summary: An x-ray was ordered after a resident complained of knee pain from falling prior to her arrival to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024434
Date of Incident: 10/1/2024
Date Received: 10/2/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: fell
prior to coming to Millcreek. She has since been having knee pain. Dr. ordered an x-ray of
her right knee to check it. The x-ray
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/3/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


state: AR

facility_name: Millcreek Behavioral Health / Habilitation Center, Inc.

summary: An x-ray was ordered after a resident injured her toe by kicking a door.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024435
Date of Incident: 10/1/2024
Date Received: 10/2/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: kicked a
door during a behavior injuring her left pinky toe. Dr. ordered an x-ray to check for
fractures. X-ray came
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/3/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was taken to Dallas County Medical Center for an x-ray after jamming his finger while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024244
Date of Incident: 9/24/2024
Date Received: 9/25/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was
playing basketball and jammed his right third finger. He was taken to Dallas County
Medical Center for an x-ray
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/25/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A CT scan was ordered for a resident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024242
Date of Incident: 9/24/2024
Date Received: 9/25/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Medical Director ordered an CT for
due to a history of CT Findings: 1.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/25/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray due to hand pain from punching a concrete wall.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024243
Date of Incident: 9/24/2024
Date Received: 9/25/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was sent to
Dallas County Medical Center for an x-ray on left hand due to complaint of hand pain after
punching a concrete wall. X-ray found d she was cleared to return to
Millcreek.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/25/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Dallas County Medical Center for evaluation after being involved in a physical altercation with several peers. The facility was cited 907.2 as a result of this incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024229
Date of Incident: 9/23/2024
Date Received: 9/24/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was
involved in an altercation on her unit. She was targeted by several peers. Code green was
called and staff separated. Staff took to Dallas County Medical Center to be
checked out due to complaint of face pain. All scans and x-rays She was
released back to Millcreek.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/24/24-Reviewed for licensing concerns. Email sent to facility
requesting safety plan for targeted client, nursing note and any incident reports and/or
witness statement. Emily Burris of Millcreek confirmed via text message there was video of
this incident. Visit scheduled for 9/25/24. 9/25/24-Facility visited and video reviewed.
Facility cited 907.2. 10/4/24-Training for staff involved provided to licensing.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A Medicaid Inspection of Care review was triggered by a complaint against the facility. Deficiencies were cited.

raw_content:
prior to leaving on pass. When deemed appropriate, body checks are completed upon returning.
While on a home pass or visit, the communication from guardians regarding the patients'
interactions, etc., will be documented in the patient's chart. Personal items may be checked by
staff upon admission and upon return from a pass as deemed necessary.
Below in a synopsis of events for the alleged victim:
• Client admitted to Habilitation Center, LLC on 2024, at
• Client was placed in Flamingo Hall in the main building on the upper campus. Flamingo Hall was placed
on quarantine from August 23, 2024, until September 6, 2024, for respiratory illness.
• The following significant events were documented in the nursing staff notes of the client’s clinical record:
o On 2024, at on the admission assessment the client’s temperature was
documented as 97.2℉ and there were no signs or symptoms of cough, congestion, or sore throat
noted in the initial assessment.
o On August 15, 2024, at 7:45 a.m. the nursing staff documented the client complained of feeling
“warm” and of a sore throat. The nurse documented the client’s temperature was 97.8℉ and throat
had some redness. given orally and given
orally. There was no follow-up documentation noted.
o On August 21, 2024, at 11:50 a.m. the client presented to the nurses’ station with complaints of
chills, stomachache, sore throat, and cough. The nursing staff documented client’s throat had
redness and irritation. The client’s temperature was documented as 101℉. The client was tested
for both strep throat and COVID-19 and both tests were negative. The client was given
orally, orally, and orally.
There was no follow-up documentation or temperature checks noted.
o On August 22-23, 2024, there was no nursing documentation of any previously documented signs
and symptoms of illness or temperature checks.
o On August 24, 2024, at 7:45 a.m. the nursing staff documented the client complained of headache
of 5/10 on pain scale and cough. The client was given orally and
orally. No temperature check was documented.
o On August 24, 2024, 9:30 a.m. the nursing staff documented follow-up with client who had no
further complaints of headache or cough.
o On August 24, 2024, at 7:40 p.m. the nursing staff documented the client complained of cough,
fever, congestion. Temperature was 103.6℉. The client was given orally and
orally.
o On August 24, 2024, at 9:00 p.m. the nursing staff documented reassessment of client’s condition
as a decrease in client’s temperature and cough. Actual temperature not documented at this time.
o On August 25, 2024, at 12:52 a.m. the nursing staff documented the client complained of cough
and fever. Temperature was 99.4℉. The client was given orally and
orally.
o On August 25, 2024, at 2:20 a.m. the nursing staff documented reassessment of client’s condition
as a decrease in temperature and cough. Actual temperature not documented at this time.
o On August 25, 2024, at 5:45 p.m. the nursing staff documented client’s temperature as 102.8℉.
The client was given orally.
o On August 26, 2024, at 2:18 a.m. the nursing staff documented the client complained of coughing
and headache. Client’s temperature was 99.5℉. The client was given orally and
orally.
o On August 26, 2024, at 7:30 a.m. the nursing staff documented the client complained of sore
throat. The client’s temperature was 98.4℉. The client was given orally.
Habilitation Center, LLC – Fordyce, AR – IOC Report 4 | P ag e

o On August 26, 2024, at 1:40 p.m. the nursing staff documented given. No other
documentation regarding client’s symptoms or requests noted in chart.
o On August 26, 2024, at 7:05 p.m. the nursing staff documented client’s temperature 100.3℉. The
client was given orally.
o On August 27, 2024, at 1:10 a.m. the nursing staff documented the client complained of cough
and congestion. The client’s temperature was 98.2℉. The client was given orally
and an allergy tablet (name, dosage, and route of medication not documented).
o On August 27, 2024, at 7:30 a.m. the nursing staff documented that the client was to be
transported to for mono spot test and a complete blood count
(CBC) to be done due to oral illness and elevated temperature. (No test results were submitted for
clinical review nor was there any documentation in the nursing staff notes regarding the client
being transported or returning to facility.)
o On August 27, 2024, at 7:40 a.m. the nursing staff documented the client’s temperature was
100.8℉ and the client requested throat spray for irritated throat. The client was given
orally and orally.
o On August 27, 2024, at 12:54 p.m. the nursing staff documented the client’s temperature was
99.6℉. The client was given orally.
o On August 27, 2024, at 7:36 p.m. the nursing staff documented the client complained of cough,
congestion, headache, and sore throat. The client’s temperature was 100.1℉. The client was given
orally and orally.
o On August 28, 2024, at 12:58 a.m. the nursing staff documented the client complained of cough
and congestion. The client’s temperature was 98.5℉. The client was given
orally.
o On August 28, 2024, at 7:15 a.m. the nursing staff documented the client complained of cough
and was given orally.
o On August 28, 2024, at 10:30 a.m. the nursing staff documented the client was transported to
for a chest x-ray due to cough and fever. (No results or
documentation was submitted regarding chest x-ray.)
o On August 29, 2024, at 7:00 a.m. the nursing staff documented the client complained of sore
throat and was given orally.
o On August 30, 2024, at 7:00 a.m. the nursing staff documented the client complained of sore
throat and was given orally.
o On August 31, 2024, at 7:15 a.m. the nursing staff documented the client’s speech as being
“hoarse” and that client requested throat spray. (No documentation in nursing staff notes of throat
spray being given to client. No medication administration records uploaded for review to verify
requested treatment given to client.)
o On September 1, 2024, at 8:05 a.m. the nursing staff documented the client requested throat spray
and was given orally.
o On September 2, 2024, at 9:30 a.m. the nursing staff documented the client returned from an on
campus pass with family. The parents of the client brought the client cough drops, tea, and
Kleenex. Items were kept at the nurses’ station.
o On September 3, 2024, at 7:45 a.m. the nursing staff documented the client was noted to have a
cough. Client refused and requested The client’s temperature was
99.8℉. The client was given orally.
o On September 3, 2024, at 2:18 p.m. the nursing staff documented receiving an order from the
physician for orally to be taken daily every morning for
Habilitation Center, LLC – Fordyce, AR – IOC Report 5 | P ag e

