Licensing Specialist: Clayton DeBoer
Children’s record review completed. All items accounted for. No citations.
*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 |
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
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.
This complaint has been founded by Licensing.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Background checks review conducted for all staff.
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
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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
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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:
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
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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
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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.
PRLU or OLTC
Visit Compliance Report
Buildings & grounds conducted for PRTF building from 9Am-10:30Am. Client/Staff ratio: 8:12. School observed to have staff/Client ratio 7:12. All sleeping areas furnished, safe, clean and in good repair except room 7, had one pair of pants with tie strings in them, room 8 had 3 pairs of pants with tie strings in them. The gaming area had a toy bag with a long string in it. The items were immediately given to the PRTF supervisor. They stated that all staff will inventory clothing for strings today. They stated that weekly checks will start being conducted to inventory for strings in clothing. All 6 bathrooms functioning, clean and sanitary with good working sinks and toilets.
MAR checked for: [Redacted]. All initialed and up to date. Americana building observed to be furnished, clean and in good repair. Bathrooms clean and sanitary. No grounds safety concerns. Client ratio residing in Americana: 5, staff present 2. Clients were at the pediatric school today. Regulations out of compliance: 911.15.F – at PRTF building room 7, one pair of pants with strings, room 8 had 3 pairs of pants with tie strings in them. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Maltreatment, Notice of Incident
Client was not following instructions and became physically aggressive towards self and staff. Staff used non-approved hold method. Staff was suspended from shift. Her agency manager was notified. Guardian-DHS Case Worker notified. Child liscensing agent notified. Witness statement describes staff put clients right arm behind his back extended up with his hand between his shoulder blades. Staff pushed his head to the floor and said “call me a bitch again”. Staff was immediately suspeneded after incident and will no longer be scheduled to work for Timber Ridge. Licesning Specialist: Clayton DeBoer. Regulations out of Compliance: 109.1.g – Engaging in behavior that could be viewed as sexual, dangerous, exploitative, or physically harmful to children. 905.4.c – The following actions shall not be used, including as discipline: Lewd or obscene language.
PRLU or OLTC
Technical Assistance, Visit Compliance Report