FOR IMMEDIATE RELEASE Contact: Tom Masseau
November 26, 2025 501-492-5750
DRA Investigation Reveals Systemic Failures at Conway Human Development Center, Urges Immediate State Action
Little Rock, AR – Today, Disability Rights Arkansas (DRA) released findings from a comprehensive, multi-year review of the Conway Human Development Center (CHDC) uncovering systemic failures in nutrition management and clinical oversight that place residents at significant and ongoing risk of harm and death.
Sparked by three serious complaints in 2023-2024, the review expanded when DRA noted that 32% of CHDC residents who died between February 2023 and February 2024 were underweight at the time of death, and that CHDC repeatedly failed to acknowledge or correct deficiencies even when notified directly.
Additional findings include:
- Twelve cases of malnutrition documented between February 2023 and January 2025.
- Hospitalizations for malnutrition
- Persistent failures to follow hospital recommendations and maintain accurate dietary records.
“During the course of our investigation, we found entrenched structural issues related to dietary needs,” says Mackenzie Bell, Advocate. “Residents have suffered severe consequences, including emaciation, pressure wounds, unnecessary feeding tube placement, and dangerous medication interactions. CHDC’s practices fall far short of basic standards necessary to protect health and dignity.”
DRA’s investigations found that CHDC’s dietary and mealtime systems are fundamentally inadequate, characterized by poor documentation, infrequent or inconsistent monitoring, outdated or incorrect diet orders, and a lack of meaningful oversight by supervisory and clinical staff.
Despite repeated communication and the provision of a draft report to the Division of Developmental Disabilities Services (DDS), the agency declined to acknowledge errors, commit to corrections, or adopt recommendations. DDS’s response focused narrowly on disputing contextual details rather than addressing underlying problems, reinforcing DRA’s concern that meaningful reform will not occur internally without outside pressure and oversight.
“It is disappointing and disheartening that DDS did not use this opportunity to work with DRA on proposing ways to improve the process to ensure residents entrusted in their care do not suffer due to lack of nutrition,” says Reagan Stanford, Abuse and Neglect Managing Attorney.
The report highlights the following systemic failures –
- Incorrect or outdated diet orders left in place for months.
- Inaccurate documentation of food intake, sometimes contradicting video evidence.
- Failure to follow hospital recommendations for supplements, diet textures, or medical follow-up.
- Inconsistent or clinically unsafe diet textures prescribed, including substituting a “chopped” diet when a purely pureed diet was required.
- Rushed or prematurely terminated mealtimes, with residents denied alternatives or supplements.
- Inaccurate weights and BMI calculations, including errors as large as 27 lbs.
- Lack of functional oversight committees, such as the Weight Committee, which lacked minutes, tracking, or continuity.
- Insufficient staffing, with only one dietician for more than four hundred residents, including individuals who are medically complex.
Across all levels—direct-care, clinical, managerial, and oversight—CHDC failed to maintain basic standards necessary to prevent nutritional decline in an at-risk population.
Given these findings, DRA concludes that CHDC’s practices place residents at significant and ongoing risk of harm, and that internal systems cannot be relied upon to self-correct. Robust, external involvement from state and federal oversight entities, as well as community scrutiny, is necessary to restore safety and accountability.
Accordingly, DRA recommends systemic reforms related to staffing, oversight, clinical practices, and accountability to ensure a basic element of safety we should all demand from a state-operated institution.
“Everyone deserves to have their basic needs met. The community should demand better,” says Ms. Stanford.
To read the report visit – Malnourished: The Recurrence of Malnutrition at a Large State-Run Facility for Individuals with Intellectual and Developmental Disabilities.
For more information at Disability Rights Arkansas visit www.disabilityrightsar.org.