The nursing staff also documented attempting to contact client’s mother to get consent to
administer antibiotic but there was no answer, so nurse left voicemail. No other attempts to
contact mother on this date were documented.
o On September 4, 2024, at 7:00 a.m. the nursing staff documented that the client was given the
first dose of orally.
o On September 5, 2024, at 7:00 a.m. the nursing staff documented that the client was still taking
the antibiotics.
o On September 6, 2024, at 7:00 a.m. the nursing staff documented that the client was still taking
the antibiotics.
o On September 7, 2024, at 7:35 a.m. the nursing staff documented that the client was still taking
the antibiotics.
o On September 9, 2024, at 7:45 a.m. the nursing staff documented that the client complained that
throat was “a little sore” and was given. Also, the nursing staff documented
the antibiotic regimen was completed the day before which would have been September 8, 2024.
o On September 13, 2024, at 8:40 a.m. the nursing staff documented the client left the facility for a
72-hour home pass.
o On September 16, 2024, at 2:05 p.m. the nursing staff documented the client had returned to
facility from 72-hour pass. While on home pass with family, the client’s mother took client to be
seen by a physician before bringing client back to facility and received a prescription for
The nursing staff documented they would contact mother for clarification of order.
• No other documentation was submitted for review after September 16, 2024, at 2:04 p.m. due to AFMC
conducted Inspection of Care on this date.
• No physician orders, physician notes, or medication administration records were submitted for review for
this client. Unable to determine if the nursing staff remained in contact with the physician regarding the
health of the client.
• The Chief Operating Officer attached a letter date September 17, 2024, to the client’s clinical record that
stated the following:
o The client was scheduled for a pass on September 2, 2024. However, due to the client’s illness,
the pass was canceled, but this information was not relayed to the family. When the family arrived
on campus, it was decided to allow the visit, modifying it to an on-campus pass due to the
quarantine. Upon their arrival, the parents were informed that the visit could proceed, but
quarantine precautions needed to be followed. They were given the option of an outdoor visit or
using a meeting room, with masks required for the duration of the visit.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Habilitation Center, LLC – Fordyce, AR – IOC Report 6 | P ag e

doc_type: IOC Report


summary: Multiple deficiencies were noted during the Inspection of Care (IOC) conducted on 9/16/24. A Corrective Action Plan (CAP) was submitted and approved.

raw_content:
September 20, 2024
Habilitation Center, LLC
1810 Industrial Dr
Fordyce, AR 71742-7110
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
Habilitation Center, LLC
Provider Medicaid ID:
Onsite Inspection Date: September 16, 2024
Onsite Inspection Time: 9:04 AM
A summary of the inspection and any deficiencies noted are outlined below.
The provider must submit a Corrective Action Plan (CAP) designed to correct any deficiency noted in the
written report of the IOC. Accordingly, you must complete and submit to AFMC a Corrective Action Plan for
each deficiency noted. The Corrective Action Plan must state with specificity the:
(a) Corrective action to be taken.
(b) Person(s) responsible for implementing and maintaining the corrective action; and
(c) Completion date or anticipated completion date for each corrective action.
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report. Please
follow the link provided in the email notice to submit either a Reconsideration or CAP for the inspection, all via
AccessPoint.
The contractor (AFMC) will:
(a) Review the Corrective Action Plan.
(b) Determine whether the Corrective Action Plan is sufficient to credibly assure future compliance; and
(c) Provide the Corrective Action Plan to the Division of Provider Services and Quality Assurance (DPSQA).
Please see § 160 of the Medicaid Manual for an explanation of your rights to administrative reconsideration and
appeal. Additionally, the imposition of this Corrective Action Plan does not prevent the Department of Human
Services from prescribing additional remedial actions as may be necessary.

Inspection of Care Summary
Facility Tour:
Upon arrival at the facility, AFMC staff were promptly greeted at the entrance by a Habilitation Center, LLC
receptionist in the main lobby. AFMC staff signed the visitor log. AFMC staff were immediately taken to a
conference room where they were met by the Chief Operations Officer and the Director of Risk Management.
AFMC staff was given the completed and signed consent form listing approval for access to the AFMC portal.
Facility staff were given the Document Request Form and AFMC staff discussed the requirements for the
Inspection of Care.
A tour of the facility was completed with the Chief Operations Officer and the Director of Risk Management.
Areas toured included multiple units and houses on the upper and lower campus, nurses station including the
medication room, cafeteria, gymnasium, several outdoor courtyards, and school building that houses the
educational classrooms. The facility environment was extremely clean, well-organized, and appeared to be in
good repair. Therapeutic group activities and classes were in session. There were no immediate issues noted
during the facility tour. Staff were able to answer questions regarding the facility.
There were two units, Eagle Hall and Kangaroo Hall, in the main building on the upper campus that were both
on quarantine precautions until September 18, 2024. Both units had 2 clients each that had tested positive for
COVID-19. Eagle Hall had 17 clients quarantined and Kangaroo Hall had 12 clients quarantined. AFMC staff
toured both units with facility staff and were required to wear surgical masks while on the unit. Outside both
units there are masks at the central nurses’ station was an area where the mask was available as well as an area
where to dispose of the mask and hand sanitizer was available for use. All clients remain in the unit for all
educational classes, activities, and meals except for some outdoor activities so clients can get exercise and fresh
air. When these units are outside, they are the only unit in the area.
AFMC staff noted structural improvements were being made throughout the campus including fresh and touch-
up paint on unit walls, new tile flooring in the cafeteria, new Tuff Grip Epoxy surfaces added to bathroom walls
and floors, and exterior Smart Siding adding to interior walls of houses covering the cinder block walls for
durability and aesthetics.
Habilitation Center has also built a brand new house called Success House where female clients that are within
30 days of discharge can move into to get ready to transition out of the facility. Here they have a few more
privileges and freedom as well as they learn Life Skills, how to budget finances, and are even taught how to
cook meals. Currently, the provider is building a house for male clients to provide this same level of care.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, the following deficiencies were
noted:
Regulation Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2; There is no documentation in the HR The provider's records lacked evidence that all
42 CFR 482.130, records that all direct care personnel are direct care personnel are trained, as well as
483.376 trained in facility's Restraint and demonstrate competency, in facility's Restraint
Seclusion policy. and Seclusion policy and appropriate
procedures to be used in Restraint and
Seclusion interventions.
Medicaid IP Sec. 2: The facility has not submitted to The attestation letter provided by the provider
221.801 Arkansas Medicaid a Letter of was submitted via fax on July 25, 2024. The
42 CFR 483.374 Attestation that the facility is in standard indicates that if July 21st falls on a
compliance with CMS standards weekend or holiday, the attestation letter is due
regarding the use of Restraint and by the next business day.
Habilitation Center, LLC – Fordyce, AR – IOC Report 2 | P ag e

