 staff members.
  • 105.4.d: No suicide awareness and protocol training for 1 staff member.
  • 105.8: No proof of 30+ hours of training or documentation of annual training for 3 staff members.
  • 105.13: No proof of 30+ hours of training or documentation of annual training for 3 staff members.
  • 105.15.d: No proof of 30+ hours of training or documentation of annual training for 3 staff members.
  • 105.15.a: No resume or application for any of the files checked today.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Building and Grounds conducted for Americana House. Census: 4. Grounds, sleeping areas, bathrooms, fire extinguisher, and emergency evacuation plan observed. MARs checked for 4 residents. No licensing concerns noted during visit.8.282

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.
Children’s Records Review conducted for 10 clients.
Facility cited 902.3: Three clients did not have proof of immunizations in their files. Proof of immunizations are required for clients by 9/11/23.

PRLU or OLTC

Visit Compliance Report

Buildings & grounds conducted from 11 AM – 12 PM. Staff/Client ratio 6:12. Living areas and kitchenette clean, safe and in good repair. Sleeping areas furnished, clean and in good repair. All bathrooms clean and sanitary with functioning sinks and toilets. Grounds clean and free of safety hazards. Emergency evacuation diagrams and client rights posted. Fire extinguisher observed. MAR checked for: [REDACTED]. All initialed and up to date. Licensing Specialist: Clayton DeBoer.

PRLU or OLTC

Visit Compliance Report

Buildings & grounds conducted for Neurorestorative Timber Ridge PRTF building from 5:30 PM-6:15 PM. Staff/Client ratio: 5:12. Grounds clean and free of safety hazards. Buildings and furnishings clean, safe and in good repair. Bathrooms clean and sanitary with functioning sinks, toilets and hot water. Room 8 had one pair of sweatpants with a drawstring in the waistband. Staff immediately removed the drawstrings from the pants. No other strings observed in clothing in sleeping areas. All sleeping areas furnished and reasonably clean.

MAR checked for: [REDACTED]. All initialed and up to date. Consultation had with director of pediatric services. Facility will design and implement a Zero-Tolerance policy/Protocol for licensing regulation 911.15F. This will be provided to licensing no later than 7/19/23. Regulations out of compliance: 911.15.F – room 8 had one pair of sweatpants with drawstring in the waistband. Licensing Specialist: Clayton DeBoer.

Medicaid Inspection of Care

Inspection of Care Report

Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.