Seclusion.
Medicaid IP Sec. 2: HR records did not indicate that all direct The provider's records lacked evidence that all
221.804 care personnel have ongoing education, direct care personnel have ongoing education,
42 CFR 482.130, training, and demonstrated knowledge of training, and demonstrated knowledge of
483.376 techniques to identify staff and resident techniques to identify staff and resident
behaviors that may trigger an emergency behaviors, events and environmental factors
safety situation semi-annually. that may trigger emergency safety situations on
a semi-annual basis.
Personnel Records – Licenses, Certifications, Training:
There was a total of 41 records reviewed: 8 (25%) professional staff and 33 (25%) paraprofessional staff. During
the review of the personnel records, the following deficiency was noted.
Personnel Record Rule Credential Reviewer Notes
Number Validated
Medicaid IP Sec. 2: Restraint and SR018054 Training expired April 11, 2024.
221.804 Seclusion
42 CFR 482.130, Training (CPI) SR018068 Training expired April 09, 2024.
483.376
Observations:
AFMC staff reviewed the final document request form with the Chief Operations Officer at the completion of the
on-site Inspection of Care and the provider signed the acknowledgement of manual requirements that were not
made available in the provider’s policy and procedures. AFMC staff explained that these findings were
preliminary and there was still an off-site portion to be completed.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in the classroom setting in the school unit and in organized
group activities throughout the campus. Clients were engaged in schoolwork and activities. Two staff members
were noted to be on their phone in two separate classrooms. Otherwise, staff were calmly interacting with clients
and providing a therapeutic environment that was conducive for learning and treatment therapies.
Medication Pass:
No active FFS Medicaid clients received medications during medication pass. Due to the observation of non-
Medicaid clients not being complaint with the HIPAA minimal necessary rule, no medication pass was
observed. AFMC RN visited with the facility’s medication nurse who was able to show AFMC RN the facility
policies and procedures regarding medication administration, count, reconciliation, and handling of controlled
substances, and medication discrepancies.
The tour of the medication room was completed with the facility’s medication nurse. The medication room was
clean and well-organized in a way to provide safety in medication administration. There was a vial of tuberculin
skin test found to be open in the medication refrigerator. The vial was not labeled with the date it was opened or
with the initials of the nurse who opened it. This was reported immediately to the Chief Operating Officer and
Habilitation Center, LLC – Fordyce, AR – IOC Report 3 | P ag e

the Director of Risk Management who stated they would take care of having the opened, unlabeled vial removed
and educating the nursing staff on properly labeling multi-dose vials. No other issues were noted during the
medication room tour.
Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Habilitation Center, LLC – Fordyce, AR – IOC Report 4 | P ag e


summary: A resident reported to her therapist that a staff member shut a door on her arm. This complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024002
Date of Incident: 9/14/2024
Date Received: 9/16/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: told her
therapist that she was having a behavior and trying to get in the storage closet. She stated
that she had her foot in the door and moved her foot out of the door and as
worker was shutting the door she put her arm in the door. stated that
shut her arm in the door. Report was made to
Interim Action Narrative: A/O placed on administrative leave pending investigation.
Maltreatment Narrative:
was
having a behavior and was laying down in the floor and trying to get in storage closet. Staff
moved ?s foot out of the door and as was shutting the door,
put her arm in the door causing to shut the door on her arm. Once staff member
realized her arm was in the door she opened door back up to remove her arm. has
a bruise on her arm from the door.
Licensing Narrative: 9/17/24-Reviewed for licensing concerns. Email sent to
asking permission to contact A/V and/or facility regarding complaint.
Received email from granting permission. 9/17/24-Facility visited. Licensing
cannot make a finding at this time. It was determined the last name of the A/O is not
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

11/21/24-Recieved notification that maltreatment was unfounded. 521 issued
including that staff will be retrained on TCI and training completion will be
provided to licensing. 11/25/2024, reviewed and approved by Program Coordinator, Case
complete.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Emerald Burris
Record Visit Date: 9/17/2024
Home Visit Date: 9/17/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited in response to complaint that staff slammed a door on client during an incident
9/14/24 in which client was exhibiting behaviors. Incident report indicates that incident happened before
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

lunch. Video reviewed of Deerfield for the entire morning of 9/14/24 which does not show this incident or
what seems to be any behavior incidents. Client interviewed and asked to point out on camera view if
where incident occurred could be seen. indicated it was not in the camera view. stated this happened
before lunch. When asked, reported that she (staff was trying to shut a door to a closet, but had
her foot in the way so the door could not shut. stated that another peer ( moved her ( foot out of
the doorway and shut the door on her arm. stated nothing was said by during or after
incident. stated she asked why she ( shut the door on her ( arm. visually had a
bruise on her right, inner forearm during today's visit. Nursing note from the day of the incident states the
same. interviewed. stated that she ( was inside the closet and was trying to get in the closet, but
staff would not let her ( stated had her foot inside the door so could not shut it.
says she kicked foot out of the doorway and the door shut on her s) arm. stated that from what
she saw this was an accident. stated she at no time saw nor has seen do anything physically
harmful to clients. When asked stated she felt comfortable notify staff, including , if she felt
threatened while at facility. No definitive evidence from today's visit presented that would determine staff
acted unprofessionally or used physical discipline in a way that resulted in physical harm to As a
precautionary measure, staff will be retrained on Therapeutic Crisis Intervention. was
suspended immediately following incident. Licensing is not prepared to make a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 9/17/2024
Provider Signature : Date: 9/17/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent for an x-ray due to complaining of hand pain from falling.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023913
Date of Incident: 9/10/2024
Date Received: 9/11/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: ) was sent
for an x-ray due to complaining of hand pain. He was
It is undetermined how this occurred. Patient stated that he was
running and bumped into another patient and fell down on his hand and that is how it
occurred.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/11/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An officer was dispatched to the facility for a staff member wanting to report his stolen laptop.

raw_content:
. 4
Incident # _24-00390 Fordyce Police Department Report Date __09/11/2

Status Exception Clearance Date Reporting Officer ORI/Agency
: Not Applicable 305 Archer, Kevin ARO200100
Active :
Assigned Officer Entered By Approving Officer
KArcher | Taylor, Johnathan

Assisting Officers

Title Sex |Resident Status
Mr U Unknown
Ethnicity
Unknown
Work Phone Other Phone ie Cell
US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes
pe oe
Milcreek
Work Address Occupation

Offenses

1810 Industrial DR Fordyce, AR 71742
Earliest Possible Date Latest Possible Date
09/10/2024 16:00 09/10/2024 23:00
7 [Siaunattose—[oesciion “iin one ne a
1 Completed] 25] 8899]

Complainant
SSN/ID/TIN

Race Unknown

Home Phone

MO Method Of Entry # Prems
a 0
Location Types 13 Hway/Road/Alley 37 Abandoned/Condemned 48 Industrial Site Bias Motivation Codes : f
14 Hotel/Motel Structure 49 Military Installation 43 Lesbian, Gay, Bisexual,

01 Air/Bus/Train Terminal 15 Jai/Prison 38 Amusement Park 50 Park/Playground ANTI- 23 Protestant or Transgender, Mixed

02 Bank/S&L 16 Lake/Waterway 39 Arena/Stadium/F air 51 Rest Area 11 White 24 Islamic (Muslim) Group (LGBT)

03 Bar/Night Club 17 Liquor Store grounds/Coliseum 52 School - 12 Black or African 25 Other Religion 44 Heterosexual

04 Church/Synag/Temple 18 Parking LoGarage 40 ATM Separate from Bank College/University American 26 Multi-religious group 45 Bisexual

05 Commercial/Off Bidg 19 Rental Storage 41 Auto Dealership 53 Schoot - 13 American Indian or 27 Atheist/Agnostic 51 Phys Disability

06 Construction Site Facility New/Used Elementary/Secondary Alaska Native 31 Arab 52 Mental Disability

07 Convenience Store 20 Residence/Home — 42 Camp/Campground 54 Shelter - 14 Asian 32 Hispanic or Latino 61 Male

08 Dept/Discount Store 21 Restaurant 44 Daycare Facility Mission/Homeless 15 Mutti-races, Group  33NotHispanicor 2 Female

09 Drug Str/Dr OfffHosp 23 Service/Gas Station 45 Dock/Wharf/Freight’ 55 Shopping Mall 16 Native Hawaiian or Latino 71 Transgender

10 Field/Woods 24 Specialty Store Modal Terminal 56 Tribal Lands Other Pacific Islander 41 Gay (male) 72 Gender Non-Conforming

11 Govt/Public Bldg 25 Unknown/Other 46 Farm Facility 57 Community Center 21 Jewish 42 Lesbian 88 None

12 Grocery/Supermarket 47 Gambling 58 Cyberspace 22 Catholic 99 Unknown

Facility/Casino/Race Track

Suspected Of Using Criminal Activity Types Weapon Type(s) 20 Knife/Cutting Instr 65 Fire/Incendiary Device
None B Buying/Receiving C Cultivating/Manuf/Publishing 11 Firearm (Auto) 30 Blunt Object 70 Drugs/Narc./Sleeping Pills
P Possessing/Concealing O Operating/Promoting/Assisting 12 Handgun (Auto) 35 Motor Vehicle 85 Asphyxiation
D Distributing/Selling T Transport/import/Transmit 13 Rifle (Auto) 40 Personal Weapons 90 Other
E Exploiting Children U Using/Consuming 14 Shotgun (Auto) 50 Poison 95 Unknown

15 Other Firearm 60 Explosives 99 None

A Simple/Gross Negiect | intentional Abuse & Torment
F Organized Abuse S Sexual Animal Abuse

Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 9/19/2024 12:32:21 PM

i 19/11/24
Incident #__24-00390 Fordyce Police Department Report Date __°
SSN/ID/TIN Title
Mr
Work Address Occupation

Incident Report j 5:25 PM
Page 2 of 3 P Report Time
Race Unknown Ethnicity
US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes
Victim Type Injury Type Aggravated Assault/Homicide Circumstances Relationship To Suspect
Individual None, None ay NA

icti Is Complainant Event #s Related
Victim #1 Ii!s p On ‘Age Sex |Resident Status
22 U Unknown
Unknown
Employer
L Milcreek
Justifiable Homicide Circumstances Taken to: (Hospital Name)

None

Injury Description

Suspect #1
Title | Name OB Age Resident Status
1 23 Unknown
Race Black / African Ethnicity Di
American Not Hispanic/Latino
US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes

— Occupation

|
|

Work Address

Suspect #2

SSN/ID/TIN Title (Nlamoe DQB Age Resident Status
23 Resident
Race Black / African Ethnicity
American Not Hispanic/Latino

Work Phone Other Phone Personal Cell Work Cell

US Citizen Legal Alien Doc Type Nationality

Yes
Home Address Employer

Work Address Occupation

Property

Involvement
Category 15 Hvy Constucvindustrial 29 Stucture-Single Occ 43 Building Materials 68 Lawn/Yard/Garden Equip 70 Medical / Lab Equipment

{ None 16 Household Goods 30 Structure-OtherDwelling 44 Camping/Hunting/Fishing 69 Logging Equipment 71 Metals, Non-Precious

2 Burned 4 Bicycles 17 Jewelry/Precious Metals 31 Structure-Commercial 45 Chemicals 47 Crops 72 Musical Instruments

3 CounterfeivForge 06 Clothes/Fur 18 Livestock 32 Structure-Industrial 46 Collections/Collectibles 48 Documents / Pers or Bus. 73 Pets

4 Destroyed/Damaged 07 Computer Hdwr/Sftwr 3 Merchandise 33 Structure-Public 47 Crops 49 Expiosives 74 Photographic/Optical

5 Recovnred 08 Consumable Goods Money 34 Structure-Storage 48 Documents / Pers or Bus. 59 Firearm Accessories 75 Portable Electronic Comm

8 Recov 09 Crediy/Debit Cards 21 Negotiable Instruments 35 Structure-Other 49 Explosives 64 Fuel 76 Recreational/Sports Equip

g Seize 10 Drugs/Narcotics 22 Non-neg, Instrument 36 Tools-Power/Hand 59 Firearm Accessories 65 Identity Documents 77 Other

3 3 ‘ n 11 Drug/Nare Equipment 23 Office-Type Equip 38 Vehicle Parts 64 Fuel 66 identity - Intangible 78 Trailers

nxnown 12 Farm Equipment 25 Purses/Handbags/Wallets 39 Watercraft 65 Identity Documents 67 Law Enforcement Equip. 79 Watercraft Parts/Access

13 Firearms 26 Radio/TVVCR ; 41 Aircraft Parts/Access 66 Identity - Intangible 68 Lawn/Yard/Garden Equip 80 Weapons - Other
14 Gambling Equipment 27 Recordings-Audio/Visual 42 Artistic Supplies 67 Law Enforcement Equip. 69 Logging Equip 88 Pending Inventory

Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 9/19/2024 12:32:21 PM

Incident #__24-00390 Fordyce Police Department Report Date __09/11/24

Category 15 Hvy Construcvindustrial 29 Structure-Single Occ 43 Building Materials 68 Lawn/Yard/Garden Equip 70 Medical / Lab Equipment
02 Alcohol 16 Household Goods 30 Structure-OtherDwelling 44 Camping/Hunting/Fishing 69 Logging Equipment 71 Metals, Non-Precious
4 Bicycles 17 Jeweilry/Precious Metals 31 Structure-Commercial 45 Chemicals 47 Crops 72 Musical Instruments

2 Burned 06 Clothes/Fur 18 Livestock 32 Stucture-industrial 46 Collections/Collectibles 48 Documents / Pers or Bus. 73 Pets

3 CounterfeivForge 07 Computer Hdwr/Sfwr 19 Merchandise 33 Structure-Public 47 Crops 49 Explosives 74 Photographic/Optical

4 Destroyed/Damaged 08 Contumable Goods 20 Money 34 Structure-Storage 48 Documents / Pers or Bus. 59 Firearm Accessories 75 Portable Electronic Comm
; 5 Recovered 09 CredivDebit Cards 21 Negotiable Instruments 35 Structure-Other 49 Explosives 64 Fuel 76 Recreational/Sports Equip

6 Seized 10 Drugs/Narcotics 22 Non-neg. Instrument 36 Tools-Power/Hand §9 Firearm Accessories 65 Identity Documents 77 Other

7 Stolen 11 Drug/Nare Equipment 23 Office-Type Equip 38 Vehicle Parts 64 Fuel 66 Identity - Intangible = 78 Trailers

8 Unknown 12 Farm Equipment 25 Purses/Handbags/Wallets 39 Watercraft 65 Identity Documents 67 Law Enforcement Equip. 79 Watercraft Parts/Access

13 Firearms 26 Radio TV/VCR 41 Aircraft Parts/Access 66 Identity - Intangible 68 Lawn/Yard/Garden Equip 80 Weapons - Other

27 Recordings-Audio/Visual 42 Artistic Supplies 67 Law Enforcement Equip, 69 Logging Equip 88 Pending Inventory

14 Gambling Equipment

Involvement
] 7

Description

1 Silver Macbook Pro (MR4NPNQMT4)

Serial# / Owner Applied# NCIC Ref # Evidence # Value
MR4NPNQMT4 $1,300.00
Narrative & Statements

Narrative - Archer, Kevin - 9/12/2024 5:08:04 PM (Initial)

On 09/11/24 at approximately 1700 |, Patrolman Archer was dispatched to Millcreek for a staff member
who wanted to report his Silver Macbook Pro (MR4NPNQMT4) stolen. Once | arrived at the facility | made
contact with [S GR stated that he had his Macbook at work and locked and placed it

in the back office so no one could mess with it. [ENstated that [EE no

fe came on shift, and worked their shift. When[iiarrived for his shift he saw his Macbook was
gone he pinged its location from his phone and it pinged a a.
GE attempted to retrieve the Macbook himself and a and spoke
with him to return the Macbook, so he wouldn’t have to get the police involved stated that
he did not have the Macbook. After (MM left the residence, he returned to work and called the

police. EEE stated that after he contacted dispatch he checked the live ping again and the Macbook
had been turned off but the last known ping was still at P|

Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 9/19/2024 12:32:21 PM

doc_type: Police Report


summary: Licensing received a complaint that Millcreek failed to provide appropriate medical care to resident. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 023861
Date of Incident: 9/9/2024
Date Received: 9/9/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Received complaint that Millcreek failed to provide appropriate
medical care to client .
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/9/24-Facility visited in response to complaint stating that
was concerned about a viral illness the resident had and that the facility physician
had not provided the client with antibiotics. Nursing notes and physician's orders provided
to licensing. The resident received on-site physician services 8/23/24 and 9/3/24. was
sent for chest x-ray to Dallas County Medical Center 8/28/24 which was reported to
licensing. Millcreek nursing notes 8/23/24-9/3/24 also reviewed. Licensing is not prepared
to make a finding at this time. 10/24/2024- Physican and nursing notes were reviewed
showing that the facility was providing care to the resident during her illness. The
complaint case has been closed as unfounded. Approved by Program Coordinator. Case
complete. .
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Emerald Burris
Record Visit Date: 9/9/2024
Home Visit Date: 9/9/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

9/9/24-Facility visited in response to complaint that client received inappropriate medical care while at
Millcreek. Nursing notes and physician's orders provided to licensing and reviewed. Licensing is not prepared
to make a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 9/9/2024
Provider Signature : Date: 9/9/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident reported that during a restraint, he bit a staff member, and the staff member hit him in the face. This complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 023851
Date of Incident: 9/8/2024
Date Received: 9/9/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: stated
that during the restraint he bit staff and the staff hit him in the face. Staff placed
on administrative leave pending investigation. Allegation reported to
Interim Action Narrative: A/O placed on leave pending investigation.
Maltreatment Narrative:
was having behaviors and was placed into a restraint.
During restraint bit a staff member. During assessment after restraint
reported that staff member hit him in the face after he bit him.
Licensing Narrative: 9/9/24-Permission granted via phone call by
for licensing to contact facility and/or A/V. Per phone call with Emily Burris of
Millcreek there is video of this incident. Visit scheduled for 9/9/24. 9/9/24-Facility visited
and video reviewed of the incident. No citations. 11/21/24-Received notification that
maltreatment investigation was unfounded. 521 issued including that staff will be
retrained on TCI. 11/25/2024, reviewed and approved by Program Coordinator, Case
complete.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Emerald Burris
Record Visit Date: 9/9/2024
Home Visit Date: 9/9/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited in response to complaint that staff hit client during a restraint. Video reviewed
of the incident. Initially staff/client ratio: 3:15. is seen throwing a paper cup of water on the ground
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

toward a staff ( then initiates a restraint and is immediately assisted by two additional
staff. A few minutes later a supervisor is seen entering and witnessing restraint in its entirety. A few minutes
after supervisor entered a nurse is seen entering and witnessing restraint. The nurse is seen evaluating
after restraint. Nursing note reviewed which does indicate a red cheek and abrasion to bottom lip. At no time
during video reviewed was any staff seen hitting Nothing can be definitively seen in restraint video that
would result in getting marks to his face. At no time did any staff participating in the restraint appear to
react to biting them. had reportedly been in a fight prior to restraint. Video backed up and reviewed. 5
minutes prior to restraint 3 clients can be seen attacking Fight video showed possibility of actionsthat
would result in getting marks to his face.Staff immediately intervene and separate clients. Licensing is not
prepared to make a finding at this time. Staff has been placed on administrative leave pending
investigation.
Provider Comments:
CCL Staff Signature : Date: 9/9/2024
Provider Signature : Date: 9/9/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Building & Grounds conducted for Rock Hill and Magnolia Houses. The facility was cited 911.15.f for strings found in one bedroom.

raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
=a! SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Millcreek of Arkansas PRTF

Facility Number: 233

Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 9/6/2024

Home Visit Date: 9/6/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulation Number: 900.911.15.f

Regulation Description: Areas used by children shall be designed, constructed, and furnished to reduce risk of
suicide and assault including, but not limited to:

Finding Description: Waistband drawstrings found in 2 pairs of shorts in Room 4 of Magnolia House.
Action Due Date: 2024-09-06

Action Due Description: Shorts immediately removed to have strings removed before returning to client's
personal belongings.

Comply Date:

Sub-Regulation Level 1 Description: Children’s personal items that contain cords, pull-ties, strings, or other
parts that could be used to inflict self-injury shall not be left in the child’s room unless the dangerous component
has been removed.

Action Due Description: Shorts immediately removed to have strings removed before returning to client's
personal belongings.

Regulations Needing Technical Assistance:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted for Rock Hill and Magnolia Houses. Magnolia House sleeping quarters
baseboard trim removed awaiting remodel. Rock Hill and Magnolia Houses are next in line for unit wide
remodel of walls and baseboard trim. Floors have already been replaced and bathrooms remodeled.

Magnolia Hall clients in school today. Usually staffed 2:10. Bathrooms clean and sanitary with functioning
sinks, showers and toilets. Sleeping areas furnished, clean and in good repair except walls were recently
repainted and remodeled in hopes that material would not chip. Material is chipping. Rock Hill and Magnolia
to undergo same wall panel installation as Pine Ridge in the near future. Living area clean and in good repair.
Two pairs of drawstring shorts seen to have drawstring still in them in Room 4. Facility cited 911.15f.

Rock Hill clients in school today. Usually staffed 3:14. Bathrooms clean and sanitary with functioning sinks,
showers and toilets. Sleeping areas furnished, clean and in good repair. Living area clean and in good repair.
No safety hazards noted.

Pine Ridge briefly observed to see new wall panel installation soon to be installed in Magnolia and Rock Hill.

MAR checked for:

All initialed and up to date.

Provider Comments:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 9/6/2024

i) V
yy

Provider Signature : Date: 9/6/2024

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3

doc_type: Compliance Report


summary: A resident was sent to Dallas County Medical Center ER for treatment after injuring his foot during recreation time.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023768
Date of Incident: 9/5/2024
Date Received: 9/6/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was injured
during recreation time when his foot collided with another patient's toenail. He received a
minor laceration on the 4th toe of his right foot. He was sent to Dallas County Medical
Center ER and . He was treated and released to
return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/6/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for an x-ray of his left hand after punching a wall while upset.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023695
Date of Incident: 9/3/2024
Date Received: 9/4/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: got
upset and punched the wall. was sent to get an x-ray of his left hand on 9/3/24. It
was found that he .
was sent back to Millcreek.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/4/24-Reviewed for licensing concerns. Client sustained injury from
punching a wall.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Three residents eloped from the facility while outside during activity time. The residents were located down the road and were returned to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023661
Date of Incident: 8/31/2024
Date Received: 9/3/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description:
were outside during activity time. The boys told staff they were
going to foot race to see who was the fastest. The boys didn't stop running when they got to
the "finish line". Code Orange was called and staff went after the boys. Police were also
contacted. Multiple staff and department heads went out and started searching for the boys.
The boys were located 3/4 mile down the road by the power lines. The boys were gone 30
minutes. The boys were returned to Millcreek and placed on unit restriction and elopement
precautions.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/3/24-Phone call made to Emily Burris of Millcreek to clarify that
incident happened last Saturday, 8/31/24. Staff were immediately aware of elopement and
followed protocol. Both clients remain at facility on unit restriction and elopement
precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for a chest x-ray due to cough, congestion, and fever. Flamingo hall has been quarantined due to multiple respiratory illnesses.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023565
Date of Incident: 8/28/2024
Date Received: 8/28/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: PRTF, was
sent to Dallas County Medical Center for a chest x-ray due to cough, congestion, and fever.
Flamingo hall has been quarantined.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/28/24-Reviewed for licensing concerns. Due to multiple respiratory
symptoms in Flamingo Hall it is currently quarantined.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for a chest x-ray due to cough, congestion, and fever. Flamingo hall has been quarantined due to multiple residents with respiratory symptoms.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023567
Date of Incident: 8/28/2024
Date Received: 8/28/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was
sent to Dallas County Medical Center for a chest x-ray due to cough, congestion, and fever.
Flamingo hall has been quarantined.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/28/24-Reviewed for licensing concerns. Due to multiple respiratory
symptoms in Flamingo Hall it is currently quarantined.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023566
Date of Incident: 8/28/2024
Date Received: 8/28/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , PRTF,
was sent to Dallas County Medical Center for a chest x-ray due to cough,
congestion, and fever. Flamingo hall has been quarantined.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/28/24-Reviewed for licensing concerns. Due to multiple respiratory
symptoms in Flamingo Hall it is currently quarantined.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident went to the Dallas County Medical Center Emergency Room due to high fever. Several residents in the same house are being x-rayed for respiratory illness. The House has been quarantined.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023555
Date of Incident: 8/28/2024
Date Received: 8/28/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: PRTF,
went to the Dallas County Medical Center ER on 8/28/24 @ 1:30 am due to high fever.
Patient returned to Millcreek at 3:50 diagnosed
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/28/24-Reviewed for licensing concerns. Phone call made to
of Millcreek. Several clients in the same house are being x-rayed for respiratory
illness. House is under quarantine at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for a chest x-ray. Flamingo Hall is quarantined due to multiple respiratory illnesses.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023564
Date of Incident: 8/28/2024
Date Received: 8/28/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: PRTF,
was sent to Dallas County Medical Center for a chest x-ray as ordered by center medical
director. Flamingo Hall is quarantined.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/28/24-Reviewed for licensing concerns. Due to multiple respiratory
symptoms in Flamingo Hall it is currently quarantined.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the Dallas County Medical Center ER due to high fever, elevated pulse ox, and heart rate.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023553
Date of Incident: 8/27/2024
Date Received: 8/28/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: PRTF,
went to the Dallas County Medical Center ER due to high fever, elevated pulse ox,
and heart rate on 8/27/24 @ 20:07. She was admitted to the hospital
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/28/24-Reviewed for licensing concerns. Email sent to facility to
notify licensing upon clients return. Phone call made to of Millcreek. Several
clients in the same house are being x-rayed for respiratory illness. House is under
quarantine at this time. 9/3/24-Recieved email from facility that client returned to
facility Sat 8/31/24.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to assist with locating a missing juvenile. Officers deployed an arial drone and located the subject. The resident was taken into custody and returned to Millcreek with no injuries.

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i 08/24/24
Incident #__24-00370 Fordyce Police Department Report Date __°%.

Page 4 of 2 Incident Report Report Time 5:23 AM
| Status Exception Clearance Date Reporting Officer ORI/Agency
Not Applicable 307 Brasse, Neil AR0200100

Assisting Officers

Taylor, Johnathan Sisson, Andrew

Complainant

Name Contact Name
Mill Creek Of Arkansas

Business Address Business Phone
1810 Industrial DR,Fordyce, AR 71742 8703528203
Offenses
Incident Location Zone Clery Location Type

Earliest Possible Date Time Latest Possible Date Time
@ [StatuteiCode [Description «iden [AUComp [loc ]ias [Wn
MO Method Of Entry
0

na

Location Types 13 Hway/Road/Alley | 37 Abandoned/Condemned 48 Industrial Site Bias Motivation Codes ;
14 Hotel/Motel Structure 49 Military Installation ANTI- 43 Lesbian, Gay, Bisexual
01 Air/Bus/Train Terminal 15 Jail/Prison 38 Amusement Park 50 Park/Playground 23 Protestant Gro LGBT) '
02 BenviSét. 16 LakeWaterway 39 Arena/Stadium/Fair 51 Rest Area 11 White 24 Islamic (Muslim) = ie srasox cal
03 Bar/Night Club 17 Liquor Store grounds/Coliseum 52 School - 12 Black or African 25 Other Religion pede ;
04 Church/Synag/Temple 18 Parking LoUGarage 40 ATM Separate from Bank College/University American 26 Multi-religious group Pa Phe Di pitt
05 Commercial/Off Bldg 19 Rental Storage 41 Auto Dealership 53 School - 13 American Indian or 27 Atheist/Agnostic 52M ys ' De ne
06 Construction Site Facility New/Used Elementary/Secondary Alaska Native 31 Arab ental Disability
07 Convenience Store 20 Residence/Home 42 Camp/Campground 54 Shelter - 14 Asian 32 Hispanic or Latino by Male '
08 DepvDiscount Store 21 Restaurant 44 Daycare Facility Mission/Homeless 15 Multi-races,Group 33 Not Hispanic or emate
09 Drug Str/Dr Of/Hosp 23 Service/Gas Station 45 Dock/Wharf/Freight 55 Shopping Mall 16 Native Hawaiian or Latino 71 Transgender ;
10 Field/Woods 24 Specialty Store Modal Terminal 56 Tribal Lands Other Pacific Islander 41 Gay (male) 72 Gender Non-Conforming
11 GovvPublic Bldg 25 Unknown/Other =——46 Farm Facility 57 Community Center 21 Jewish 42 Lesbian $s Nore
12 Grocery/Supermarket 47 Gambling 58 Cyberspace 22 Catholic nknown

Facility/Casino/Race Track

Suspected Of Using Criminal Activity Types 20 Knife/Cutting Instr 65 Fire/Incendiary Device

Weapon Type(s
pon Type(s) 70 Drugs/Narc./Sleeping Pitls

11 Firearm (Auto) 30 Biunt Object

B Buying/Receiving C Cultivating/Manuf/Publishing - ag:
None P Possessing/Concealing O Operating/Promoting/Assisting 12 Handgun (Auto) 35 Motor Vehicle 85 Asphyxiation
D Distributing/Selling _T Transport/imporvTransmit 13 Rifle (Auto) 40 Personal Weapons 90 Other
E Exploiting Children U Using/Consuming 14 Shotgun (Auto) 50 Poison 95 Unknown
15 Other Firearm 60 Explosives 99 None

A Simple/Gross Neglect | Intentional Abuse & Torment
F Organized Abuse S Sexual Animal Abuse

Suspect #1

Race White Ethnicity OL (#, ST)

Age Sex |Resident Status
12 F Unknown
Not Hispanic/Latino

ii | Work Phone Other Phone Personal Cell Work Cell
US Citizen Legal Alien Doc Type Immig Doc # Nationality

Yes
Home Address Employer

Narrative & Statements
Narrative - Brasse, Neil - 8/24/2024 5:30:33 AM (Initial)

On Friday, August 23rd, 2024, |, Officer Neil Brasse was dispatched to Mill
Creek to assist with the locating of a missing juvenile. The juvenile was
Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 9/19/2024 12:30:36 PM

’

Incident #__24-00370 Fordyce Police Department Report Date __ 08/24/24

Page
Narrative & Statements

Narrative - Brasse, Neil - 8/24/2024 5:30:33 AM (Initial)

described as white female, ecraerayarrah comer geese
hair, wearing a dark blue hoodie and black leggings. olall a stated
that she escaped from the facility while attending the on-site school. Staff
followed her from the school to HWY 79, where they lost track of her. Upon my
arrival | began searching the immediate area North and East of the facility.
During which time, Dallas County Sheriffs Deputies deployed an arial drone.
During a search through the woods east of the facility, one of the staff located
her and she attempted to flee. Using my vehicle, | drove ahead to cut her off. At
this point | found her standing behind a large tree at 2321 US-79. | notified staff
and deputies where she was and she was taken into custody. At this point she
was safely returned to Mill Creek with no obvious or apparent injury.

Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 9/19/2024 12:30:36 PM

2 of 2 Incident Report Report Time 5:23 AM


summary: A resident was in school and ran out of the side doors. Supervisors followed the resident but lost sight of her after she turned at the stop sign and went in the woods.  Police were contacted and came to assist with the search using a drone. The resident was located in woods and returned to unit. She has been placed on unit restriction.

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Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023474
Date of Incident: 8/23/2024
Date Received: 8/26/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: (PRTF, ) was in
school and ran out of the side doors. Code was called. Supervisors followed patient but lost
sight of her after she turned at the stop sign and went in the woods. Sight of patient was lost
at 13:40. Police were contacted and came to assist with search using a drone. Patient was
located at 14:58 in woods and returned to unit. Patient has been placed on unit restriction.
Interim Action Narrative: Staff followed the resident but lost sight. The police were called
and resident was placed on unit restriction.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Resident was located, returned to the facility by the police, and placed on unit restriction.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported she brought a vape into the facility with her and a staff member found her vape charger. The resident stated the staff member told her to give them her vape and they would keep it for her so she wouldn’t get in trouble.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 023283
Date of Incident: 8/17/2024
Date Received: 8/19/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: states
that workers found her charger to her vape. She stated that they didn't find her vape though.
She stated that staff member told her to give her the vape so she wouldn't get
in trouble for it and she ( would keep it for her and charge it for her and bring it in
for her to vape off of when needed. Report made to
Interim Action Narrative: placed on administrative leave pending
investigation.
Maltreatment Narrative:
It is reported that stated that she brought a vape in with her
when she came to Millcreek. She states that staff found her vape charger and told
her to give her the vape so she wouldn?t get in trouble. states that keeps the
vape in her car and will bring it in during her shift (3rd shift) and let her take a couple of
drags off of it.
Licensing Narrative: 8/19/24Program Coordinator checked no
assigned at this time but will check again later today. Facility emailed for witness
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

statements from A/O and A/V. Email received from Emily Burris of Millcreek as follows:
A/O has been placed on leave. A/V can?t give any specifics on timeframes. All I got was
that it was the first weekend she was here that worker let her vape. I have reviewed video
and found nothing. A/v states that worker let her vape in her room. A/O works 3rd shift and
roommate has never seen this occur. Per phone call with Emily Burris of Millcreek, A/V
stated she brought the vape pen into Millcreek in her bra. Pat downs are conducted upon
entry to Millcreek, but not around the bra area. 8/19/24-Witness statements from A/V, A/O
and peers including A/V's roommate reviewed. A/V's statement states that A/O held A/V's
vape for her and let her vape. All other witness statements, including A/O's, state that at no
time did A/O provide a vape to A/V. This complaint was staffed with Program Coordinator
Kendra Rice and Program Manager Chelsea Vardell. Licensing is not prepared to make a
finding at this time. 8/20/24-Email sent to to share any
additional information she may gain from investigation with licensing. 10/8/24-Reviewed
for closure. There is still no maltreatment finding. 11/21/24-Received notification that
maltreatment was unfounded. 521 issued including that staff will be retrained on
staff/client boundaries. Completion of training will be sent to licensing. 11/25/2024,
reviewed and approved by Program Coordinator, Case complete.


summary: A resident was taken to Dallas County Medical Center for treatment after sustaining an injury during a physical altercation with several other residents.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023147
Date of Incident: 8/10/2024
Date Received: 8/12/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: (PRTF, :
was involved in a physical altercation with several other girls. sustained
a . was taken to Dallas County Medical Center and
received .
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/12/24-Reviewed for licensing concerns. There is video of this
incident. Client was assigned to a different dorm. Visit scheduled for 8/13/24. 8/13/24-
Facility visited. Video reviewed of incident. No citations.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Emerald Burris
Record Visit Date: 8/13/2024
Home Visit Date: 8/13/2024
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
8/13/24-Facility visited and video reviewed of incident in which client received emergency medical
treatment. Ratio in nurses' station area begins 2:3 ending in 7:6 after altercation breaks out. Several clients are
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

seen attacking client Staff are present and within arm's length and immediately intervene. Additional staff
are seen assisting breaking up and de-escalating the altercation. No unprofessional conduct or undue physical
force by staff is seen in video.
Provider Comments:
CCL Staff Signature : Date: 8/13/2024
Provider Signature : Date: 8/13/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: During a behavior, a resident attempted to kick staff. The staff member grabbed the resident’s leg and pulled him out of the chair to the floor. The staff member walked out immediately following the incident and has been terminated. The facility was cited 110.9, 109.1.g, and 905.4.g.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022969
Date of Incident: 8/3/2024
Date Received: 8/5/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: , PRTF, was
having a behavior. went to kick staff and grabbed
leg and pulled him out of the chair to the floor.
Interim Action Narrative: Staff walked out immediately following incident and has been
terminated.
Licensing Narrative: 8/5/24-Reviewed for licensing concerns. There is video of this
incident. Received permission from to contact facility. Visit
scheduled for 8/6/24. Per phone call with of Millcreek, staff provided an
incident report, meaning they were aware of the incident, which was not seen until the next
day by other staff who alerted administration who Staff
aware of incident who did not immediately report it are already to be retrained on mandated
reporting. Reg 110.9 will be reviewed during visit. Per of Millcreek, staff
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

walked out immediately following the incident and has since been terminated. 8/6/24-
Facility visited and cited 110.9, 109.1g and 905.4g.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Emerald Burris
Record Visit Date: 8/6/2024
Home Visit Date: 8/6/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulation Number: 100.109.1.g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Finding Description: Staff is seen on video aggressively pulling client out of his chair causing him to
hit the floor.
Action Due Date: 2024-08-03
Action Due Description: Staff terminated.
Comply Date:
Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
Action Due Description: Staff terminated.
Regulation Number: 100.110.9.a
Regulation Description: 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
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Finding Description: Incident occurred 8/3/24 around 6PM and was not reported until
8/4/24 around 8:30PM.
Action Due Date: 2024-08-23
Action Due Description: Unit wide training will be held on mandated reporting. Training sign-in sheet will be
provided to licensing.
Comply Date:
Sub-Regulation Level 1 Description: Been subjected to child maltreatment
Action Due Description: Unit wide training will be held on mandated reporting. Training sign-in sheet will be
provided to licensing.
Regulation Number: 900.905.4.g
Regulation Description: The following actions shall not be used, including as discipline:
Finding Description: Staff is seen on video aggressively pulling client out of his chair causing him to
hit the floor.
Action Due Date: 2024-08-03
Action Due Description: Staff was terminated.
Comply Date:
Sub-Regulation Level 1 Description: Physical injury or threat of bodily harm;
Action Due Description: Staff was terminated.
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited in response to complaint that staff grabbed client out of his chair after kicked
him. Video reviewed shows just that. Two staff appear to be counseling client while he was sitting in a
chair visibly upset. Staff walks toward at which time kicks staff Staff then
aggressively grabs client leg and pulls him out of his chair, hitting the floor. Facility cited 109.1g
and 905.4g. Staff immediately walked out of facility after this incident and has since been terminated.
This incident occurred 8/3/24 around 6PM and was not until 8/4/24 around
8:30PM. Facility cited 110.9. Unit wide training will be held on mandated reporting. Training sign-in sheet
will be provided to licensing.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

This incident does not reflect the standard practices or the de-escalation techniques that our facility rigorously
implements to train staff in the interaction and management of residents in our care. The actions mentioned in this
citation were conducted by an individual staff member who strayed from the extensive training and protocols our
facility has established. We take incidents of this nature and patient safety with utmost seriousness. The actions
taken by this employee were outside of their assigned responsibilities. Our facility made the decision to terminate
the employee due to their actions deviating from our company policies. He chose to resign effective immediately.
His resignation was accepted and he will not be eligible for rehire at any time. Furthermore, our staff are trained in
timely mandated reporting. We will be conducting another training about mandated reporters and timelines.
CCL Staff Signature : Date: 8/6/2024
Provider Signature : Date: 8/6/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A visit to the facility was conducted in order to review fire and severe weather drill logs. No severe weather log could be located. The facility was cited 914.9 for the missing log.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Emerald Burris
Record Visit Date: 8/1/2024
Home Visit Date: 8/1/2024
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulation Number: 900.914.9
Regulation Description: A record of drills shall be maintained, showing date and time of day of the drill, number
of participants, and length of time required to reach safety.
Finding Description: No severe weather drill log could be located during today's visit.
Action Due Date: 2024-08-09
Action Due Description: Severe weather drill log will be located and provided to licensing.
Comply Date:
Action Due Description: Severe weather drill log will be located and provided to licensing.
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Visit conducted to review fire and severe weather drill logs. Fire logs were documented per licensing
standards and completed every month until recently. No severe weather log could be located. Maintenance
Supervisor was contacted who stated they were not available. Facility cited 914.9. Per Risk Managment Emily
Burris of Millcreek severe weather drills have been completed, some of which she participated in. Severe
weather logs will be located and provided to licensing by 8/9/24.
Provider Comments:
CCL Staff Signature : Date: 8/1/2024
Provider Signature : Date: 8/1/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A Complaint Investigation survey was conducted on July 31, 2024. No deficiencies were cited during the survey. Complaint #AR00033837 was in compliance.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
August 6, 2024
Brady Serafin, Administrator
Habilitation Center, Llc
P.O. Box 727
Fordyce, AR 71742
Dear Mr.. Serafin:
A Complaint Investigation survey was conducted on July 31, 2024. We are pleased to inform you that
no deficiencies were cited during the survey and that your facility was in compliance with the
requirements of 42 CFR Part 483, Subpart G, Requirements for Psychiatric Residential Treatment
Facilities. Your certification remains in effect unless terminated due to non-compliance with program
requirements or voluntary withdrawal from the program.
We have enclosed form CMS 2567, “Statement of Deficiencies and Plan of Correction” for the July 31,
2024 Complaint Investigation survey conducted at your facility for participation in the Medicaid
program. CMS 2567 is enclosed, indicating your facility's compliance status. Please sign and
date the 2567 and email to Theresa.Forrest@dhs.arkansas.gov.
If you have any questions please contact your reviewer at 501-320-6235.
Sincerely,
DPSQA/Office of Long Term Care
Survey and Certification Section
tf
cc: DRA
Brady Serafin - Habilitation Center, Llc - 08/06/2024- (AOLTC - PRTF No Def) Page 1]

PRINTED: 08/06/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L103 B. WING _____________________________ 07/31/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1810 INDUSTRIAL DRIVE
HABILITATION CENTER, LLC
FORDYCE, AR 71742
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
Complaint #AR00033837 was in compliance.
The facility was in compliance with §483, Subpart
G - Conditions of Participation for Psychiatric
Residential Treatment Center.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TEHN11 Facility ID: 3002 If continuation sheet Page 1 of 1

doc_type: Complaint Survey


summary: A resident was sent to Dallas County Medical Center for an x-ray after a physical altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022878
Date of Incident: 7/29/2024
Date Received: 7/30/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: and a peer
got into a verbal altercation, the two were separated. stated that the peer was still
talking about her so she walked up to her and told her to mind her own business, the peer
then hit in the nose. was sent to Dallas County Medical Center for an x-ray of
nose. X-ray . Medical director is sending for a follow up
CT to be sure due to some questionable areas/views on the x-ray.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/30/24-Reviewed for licensing concerns. Email sent to facility for
safety plan for Received safety plan that and peer in altercation were placed in
separate units. 7/31/24-See Case#022890. UPDATE TO PRIOR REPORT: CT scan
shows
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022890
Date of Incident: 7/29/2024
Date Received: 7/30/2024
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: UPDATE TO PRIOR REPORT:
CT scan .
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/31/24-Reviewed for licensing concerns. See Case#022878.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov