summary: A resident was transferred to an acute treatment facility after engaging in self-harm and suicidal ideation behaviors.

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: 026701
Date of Incident: 1/8/2025
Date Received: 1/9/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 1/8/25 and day prior, private
was engaging in suicidal ideation and self harm behavior at the facility. It was
recommended that be transferred to an acute treatment facility to address his
behaviors, provide a stabilization period, and address any medication adjustments that
could improve his mental health and suicide behavioral issues. He was admitted around
1000 to in , AR. The plan at this time is for the resident
to return to PRTC upon his stabilization.
Interim Action Narrative: Resident was assessed and transported to .
Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Licensing inquired about a safety upon resident's return and nurse's note 1/15/2025 -
Licensing specialist reviewed the report. 1/31/2025 - nursing notes received, reviewed and
uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


state: AR

facility_name: Yellow Rock Behavioral Health (formerly Piney Ridge)

summary: A resident woke up with a stomachache and reported pain 9/10. The resident was pale and sweaty, and his blood pressure and heart rate were elevated.

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: 026652
Date of Incident: 1/7/2025
Date Received: 1/7/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
private) On 01/07/2025 this resident woke up with a stomach ache, He reported it
being the worst pain he ever felt. He reports 9/10 pain, he was also pale and sweaty. Vitals
were taken and blood pressure and heart rate is elevated, he is afebrile. He was taken via our
transport to for assessment per orders from our APRN. He left here
at 0411. He was assessed in the , . He was
sent home with new . He returned to the facility at approx.
10am. He will follow up with Dr in approx. 1 week.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist reviewed the report and will request nursing notes
and hospital discharge summary. Licensing received nursing notes and hospital discharge
summary. Documentation was reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: Licensing visited the facility to conduct a walkthrough of the new facility campus at 2601 Habberton Rd. Springdale, AR.

raw_content:
& &® KA KE AE
BSEPARYMENT OF

7 HUMAN
ai SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

A

521 Visit Compliance Report

Licensee: Piney Ridge Treatment Center

Facility Number: 203

Licensee Address: 2805 E ZION RD
FAYETTEVILLE AR 72703

Licensing Specialist: Jarred Parnell
Person In Charge:

Record Visit Date: 1/6/2025

Home Visit Date: 1/6/2025

Purpose of Visit: New Study

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

The Program Manager and Licensing Specialist conducted a walkthrough of the new Piney Ridge Treatment
Center/Yellow Rock campus located at 2601 Habberton Rd. Springdale, AR.

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

914.6-Emergency escape diagrams were posted in all areas used by children.

911.3-The facility reports that they have already had a fire inspection and are waiting on the final report.
Licensing requested a copy of that report once it has been received by the facility.

911.4The facility reports that the health inspection is scheduled for this Wednesday 1/8/2025. Licensing
requested a copy of that report once it has been received by the facility.

The facility reports that they would like to move the residents as soon as possible and believe that they can
move all the residents, their belongings, beds, mattresses, and bedding to the new facility within one to two
days. .

Construction crews were still on site working on the building. Construction materials to include tools and
materials were located throughout the building. Areas still being finished were seen with exposed wires
waiting to be secured into place, missing ceiling tile in the library, areas with missing floor trim, and TVs in
boxes waiting to be wired in and secured in their protective casings to the walls. The facility reports that the
remaining finishing touches should be completed within the next week and the facility will be ready for
resident occupancy. Licensing informed the facility that a final walkthrough of the building will have to be
done by the specialist to ensure all remaining items are completed prior to the residents occupying the
building.

*e*** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of noncompliance is
in error, you may ask for reconsideration. The request for reconsideration must be in writing and delivered to
the Department by certified mail within twenty (20) business days of receipt of the notice of
noncompliance. The request must specify the parts of the notice that are alleged to be in error, explain why
you believe those parts are in error, and include documentation to support the allegation of error. Once
received the Department shall issue a decision on your request within twenty (20) days after receipt of the
request.

Provider Comments:

CCL Staff Signature : Chelaca BE Date: 1/6/2025
Provider Signature : Gene Date: 1/6/2025

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

Hegel:

doc_type: Compliance Report


summary: While outside, a resident eloped from facility grounds. The resident returned to the facility with officers an hour later.

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: 026504
Date of Incident: 12/30/2024
Date Received: 12/31/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 12/30/24 at approximately 1530
was outside with the rest of crossover unit when he claimed to have saw a
dog by the road. He stated that he was concerned for the dog's safety and repeatedly asked
staff to allow him to leave to go help the dog. He was directed that he could not and was
redirected various times when he asked. started to walk down out of the outside
area toward Crossover Road. Staff followed and was with him the whole time that he was off
grounds. refused to follow any staff's directions and the police were notified at
1555 to assist with returning the resident to the facility. He came back with police and
supervisor by 1630. He was placed on elopement precautions to be reassessed in 24 hours.
will be meeting with therapist to process safety issues and planning.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/31/2024-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: While outside, two residents eloped from the facility grounds by busting through a gate.

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: 026459
Date of Incident: 12/25/2024
Date Received: 12/30/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 12/25/24 at approximately 12:10pm
were outside in the west unit
court yard with other youth from their unit. They were able to bust through the gate
breaking the locking mechanism and wood it was attached it. Staff was unable to stay with
them, local PD was contacted immediately. was returned by PD at 2:14pm. returned
on his own as 4:55pm. The gate was fixed yesterday and is secure. had an abrasion
on his neck from when he jumped off of fence. He was placed on elopement precautions to
be assessed in 24 hours. Both was placed on RTU to be assessed in 24
hours.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing specialist reviewed the report and will inquire with the
facility concerning video footage of the incident, staff ratios and witnesses who were present
during the incident. 1/3/2025 - Facility response received: "We do not have camera footage
because of the time frame and because it occurred outside." Facility will provide ratio
numbers as soon as possible. Licensing specialist followed up with the facility for the ratio
numbers for the day of the incident. The ratio for the 3:16
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to missing residents. One resident was located by officers and transported back to the facility.

raw_content:
Incident Report
Print Date/Time: 01/17/2025 09:25 Fayetteville Police Department
Login ID: adiaz ORI Number: AR0720100
Unit:389
Disposition Count Date/Time
03NORPT 1 12/25/2024 14:28
Unit:480
Disposition Count Date/Time
03NORPT 1 12/25/2024 14:31
Unit:521
Disposition Count Date/Time
03NORPT 1 12/25/2024 14:34
Unit:529
Disposition Count Date/Time
01RPT 1 12/25/2024 14:41
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 2 of 3

Public Records Exemptions
Enclosed please find a copy of the response documents for your public
records request. The following information is provided to explain the
process employed to review and produce the response documents.
Reason Description Pages
1, 3
1 of 1

doc_type: Police Report


summary: A resident complained of pain to her right knee after falling. An x-ray was ordered.

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: 026381
Date of Incident: 12/23/2024
Date Received: 12/23/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: On 12/20/24 jumped onto
another residents back for a piggyback ride. This resident fell on the concrete and landed on
her right knee, she complained of pain but no swelling noted at the time of the injury but we
gave her ibuprofen and ice. She was also seen by the APRN and an x-ray was ordered. The
X-ray in house was ordered and show no fracture. Resident reported that it was still tender
to walk on so she was sent to Ozark Orthopedic for follow-up. She was seen today
12/23/2024, with findings of . She will be on crutches at all time with
a knee immobilizer. She will be seen again on 12/31/24.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and received nursing notes for the
incident. They were reviewed and uploaded to ELS. Licensing specialist will follow up with
the facility to inquire about supervising staff when the incident happened.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: While outside, two residents eloped from the facility grounds by climbing a fence. One resident returned a few minutes later.

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: 026390
Date of Incident: 12/23/2024
Date Received: 12/24/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Resident resident in
IR: 12/23/2024 @1610 Per staff report: While outside on West court, a peer
kicked down a gate leading to an unauthorized area for residents. This resident along with
peers ran into the area to find more items to play with. Once the resident and peers were
directed to the proper area, this resident and a peer ran to the unauthorized area and
climbed on top the fence. The resident and peer climbed over the fence and off facility
grounds, ignoring all verbal redirections from staff members and supervisors. A supervisor
followed this resident, who was headed towards the city lake. The supervisor lost sight of
the resident at this time. Fayetteville Police Department was notified and given physical
description of the resident @1618. Administrator on call / Director of Nursing notified via
telephone @1615. Police officers Kyle Jeney, badge #409, C. Harris, badge #433, and J.
Grubb, badge #528 responded to the facility and a missing persons incident was reported.
The resident returned to the facility grounds at approximately 2150. The resident
approached the back of the facility and was allowed in by a staff member. Upon residents
return, the resident was in wet clothes from the outdoors and had five candy bars that the
resident reported to have 'stolen' from a gas station. Body search was completed by nursing
and the resident was directed to the multi-purpose room for the evening. The resident was
directed to change into warm clothing for bed time. Administrator on call / Director of
Nursing notified via telephone @2150. Fayetteville Police Department notified via telephone
@2155. Officer Herber Espinal, badge #493 arrived to facility grounds to close out
Fayetteville Police investigation. The resident was not injured during this incident. Resident
placed on elopement precautions and restricted to the unit for twenty-four hours. There was
another resident that left the grounds with him, He is
a resident from in parental custody. He was only gone from the facility for a few
minutes, staff was able to maintain visual on him and he returned without any issues.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report. Licensing specialist will follow up with
the facility for nursing notes and body searching when the resident returned. Police
documentation requested. 12/30/2024 - Licensing specialist received facility policy for
searching residents. Documentation reviewed and uploaded to ELS. 12/31/2024, police
documentation received and Licensing Specialist informed. 12/30/2024 - Licensing received
the facility search policy for the incident. The policy was reviewed, and uploaded to ELS.


summary: Officers were dispatched to the facility in response to a 911 hang up call. Officers made contact with a staff member who advised that there was no disturbance.

raw_content:
Incident Report
Print Date/Time: 01/17/2025 09:24 Fayetteville Police Department
Login ID: adiaz ORI Number: AR0720100
Incident: 2024-00089182
Incident Date/Time: 12/22/2024 6:05:27 PM Incident Type: 911 HANGUP
Location: 2805 E ZION RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (479)396-4059 Source: 911
Report Required: No Priority: 1-High
Prior Hazards: No Status: In Progress
LE Case Number: Nature of Call:
Unit/Personnel
Unit Personnel
473 473-ALGEO
478 478-VEGA
480 480-PERALEZ
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller E911 (479)396-4059
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:473
Disposition Count Date/Time
03NORPT 1 12/22/2024 18:32
Unit:478
Disposition Count Date/Time
03NORPT 1 12/22/2024 18:11
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 1
Page: 1 of 2

CAD Narrative
12/22/2024:18:31:54salgeoNarrative:MADECONTACTWITHSOMEONEATTHENURSESSTATI0N.
12/22/2024:18:22:07cadlerNarrative:NOANSWERX3
12/22/2024:18:20:15cadlerNarrative:NOANSWERX2
12/22/2024:18:19:28cadlerNarrative:NOANSWERX1
12/22/2024:18:18:47cadlerNarrative:473REQCONTACTBUISNESSTOBELETINATADMINOFC
12/22/2024:18:10:12tkelleyNarrative:MADECONTACTWITHCHARGENURSE,SHEADVEVERYTHINGWAS10-4WOULD
CALL911IFSOMETHINGCHANGES
12/22/2024:18:09:28tkelleyNarrative:VOIPCALLERIDADVCOMPUTERLAB
12/22/2024:18:08:20cadlerNarrative:CALLERCALLEDBACKIN2NDTIME//ADVTOGETOFFICERSTO4281
(UNINTELLIGABLESTRTNAME)IMMEDIATELY,THENTHECALLERSCREAMEDANDDISCONNECTED
12/22/2024:18:08:16tkelleyNarrative:--ATCPINEYRIDGE
12/22/2024:18:07:29tkelleyNarrative:HUNGUP
12/22/2024:18:06:51tkelleyNarrative:CALLERBACKONLINE
12/22/2024:18:06:39tkelleyNarrative:ISVOIPPHONE,MAYHAVECOMEFROMPINEYRIDGEHOSPITAL,
12/22/2024:18:06:04tkelleyNarrative:FEMALESAIDHELLOTHENHUNGUP
12/22/2024:18:05:55tkelleyNarrative:SOUNDSOFDISTURBANCE
Page: 2 of 2

Public Records Exemptions
Enclosed please find a copy of the response documents for your public
records request. The following information is provided to explain the
process employed to review and produce the response documents.
Reason Description Pages
2
1 of 1


summary: A resident complained of pain to his tailbone after falling while playing basketball. An x-ray was ordered.

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: 026267
Date of Incident: 12/19/2024
Date Received: 12/19/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: On 12/17/2024 Resident was playing basketball, he reported on
12/18/2024 that while he was playing another resident tried to get the ball and he fell on his
tailbone. He would not let the nurse or APRN assess it. X-ray was ordered and completed in
house on 12/18/2024. There is no fracture noted.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/20/2024 - Licensing reviewed the report and received nursing
notes from the facility, they were reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported to staff that two other residents had engaged in sexual behavior. The complaint was UNFOUNDED by Licensing.

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: Piney Ridge Treatment Center
Facility Number: 203
Licensee Address: 2805 E ZION RD
FAYETTEVILLE AR 72703
Licensing Specialist: Jarred Parnell
Person In Charge:
Record Visit Date: 2/14/2025
Home Visit Date: 2/14/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No in-person visited was conducted on 2/14/2025.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Licensing received a report on 12/19/2025 for case #026261.
The complaint isUNFOUNDEDby Licensing.
Provider Comments:
CCL Staff Signature : Date: 2/14/2025
Provider Signature : Date: 2/14/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident complained of pain to his right hand after punching a wall the day before. An x-ray was ordered.

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: 026266
Date of Incident: 12/18/2024
Date Received: 12/19/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: ) Description of report:
On 12/18/2024 this resident reported to the APRN that his right hand was hurting. Upon
assessment he reported that he had punched the wall the day prior. His hand had slight
swelling, he does have full range of motion with his hand. X-ray was ordered and completed
in house, x-ray shows no fracture. This resident will be on no sports for one month.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and requested nursing notes and x-ray
results for the resident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident became upset and began punching walls, the TV, and a window, injuring his hand. An x-ray was ordered.

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: 026239
Date of Incident: 12/17/2024
Date Received: 12/18/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: On 12/17/2024 this resident got upset and started punching the walls,
the tv and the window in the dayroom. He was upset over a room change. After he calmed
down the nurse was able to assess his hand, there was swelling and redness noted left hand.
Order received from APRN to complete X-ray in house. X-ray was complete with no fracture
noted. Nothing else ordered at this time.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report. Facility sent nursing notes and X-ray
results, documentation reviewed and uploaded to ELS. The resident was not placed on any
restrictions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident became upset and kicked a wall multiple times, injuring his foot. An x-ray was ordered.

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: 026240
Date of Incident: 12/17/2024
Date Received: 12/18/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: On 12/17/2024 this resident came in from outside, he was upset and
kicked the wall multiple times. Resident was limping and having a hard time putting weight
on his foot. He was assessed by nursing and order was obtained for x-ray. Resident was
given ibuprofen and ice. X-ray was completed in house on 12/18/2024, no fracture noted.
Upon assessment today by myself, he is able to walk without pain and denies any
complaints today. No further orders given.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and will request nursing notes and
restriction information. Nursing notes and report information received, reviewed, and
uploaded to ELS. Licensing specialist inquired about the documentation received, nursing
notes and incident report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Children’s Hospital due to complaints of pain and swelling to his right testicle.

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: 026192
Date of Incident: 12/15/2024
Date Received: 12/16/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
also) Description of report: On 12/15/2024 this resident reported that his right
testicle was swollen and hurting. Resident was referred out to Children?s Hospital
Emergency Room. He was transported via our transportation, He returned to the facility at
2235 with diagnosis of . He will use nystatin powder 4 times a
day for 10 days and will follow-up with our APRN here at the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report. Nursing notes and hospital paperwork
received, reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident complained of pain to the right foot due to an injury sustained while playing soccer.

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: 026190
Date of Incident: 12/13/2024
Date Received: 12/16/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: Description of
report: Resident c/o pain to right foot d/t injury that occurred previously from playing
soccer and was seen by APRN and X-ray was ordered. X-ray results came back
APRN was called and notified and gave order to send
patient to Ozark Ortho on Monday, guardian emailed to notify and Resident is on No sports
until released by Ozark Ortho.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and will follow up with the facility for
medical documentation. Nursing notes and X-ray results received from the facility. The
documents were reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Conway Behavioral Health for acute care due to experiencing hallucinations and suicidal ideations.

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: 026070
Date of Incident: 12/10/2024
Date Received: 12/11/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 12/10/24 at approximately 1800
was placed at Conway Behavioral Health as she was struggling with delusional
thought patterns, visual/auditory hallucinations, and suicidal ideation. At this time it is
anticipated that she will return to PRTC upon discharge from acute care. Guardian is aware.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident received orders for an x-ray after swallowing a metal Monopoly game piece, paper, and the tip of a pencil.

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: 026002
Date of Incident: 12/9/2024
Date Received: 12/10/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: TOn 12/10/24 at approximately 1950
) this resident swallowed a metal Monopoly piece while in the multi-purpose
room while received redirections. She also swallowed paper and a tip of a pencil. Resident
denied discomfort or pain to nursing on duty. APRN contacted @2030. Orders received for
an abdominal x-ray and clear liquid diet x3 days. Resident placed on self-harm precautions
to be assessed in 24 hours. She will see the APRN later in the week. In addition the resident
will process with therapist.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and will follow up with facility for
nursing notes and safety precautions. Nursing notes received, reviewed, and uploaded,
resident is on 24 hour observation as a safety precaution.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Children’s Hospital NWA to be assessed for seizure-like activity.

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: 025926
Date of Incident: 12/5/2024
Date Received: 12/6/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 12/5/24 around 1230 the resident
was face down on the ground with hands shaking. Resident did not respond to nurse
requests to turn over for further evaluation. Psychiatrist and DON evaluated resident with
nursing. After 2-3 minutes, resident turned over and stated that he felt dizzy. Resident sat in
the educational hallway with nurses for 5 minutes until resident felt ready to return to the
unit. Psychiatrist and medical APRN ordered resident to be evaluated at Children's
Hospital NWA for seizure-like activity. While walking back to the unit to await transport,
the resident began complaining of chest pain and began to sink to the ground. Resident
safely lowered to the ground with assistance from nursing and staff. Vital signs assessed and
WNL. Resident continued clutching at his chest and complaining of pain and trouble
breathing. O2 saturation 98%. The facility notified his worker whom informed us that the
resident has a history of faking seizure like activity. While this was again suspected but
because the resident is new to the facility and we do not have medical documentation to
back this up - he was sent on transport at 1245. Resident returned from Children's Hospital
NWA at 1530. CXR 2 view completed, EKG completed, urinalysis, CBC w/ diff, CMP
completed. No abnormal findings noted. Resident discharged to PRTC with instructions to
continue all medications as prescribed. This will be processed clinically.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing reviewed the report. Licensing specialist will follow up with
the facility for nursing notes, discharge summary and safety precautions. 12/9/2024 -
Nursing notes and medical information received, reviewed and uploaded to ELS.


summary: A resident was transported to Children’s Hospital for assessment due to complaints of abdominal pain, nausea, and watery stools.

raw_content:
AR KANS A S&S
DEPARTMENT OF

i¢ SaRVICES

Placement and Residential Licensing Unit
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 025839
Date of Incident: 11/28/2024

Date Received: 12/2/2024

Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing

Report Description: >) Description of report:
On 11/28/2024 the resident complained of abdominal pain, nausea and watery stools.
Resident was assessed, abdomen was hard and tender to touch. Resident was taken to
Childrens Hospital for assessment where he was admitted. Resident had an
while in the hospital due to nausea and unable to take the medications they had for him. On
Friday the hospital did

He returned to the facility approx.. 2pm today 12/02/2024. He came
with 3 new prescriptions for nausea and constipation and follow-up with Dr. Alberty in 2
weeks. They did not give him any new diagnosis at this time.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Licensing reviewed the report, Nursing notes and medical
documentation received, reviewed and uploaded to ELS. Facility update received: " About
an hour or so after the resident returned to the facility, his heart rate was around 170 ? It was
155 when discharged and they stated to monitor for an hour and if continued to be elevated
to return to the ER. It remained elevated so we took him to the ER to be evaluated a little
while ago."

We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to a 911 hang up. False alarm.

raw_content:
Incident Report
Print Date/Time: 12/17/2024 10:43 Fayetteville Police Department
Login ID: aarcher ORI Number: AR0720100
Incident: 2024-00083606
Incident Date/Time: 11/28/2024 7:25:25 AM Incident Type: 911 HANGUP
Location: 4253 N CROSSOVER RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (918)568-0799 Source: 911
Report Required: No Priority: 2-Medium
Prior Hazards: No Status: Not In Progress
LE Case Number: Nature of Call:
Unit/Personnel
Unit Personnel
487 487-HAWLEY
519 519-SANDERS
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller E911 (918)568-0799
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:487
Disposition Count Date/Time
03NORPT 1 11/28/2024 07:45
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 1
Page: 1 of 2

CAD Narrative
11/28/2024:07:44:49adunlapNarrative:SMARTCHATSHOWINGTOHAVEBEENSENTINSPANISH
11/28/2024:07:44:29adunlapNarrative:SMARTCHATRESPONSE
ThisisFayetteville911,yourcellphonecalled911.Doyouhaveanemergency?
16minsAshleyD.
No
Now
11/28/2024:07:34:45fcarterNarrative:STILLNOANSWERONCALLBACKATTEMPTS
11/28/2024:07:29:38adunlapNarrative:RAPIDMAPSHOWSPLOTATTHEBUILDINGIMMEDIATELYWESTOFVANTAGE
POINT,NOTQUITEATVALLEYLAKEAPTS
11/28/2024:07:27:40adunlapNarrative:https://w3w.co/motorboat.daisies.chief
11/28/2024:07:27:29adunlapNarrative:SMARTCHATSENTVIARAPIDDEPLOY
11/28/2024:07:26:46adunlapNarrative:NOANSWERONCALLBACKX2,LEFTVM
11/28/2024:07:26:38adunlapNarrative:NORETURNWTRLOGS
11/28/2024:07:26:31adunlapNarrative:NOHXW/88
11/28/2024:07:26:19gabbickNarrative:NOSOUNDSOFDISTRESS
11/28/2024:07:25:46adunlapNarrative:21MPLOT
Page: 2 of 2


summary: Officers were dispatched to the facility in response to a missing resident. Officers located the resident and transported him back to the facility.

raw_content:
Incident Report
Print Date/Time: 12/17/2024 10:39 Fayetteville Police Department
Login ID: aarcher ORI Number: AR0720100
Incident: 2024-00083089
Incident Date/Time: 11/26/2024 10:38:00 AM Incident Type: MISSING PERSON
Location: 2805 E ZION RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (316)303-4040 Source: 911
Report Required: No Priority: 1-High
Prior Hazards: No Status: In Progress
LE Case Number: Nature of Call:
Unit/Personnel
Unit Personnel
317 317-LICHTI
472 472-GONZALEZ
527 527-HOUSE
433-HARRIS
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller VASINA, STEPHANIE 4253 N CROSSOVER RD Unknown Female 01/20/1977
FAYETTEVILLE AR 72703
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:317
Disposition Count Date/Time
03NORPT 1 11/26/2024 11:08
Unit:472
Disposition Count Date/Time
03NORPT 1 11/26/2024 11:15
Unit:527
Disposition Count Date/Time
03NORPT 1 11/26/2024 11:07
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 1
Page: 1 of 2

CAD Narrative
11/26/2024:11:14:02agonzalezNarrative:JUV.TRANSPORTEDBACKTOPINEYRIDGE.D3
11/26/2024:11:07:48beharrisNarrative:WITHJUV
11/26/2024:10:51:43tbryantNarrative:NOCONFRONTATIONBEFORE LEFT
11/26/2024:10:51:15tbryantNarrative:THISISTHEFIRSTTIME HASDONETHIS
11/26/2024:10:51:07tbryantNarrative:NOKNOWNLOCATION WOULDGO
11/26/2024:10:50:51tbryantNarrative:NOPHONEFORTHEJUVENILE
11/26/2024:10:50:28tbryantNarrative:WASONFOOT
11/26/2024:10:49:16tbryantNarrative: ISINTHESTATESCUSTODYANDISFROM
11/26/2024:10:47:30tbryantNarrative:THEYDOHAVEAPICTURE
11/26/2024:10:47:11tbryantNarrative:PRIMARYLANGUAGEISENGLISH
11/26/2024:10:47:05tbryantNarrative:NOPERSONALBELONGINGSWITH
11/26/2024:10:46:51tbryantNarrative:NOKNOWNINJURIES
11/26/2024:10:46:40tbryantNarrative:HASADHDANDDISRUPTIVEMOODDISORDER
11/26/2024:10:46:07tbryantNarrative: ISPREDIABETICANDHASALOTOFMENTALHEALTHDIAGNOSIS
11/26/2024:10:45:44tbryantNarrative:NOSMT,NOBAGS
11/26/2024:10:45:20tbryantNarrative:
11/26/2024:10:44:19tbryantNarrative: ISNOTWEARINGSOCKSANDDOESNOTHAVEACOAT,THEYARE
CONCERNEDDUETOWEATHER
11/26/2024:10:43:54tbryantNarrative:THINKS WENTTHROUGHTHEAPTSTOTHESIDEOFTHEMANDTHENBACK
ETOWARDCROSSOVER
11/26/2024:10:43:05tbryantNarrative:LASTSEENBYANOTHEREMPLOYEE.JUVENILEJUMPEDTHEFENCE
11/26/2024:10:42:36tbryantNarrative: ISONPSYCHIATRICMEDSANDDIDNOTTAKETHEMTHISMORNING,
COULDBECOMESUICIDAL
11/26/2024:10:42:11tbryantNarrative:NOC1,NOTC2
11/26/2024:10:41:55tbryantNarrative:NOWADVTHERAPISTISTHE INTHEOLIVEGRNSHIRTANDTHEYARE
NOTTOGETHERBUTTHETHERAPISTTRIEDTOFOLLOW ANDHASNOTRETURNED
11/26/2024:10:41:07tbryantNarrative:THEYWEREFOLLOWING BUTLOST
11/26/2024:10:41:01tbryantNarrative:20MINDELAYINCALLING
11/26/2024:10:40:41tbryantNarrative:JUVENILEIS
11/26/2024:10:40:23tbryantNarrative:LASTSEENHEADINGETOWARDCROSSOVER
11/26/2024:10:40:06beharrisNarrative:377*
11/26/2024:10:40:04beharrisNarrative:34410-4
11/26/2024:10:39:40tbryantNarrative:MALETHAT LEFTWITHISATHERAPIST
11/26/2024:10:39:19tbryantNarrative: ISWITHANADULTW/MWEARINGOLIVEGRNSTRIPEDSHIRTANDGLASSES
11/26/2024:10:38:57tbryantNarrative:LSWBLKPOLOSHIRTWITHWHISTRIPEONCOLLAR,BLUJEANSANDNAVY
BLUSHOESWITHSKYBLUONTHEM
11/26/2024:10:38:30tbryantNarrative:
Page: 2 of 2

Public Records Exemptions
Enclosed please find a copy of the response documents for your public
records request. The following information is provided to explain the
process employed to review and produce the response documents.
Reason Description Pages
2
1 of 1


summary: A resident eloped off the grounds of 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: 025770
Date of Incident: 11/26/2024
Date Received: 11/26/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 11/23/2024 at approximately 1040 the Fayetteville Police
Department was called because resident
walked off the grounds while being redirected by supervisor, nurse and therapist. He walked
down the wooded area to Millennium Drive. The police brought him and the therapist back
to the facility shortly afterwards. At first the resident refused a gown search required for
safety by policy. After speaking to CASA worker and much conversation of staff members,
he did the gown search and then went to his therapist office and completed a personal
safety plan. He will be on elopement precautions that will be reassessed in 24 hours.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/3/2024 - Licensing reviewed the report and will follow up with
facility to inquire how the resident walked off of the grounds. Facility response received:
"He climbed up part of the fence and to the shed and over. Staff walked with him as he was
leaving grounds."
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident swallowed a small piece of glass or a clear Lego. An x-ray was ordered.

raw_content:
AR KANS A S&S
DEPARTMENT OF

4 HUMAN
<a¥ SERVICES

Placement and Residential Licensing Unit
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 025773
Date of Incident: 11/26/2024

Date Received: 11/26/2024

Facility Name: Piney Ridge Treatment Center
Facility Number: 203

Incident Type: Licensing

Report Description: On 11/25/ 2 Re) This resident

had a small piece of glass or clear lego. He was seen putting a small piece in his mouth and
chewing on it. It appears that he swallowed that piece. He did not complain of any stomach
pain, but the APRN ordered an x-ray to check for any issues. On X-ray completed in house

and shows ii A* the time he was placed on

precautions to be reassessed in 24 fhours. He will be processing with therapist.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Licensing reviewed the report and will confirm the injury information
and request nursing notes and x-ray results from the facility. 12/4/2024 - nursing notes and
x-ray results received, reviewed and uploaded to ELS.

We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain after falling while playing kickball. An x-ray was ordered.

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: 025731
Date of Incident: 11/23/2024
Date Received: 11/25/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 11/23/2024 was in the
gym with unit for RT playing kickball when she lost her balance and fell against the wall
catching herself with her left hand on the wall. The resident reported pain 6/10 after the
incident and was given ice and ibuprofen. Resident was assessed again approximately 1
hour later and had mild to moderate swelling on the palm and 1st digit of left hand. APRN
was notified and x ray was ordered. XRay occurred on 11/23/24 with a normal findings. No
additional care required at this time.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and will follow up for nursing notes and
resident restrictions. Nursing notes and injury information received, reviewed and uploaded
to ELS. Facility response received - the resident was not placed on any restrictions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Policies and Procedures Findings:
Upon review of the identified policies there were no deficiencies noted. The following observations were
noted:
• The Emergency Safety Intervention policy recognizes physical restraints as “The application of
physical external force (not to include mechanical restraint) on the resident to limit mobility. It
shall be used for a period of time as brief as possible and in such a manner that reduces the chance
of physical harm as much as possible. Physical restraint shall not restrict respiratory movements or
other vital functions. A physician's order is required for physical restraints. Physical restraint is a
crisis intervention used to resolve an emergency safety situation to contain severe, out of control
behavior, which is likely to cause harm to the resident, other residents, or staff.”
• The Emergency Safety Intervention policy states that “If a staff member or resident receives a
serious injury during an emergency safety intervention, the staff involved will debrief with the
supervisor. A body assessment completed, identifying any injuries to staff or resident that occurred
during the time of the emergency safety intervention. Identification of the cause of the injury and a
description of the injury will be documented on the body assessment form included in the
Emergency Safety Intervention Justification form. This form is to be filed in the resident's medical
record following the ESI Justification form. During the debriefing, staff involved will determine
what can be done to prevent such injuries during the ESI in the future. The staff involved may
receive retraining from the certified Handle with Care techniques instructor to prevent potential
injuries in the future. All serious injuries will be reported to the Office of Long-Term Care and
Disability Rights Center by the close of business the next day.”
• Training requirements within the Emergency Intervention policy are outlined as follows, “Staff will
complete Handle with Care recertification training annually. Direct care staff also participate in a
Handle with Care refresher training within six months of certification/recertification.”
• The providers policy for reporting incidents are as follows:
o An "incident" is an unanticipated event, which results in, or nearly causes, a negative
impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or
permanent and range in severity from no Obviates or significant injury, up to death.
▪ Supervisor will review the Incident Report for legibility, completion, and date.
Supervisor will notify facility Risk Manager of a serious incident as well as take
the lead in investigating non-serious incidents.
▪ The Incident Report will be routed to the facility Risk Manager within 24 hours of
incident.
▪ Completed, reviewed, and signed Incident Reports must be entered into the Risk
Management Information System ("RiskQual/HAS" incident reporting system).
The “Level l" and "Level Il" incidents must be entered within 24 hours. 'Level Ill"
and "Level IV" incidents must be entered within 5 calendar days.
▪ If the incident involves a patient, staff must chart relevant and factual information
in the patient's medical record. When documenting incidents in the medical
records, staff will chart precisely what happened without referring to an "error" or
that an Incident Report was completed. Staff should not attribute any cause to the
unanticipated event.
Clinical Review Deficiencies:
AFMC was provided with the alleged victim’s file for review.
The provider uploaded records which were then reviewed for compliance with licensure standards. Based
on the review of clinical components of licensure requirements, the following deficiencies were noted:
Piney Ridge Treatment Center, LLC.- Fayetteville, AR - IOC Report 2 | P ag e

doc_type: IOC Report


summary: No deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.

raw_content:
7 HUMAN SERVICES Safmc
- Division of Provider Services y m C

and Quality Assurance Improving health care. Improving lives.

UPDATED: December 4, 2024
November 26, 2024

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.

An incident occurred at the following service site that prompted an order for an additional review. Upon
review of the policies relevant to the incident, the findings are noted below:

Piney Ridge Treatment Center, LLC
4253 N Crossover Rd
Fayetteville, AR 72703-4593

Provider Medicaid Number:
Onsite Inspection Date: November 21, 2024
Onsite Inspection Time: 11:10 a.m.

A summary of the policies reviewed, and findings are noted below:

Inspection of Care Summary

Health and Safety-Policy Review

This additionally ordered inspection was triggered by a complaint against Piney Ridge Treatment Center,
LLC. Based on the nature of the incident, the following were requested for review:

Q15 Observation Policy

521 Visit Compliance Report

Daily Staff Schedules

The alleged victim’s chart was not reviewed due to client being an out of state resident.

Policies and Procedures Findings:
Upon review of the identified policies no deficiencies were noted. The following observations were noted:

e Staff are to complete patient observations and document every fifteen (15) minutes.

e The Q15 Observation policy identifies that staff are not to complete fifteen (15) minute
observations from the doorway or at a distance. During hours when residents are awake, staff are
expected to approach the residents and engage verbally. During sleeping hours, staff are to visually
check the resident’s identity, observe respirations, and check that they are not in distress.

Summary of Findings and Resolution:
e Upon review of the daily staff schedules for October 31, 2024, to November 04, 2024, the
provider had a ratio of one staff to every six clients.

1020 W. 4TH ST., SUITE 300 | LITTLE ROCK, AR 72201 | 501-212-8600 | FAX: 501-375-0705

e Upon reviewing the 521 Visit Compliance Report, it was noted that the alleged offender did not
physically touch the victim, but did make inappropriate comments of a sexual nature. The victim
noted that they notified the staff of the comments, and that staff implemented precautions that the
residents stay at a distance and supervision was increased. The alleged offender was also

interviewed and collaborated with the same story.
e The incident was reported a. the client’s out of state case worker after
speaking with the client. Th was not accepted per the facility’s Chief Executive

Officer.
e There were no deficiencies noted.

Respectfully,

Inspection of Care Team
InspectionTeam@afmc.org

Aafme

Improving health care. |mproving lives.
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 ¢ afmc.org

Piney Ridge Treatment Center- Fayetteville, AR. - IOC Report 2/Page


summary: Complaint #AR 00036017 was in compliance.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
December 10, 2024
Justin Hoover, Administrator
Piney Ridge Treatment Center, Inc.
2805 E Zion Rd
Fayetteville, AR 72703
Dear Mr. Hoover:
A Complaint Investigation survey was conducted on November 20, 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
November 20, 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 breanna.marengo@dhs.arkansas.gov.
If you have any questions please contact your reviewer at 501-320-6280.
Sincerely,
for Jeff Rosenbaum
DPSQA/Office of Long Term Care
Survey and Certification Section
bbm
cc: DRA
Justin Hoover - Piney Ridge Treatment Center, Inc - 12/10/2024- (AOLTC - PRTF No Def) Page 1]

PRINTED: 12/10/2024
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
04L117 B. WING _____________________________ 11/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2805 E ZION RD
PINEY RIDGE TREATMENT CENTER, INC
FAYETTEVILLE, AR 72703
(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 AR00036017 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:BY2I11 Facility ID: 3016 If continuation sheet Page 1 of 1

doc_type: Complaint Survey


summary: A resident became escalated and attempted to attack a peer and facility staff. The resident was arrested by Fayetteville Police and transported to JDC. The facility was cited 110.17 for late reporting.

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: 025646
Date of Incident: 11/19/2024
Date Received: 11/21/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 11/18/2024 at approximately 0710
) became escalated, was attempting to attack a peer and staff attempted to
place the resident in a physical hold but resident slipped out. Because of this, staff released
resident completely and stepped away. continued to engage in unsafe behaviors and
when placed in a hold again he punched a staff member Brandon Barrett in the face. He
was eventually able to calm down, process and take his PRN medication. On 11/19/2024 the
staff member contacted the Fayetteville Police Department and pressed charges on the
resident. At approximately 1810 the police department arrived and transported the resident
to juvenile detention.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/21/2024 - Licensing reviewed the report and will follow up with the
facility regarding if the resident has returned. The facility provided a statement for the late
report date: "I placed an arrest of a resident in the portal a day late (entered on 11/21/2024,
we do not have residents arrested very often at the facility therefore I forgot to report in
portal on 11/20/2024. I apologize for this oversight." Program Coordinator requested police
documentation. 11/22/2024 - Licensing specialist inquired if there was video footage
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

available. Facility states there is not video footage available. Licensing specialist requested
witness statements for the incident from residents and staff who saw the incident. Police
documentation received and Licensing Specialist informed. Facility cited for 110.17 - 521
report sent to the facility for signature.


summary: Police were dispatched to the facility in response to a report of a patient assaulting a staff member.

raw_content:
Incident Report
Print Date/Time: 12/17/2024 10:44 Fayetteville Police Department
Login ID: aarcher ORI Number: AR0720100
Incident: 2024-00081221
Incident Date/Time: 11/19/2024 4:03:02 PM Incident Type: ASSAULT BATTERY
Location: 4253 N CROSSOVER RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (281)757-0887 Source: Phone
Report Required: No Priority: 3-Low
Prior Hazards: No Status: Report
LE Case Number: 2024-00081221 Nature of Call:
Unit/Personnel
Unit Personnel
478 478-VEGA
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller BARRETT, BRANDON 1772 N OAKLAND AVE (281)757-0887 White Male 06/29/1995
ALEXANDER
FAYETTEVILLE AR 72703
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:478
Disposition Count Date/Time
07FARREST 1 11/19/2024 19:16
01RPTF 1 11/19/2024 19:16
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 1
Page: 1 of 2

CAD Narrative
11/19/2024:19:08:29mtheriaultNarrative:EM080
11/19/2024:18:50:56mtheriaultNarrative:BM071
11/19/2024:18:39:39mtheriaultNarrative:478BODYCAM10-7
11/19/2024:18:09:59mtheriaultNarrative:4781015
11/19/2024:16:06:43mkurtzNarrative:THEREISONLYIN-HOUSEDOCUMENTATIONBUTPOLICEREPORTIS
REQUIRED.
11/19/2024:16:05:44mkurtzNarrative:THEREWASALSOANOTHERSTAFFMEMBERWHOWASTHREATENEDTODAY
BUTTHATPERSONISNOTCURRENLTYAROUND.
11/19/2024:16:05:09mkurtzNarrative: HITCALLERINTHEFACEWITHAWALKIETALKIE,SPATONHIM,TRIED
TOKICKANDPUNCHTHEGROINAREA.
11/19/2024:16:04:44mkurtzNarrative: ALSOMADEATHREATOFVIOLENCETODAY.SAID WOULDHITCALLER
INTHEFACE.
11/19/2024:16:04:21mkurtzNarrative:ADVHEWASASSAULTEDBYJUVENILEPT, YESTERDAYMORNING.
11/19/2024:16:04:08mkurtzNarrative:CALLERWORKSFORPINEYRIDGE.
11/19/2024:16:03:31mkurtzNarrative:CONTACTBYPHONE.
Page: 2 of 2

Public Records Exemptions
Enclosed please find a copy of the response documents for your public
records request. The following information is provided to explain the
process employed to review and produce the response documents.
Reason Description Pages
2
1 of 1


summary: A resident was transported to Children’s Hospital Emergency Room due to rectal bleeding.

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: 025501
Date of Incident: 11/13/2024
Date Received: 11/14/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: Date of occurrence: 11/13/2024
The resident has long standing diagnosis called his primary Dr.
yesterday and we received notice that they wanted him to go to Childrens ER to be
evaluated due to rectal bleeding. He was transported to the ER via our transport. Corrective
Action taken by the agency or follow up done: Resident returned from AR Children's on
11/13/24 at approx 2343. Resident returned with orders to have a follow up with Dr. John
Alberty as soon as possible. Resident has orders for labs for Giardia / Cryptosporidium
antigens. Notified guardian, via telephone at approx 0020 of residents return.
We will continue with his current medications until we have direction from his primary.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and followed up with facility for nursing
notes, hospital discharge and follow up with PCP. Nursing notes received, reviewed and
uploaded to ELS 11/15/2024 - Licensing received nursing notes for for the last two
weeks, reviewed and uploaded to ELS. 11/22/2024 - follow up with facility concerning the
residents medical condition and scheduled follow up visits
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A complaint was received that a resident was given the wrong medication. The complaint was FOUNDED by Licensing. The facility was cited 907.2.

raw_content:
AR KANS A S&S
DEPARTMENT OF

i¢ SaRVICES

Placement and Residential Licensing Unit
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 025410
Date of Incident: 11/9/2024

Date Received: 11/12/2024

Facility Name: Piney Ridge Treatment Center
Facility Number: 203

Incident Type: Licensing

Report Description: A report was received that client was given the
wrong medication and sent to Vantage Point acute hospital on 11/9/2024. fF
reports that they did not receive a phone call about the incident, but instead received an
email. Due to the situation, MM felt that it would have warranted a phone call

rather than an email.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: 11/12/2024-Program Manager emailed the facility to confirm if the
facility has a resident by this name that was admitted into acute care on 11/9/2024. The
facility reports that they do have a resident by this name, but he was never taken for acute
care since he has been admitted to the program. A phone call with Angie Smith revealed
that the resident was given the wrong medication by nursing staff on 11/9/2024 after the
nurse was having a BHA help during medication pass. The BHA was bringing the children
to the nursing station for the nurse to distribute the medication and when the resident came
to the window, the nursing staff failed to ask for a DOB before providing the medication to
the resident. The facility reports they immediately recognized their mistake and called the
DON who spoke to the physician. The physician gave orders to hold the resident's

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humanservices.arkansas.gov

prescribed nightly medications and monitor him for any adverse reactions to the
medications he was given. The resident was monitored and never had any adverse reactions
therefore it was determined that further outside medical treatment was not necessary. Angie
Smith will be sending the name of the medications, the nursing notes, and the retraining
that was done with the staff to licensing for documentation. 11/14/2024-Licensing requested
further documentation to show that the staff has been retrained and the list of the
medications that the resident is currently prescribed. Program manager spoke to the
Po who reported that the resident was not in acute care or in Vantage point,
but when she calls she gets transferred to the Vantage Point phone line. reports
that she has had concerns with the facility and that was seen in the emergency room
yesterday 11/13/2024 after he has been complaining of rectal bleeding for the last few
weeks. The HB <<ports the child has and is under a specialist care in
Jonesboro, AR. a st several screenshots of conversations she has had with
Piney Ridge staff regarding the care of J Also, IM states that the ER
paperwork states that the child was kicked in the stomach a few weeks ago, but
reports that she was never made aware of that incident. 11/18/2024 - Licensing specialist
received and uploaded proof of training for medication distribution. Reviewed and uploaded
to ELS. 12/3/2024-Licensing emailed the facility to check on the status of the resident and
determine if there was an incident in which the resident was kicked in the stomach by a
peer between his admission and the day he was sent to the emergency room. The DON
reports that they reviewed the client's chart and there is no mention, nor does she remember

any incident in which the resident was kicked in the stomach by a peer since his admission.
1/8/2025 - The case was founded by Licensing. 2/18/2025, case reviewed and founded by
licensing. case complete.

& @#®# & KE AS
SEPARYMENRT OF

} 7 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: Piney Ridge Treatment Center

Facility Number: 203

Licensee Address: 2805 E ZION RD
FAYETTEVILLE AR 72703

Licensing Specialist: Cheisea Vardell
Person In Charge:

Record Visit Date: 1/8/2025

Home Visit Date: 1/8/2025

Purpose of Visit: Complaint Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Regulation Number: 900.907.2

Regulation Description: Child caring staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s
age, individual differences and abilities, surrounding circumstances, hazards and risks.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 7 of 3

FeREL ES

Finding Description: The facility failed to provide the adequate level of supervision to a resident to ensure their
safety and well-being when the nursing staff failed to ensure the correct medications were being provided to the
resident on 11/9/2024

Action Due Date: 2024-11-15

Action Due Description: The staff involved in the incident were retrained on medication distribution and
retraining documentation was provided to licensing.

Comply Date:

Action Due Description: The staff involved in the incident were retrained on medication distribution and
retraining documentation was provided to licensing.

Narrative:

Licensing received a complaint regarding a resident who was given the wrong medication and sent to Vantage
Point acute hospital on 11/9/2024. Licensing has investigated this complaint and determined it to befounded.

The facility nursing staff provided the wrong medication to the resident on 11/9/2024. The medications
included were Trazodone 50mg, Geodon 40mg, and Depakote 250mg.

The resident was monitored for adverse reactions and orders were received from the physician to without
prescribed nightly medications. The facility reports that the resident had no adverse reactions, and no outside
medical care was necessary.

The staff involved in the incident were retrained on medication distribution and retraining documentation was
provided to licensing.

The facility reports that the resident did not go to acute care or receive any emergency care as a result of this
incident.

The facility failed to provide the adequate level of supervision to a resident to ensure their safety and
well-being when the nursing staff failed to ensure the correct medications were being provided to the resident
on 11/9/2024. This is a violation of standard907.2"Childcare staff shall be responsible for providing the level
of supervision, care, and treatment that is necessary to ensure the safety and well-being of each child at the
facility, taking into account the child’s age, individual differences and abilities, surrounding circumstances,
hazards, and risks."

“ee Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of noncompliance is in error, you
may ask for reconsideration. The request for reconsideration must be in writing and delivered to the Department by certified
mail within twenty (20) business days of receipt of the notice of noncompliance. The request must specify the parts of the
notice that are alleged to be in error, explain why you believe those parts are in error, and include documentation to support
the allegation of error. Once received the Department shall issue a decision on your request within twenty (20) days after
receipt of the request.

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

Se TEEE TY

Provider Comments:

CCL Staff Signature : GL WA Date: 1/8/2025

Provider Signature : Clon— Date: 1/8/2025

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


summary: A resident reported that she had been sexually assaulted by another resident at the facility. 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: 025353
Date of Incident: 11/5/2024
Date Received: 11/5/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: spoke with
that stated she came to Arkansas to visit a child placed at Piney Ridge. The
child was very upset and stated that she was sexually assaulted by the child in the room next
to her. She stated she told staff she needed space from the other child because she was in
the room beside her. The staff at Piney reported to that they didn?t know about
the incident and the they are still in rooms next to one another.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: A visit was conducted at the facility to interview residents. The
inspection # is 081216 A visit was conducted at the facility to interview the residents and
obtain more information regarding the incident and address concerns with facility staff.
Licensing specialist J. Parnell interviewed the resident at the facility. The resident shared
information about the location of the incident and identified the alleged offender and staff
persons who were notified of the incident. The resident stated the location was in the
sunroom. The resident stated more than once the alleged offender did not physically touch
her during the alleged incident but made inappropriate sexual comments. The resident
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

stated she notified staff of the verbal comments during the incident and staff implemented
precautions that residents stay at a distance and supervision increased. Licensing specialist
interviewed the alleged offender named by the alleged victim in regards to the allegations.
The resident recalled the same incident and shared information. The resident stated there
was no physical contact with the alleged victim and admitted that she made inappropriate
sexual comments to the alleged victim because she was trying to flirt with her. The resident
stated staff were made aware by the alleged victim and they were put on a proximity
precaution and were not allowed to go near to one another. 12/26/2024 - The complaint is
unfounded by licensing. 521 report sent to the facility for signature. 1/3/2025, case reviewed
and approved. A timeframe was not provided to determine if there was a supervision issue.
Case complete.


summary: A resident complained of pain after falling while doing handstands. An x-ray was ordered.

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: 025176
Date of Incident: 10/31/2024
Date Received: 11/4/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/31/24 at approximately 1831
) was doing handstands and fell while doing one. She had a small "carpet
burn" mark on her face. She started crying and said it hurt badly. He was given first aid of
ice and bandage. The APRN ordered a x-ray next time mobile xray was here. She received
the xray on 11/1/24 and results came in that it was not fractured. No follow up care needed
at this time.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/4/2024 - Licensing specialist reviewed the report and will request
nursing notes for the incident. 11/14/2024 - Followed up for nursing notes again requesting
documentation for the report. 11/18/2024 - Nursing notes received, reviewed, and uploaded
to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain after being restrained. The resident stated that a staff member shoved him against the fence and down to the ground, scraping his shoulder and the side of his ear. The facility was cited 109.1.g as a result of this incident.

raw_content:
AR KANS A S&S
DEPARTMENT OF

4 HUMAN
<a\ SERVICES

Placement and Residential Licensing Unit
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 025131
Date of Incident: 10/31/2024

Date Received: 11/1/2024

Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Dual

Report Description: On 10/31/2024 at approximately 1640
) re ee i ssssi(‘ésSy were horse playing by slapping
a staff member, ery 00 etCi reportedly made a comment along the
lines of "if you hit me again I'll restrain you" and [J hit the staff member with his jacket
again. J placed J into a standing HWC restraint. According to the resident,
while he was struggling against the restraint, the staff member shoved resident against the
fence wall and down onto the ground, scraping his shoulder and the side of his ear in the
process. Employee was suspended pending investigation. On 10/31/2024 at approximately
1730 the

. was at
the facility on 11/1/24 and spoke with the resident Hand staff member that

was present for part of the situation.

Interim Action Narrative: staff member suspended pending the investigation.

We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Program Coordinator checked for the a. Licensing
specialist reviewed the report. Licensing specialist will acquire permission from PY
FO reach out to the facility for video footage archiving and safety plan. Facility
staffed responded stating there is no video footage because the alleged incident occurred
outside. Licensing specialist received permission from investigator J Licensing
specialist requested witness statements from staff PF and resident a.
11/8/2024 - Licensing specialist sent a reminder email to the facility for the requested
documentation 11/13/2024 - Licensing specialist staffed with program director c. vardell
and sent a notification to the facility to provide the requested documentation by the end of
the day. 11/14/2024 - Risk manager R. Adams contacted licensing specialist to inform the

and the facility would be doing retraining
for staff| | COS 11/15/2024 Licensing specialist attempted to contact facility to follow
up with information regarding the report, risk manager R. Adams is out of the office until
Monday 11/18/2024. Licensing specialist will follow up on monday. 11/20/2024 - Licensing
specialist contact the facility to inquire if they felt the restraint done by staff fF was
necessary and met minimum standards. The facility responded stating they believe the
restraint was necessary and met minimum standards. 11/20/2024 - Retraining
documentation for handle with care has been received, reviewed and uploaded to ELS.
11/22/2024 - Licensing specialist staffed case with supervisor. 12/6/2024 - A visit was
conducted at the facility to review information for the complaint and discuss the incident
with facility staff. Facility was cited for 109.1 G based on information obtained during the
investigation concerning the conduct of the employee horse-playing with the resident prior
to the incident, wiping his face with the residents shirt, and refusing to leave the area when
asked by another staff who was taking over for the restraint. Licensing specialist spoke with
the facility staff to address concerns with boundaries and horse playing. 12/9/2024 - 521
inspection report sent to the facility. ICA was lifted by Program Coordinator C. Vardell
Signed 521 inspection report received from the facility, uploaded to ELS. 12/27/2024, this
complaint has been founded by licensing. Program Coordinator reviewed and approved
complaint. Case complete.

A ®@ RAM EAR B
BEPARYMERT OF

om: SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Piney Ridge Treatment Center

Facility Number: 203

Licensee Address: 2805 E ZION RD
FAYETTEVILLE AR 72703

Licensing Specialist: Jarred Parnell
Person In Charge: Ronissa Adams
Record Visit Date: 12/6/2024
Home Visit Date: 12/6/2024

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: 109.1.g- 109.1.g- Horse playing with residents, failing to leave the area after being
prompted multiple times by staff restraint instructor, and using the residents shirt to wipe his face causing the
resident to further escalate.

Action Due Date: 2024-12-09

Action Due Description: The facility provided re-education on 11/19/2024 for seclusion and restraint policies and
the Handle with Care verbal program.

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: The facility provided re-education on 11/19/2024 for seclusion and restraint policies and
the Handle with Care verbal program.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 4 of 2

oops

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:
A visit was conducted at the facility to speak with facility staff for case number 025131.

Based on the information received during the investigation the facility is being cited for standard 109.1.G: "
Unprofessional conduct in the practice of child welfare activities shall include without limitation: (g)
Engaging in behavior that could be viewed as sexual, dangerous, exploitative, or physically harmful to
children. (Founded)

Due to conflicting reports and a lack of video evidence, licensing was unable to determine if excessive force
was used during the restraint hold. 905.9"'Physical restraints shall be performed using minimal force and
time necessary. Physical restraint means the application of physical force without the use of any device,
for the purpose of restraining the free movement of a resident's body. Briefly holding a child without
undue force in order to calm or comfort them or holding a hand to safely escort a child from one area
to another, is not considered a physical restraint."'(Unfounded)

The Interim Corrective Action has been lifted, and the employee may return to normal job duties.
Provider Comments:

This event described should have more content around the situation. The youth involved had a propensity to not respond
to various interventions and clinical therapy, objective and goals. The youth was easily elevated and had previous
incidents including what not limited to property destruction, elopement and physical aggression toward others. The
facility had regular communication with the legal guardians about the youth’s lack of process and ongoing unsafe
behavior and overall lack of willingness to make necessary strides in his treatment. The facility had identified the youth
was no longer appropriate due to unsafe behavior but understanding the guardian didn’t have other options the facility
decided to continue to serve the youth until the guardians and facility could ensure a plan was in place with the
assistance with other 3% party members. The multi-disciplinary team was assisting the guardians in this endeavor.

The facility has been cited for Unprofessional conduct in the practice of child welfare activities shall include without
limitation: (g) engaging in behavior that could be viewed as sexual, dangerous, exploitative, or physically harmful to
children. (Founded by PRLU) The incident was review by OLTC, AFMC and Washington County DCFS investigator and at
the current time, the facility has not been cited by any of those entities. Furthermore, the citation in which the facility
received is very serious “engaging in behavior that could be viewed as sexual, dangerous, exploitative, or physically

harmful to children”, yet the employee has been approved to return to work from DHS.

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

SMa Ter edasieeet Eres.

Parts of the investigation reveals that the employee did or stated something as:

“If you don’t stop, or if you do that again you will be restrained” while this is not a therapeutic response this was a youth
who did not respond to staff redirects to stop the physically aggressive behavior.

It was stated that the employee did not immediately leave the restraint when directed, however it was later discovered

that the employee did not want to leave the only other stronger staff alone while in an emergency safety issue which is a
best practice.

The staff member wiped his face with the shirt/jacket of the youth that was on the ground but later discovered this
because the youth had spit in the staff face multiple times and this was the closest item to use.

While there is always opportunity’s for improvements when conducting an emergency safety intervention. We do not
agree with the citation, we have to look at these events in context. This youth is stronger in size and has a history of
unsafe behavior and an unwillingness to participate and or engage in treatment.

CCL Staff Signature : _— \ Si Date: 12/6/2024
Provider Signature : Date: 12/6/2024

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

&


summary: A resident eloped from the facility by jumping a fence while outside.

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: 025008
Date of Incident: 10/27/2024
Date Received: 10/28/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/27/24 at approximately 1801
was outside on main court when staff witnessed the resident pass a note to a female
resident as south unit transitioned through. Staff redirected resident, which upset the
resident. The resident then refused to transition off of main court to dinner with the rest of
north unit. Nursing was called and attempted to process with the resident, but the resident
refused. The resident then got up and and proceeded to climb the fence and then hop over
the edge off of facility property. Resident left the property at 1801. At 1802, administrator on
call and Fayetteville PD notified. Nurse followed the resident and was able to keep eyes on
the resident at all times. The resident eventually processed with nurse and walked willingly
back to the facility. Resident returned to PRTC with nurse at 1830. Resident was assessed
after the incident and no injury was observed. Resident denied pain. Resident placed on
elopement precautions x 24 hours. Resident Restricted to Unit x 24 hours. He will process
with his primary therapist.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 10/29/2024 - Licensing reviewed the report and will follow up with the
facility in regards to camera footage. 11/13/2024 - Facility response received: " We do not
have video outside. I or Angie will send the documentation tomorrow."


summary: Staff advised dispatch that a juvenile ran away from the facility.

raw_content:
Incident Report
Print Date/Time: 11/18/2024 09:55 Fayetteville Police Department
Login ID: aarcher ORI Number: AR0720100
Incident: 2024-00075279
Incident Date/Time: 10/27/2024 6:03:03 PM Incident Type: MISSING PERSON
Location: 4253 N CROSSOVER RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (479)684-7753 Source: Phone
Report Required: No Priority: 1-High
Prior Hazards: No Status: In Progress
LE Case Number: Nature of Call:
Unit/Personnel
Unit Personnel
520 520-WYATT
422-MILLS
522 522-SCHMITT
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller SUGG, KEATON (479)684-7753 Male 05/07/1999
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:520
Disposition Count Date/Time
03NORPT 1 10/27/2024 18:30
Unit:522
Disposition Count Date/Time
03NORPT 1 10/27/2024 18:27
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 1
Page: 1 of 2

CAD Narrative
10/27/2024:18:23:04awyattNarrative:JUVENILEWILLINGLYWALKEDBACKTOPINEYRIDGEWITHSTAFF.D3
10/27/2024:18:15:53mtheriaultNarrative:UPDATEDLOCFROMCALLERSTAFFHASEYESON ATTHECORNEROF
ZION/CROSSOVERACROSSTHESTREETINSOMEONEYARDFROMTHEGASSTATION
10/27/2024:18:12:48lusmithNarrative:CALLERADVSTAFFISTOOFARTOBEONTHERADIO-NOTANSWERINGCELL
PHONES
10/27/2024:18:11:02tkelleyNarrative:STAFFISSTILLFOLLOWINGUNKWHERETHEYARECALLERHASNOTGOTTEN
ANYUPDATES
10/27/2024:18:10:23tkelleyNarrative:WASALONE
10/27/2024:18:10:16tkelleyNarrative:ATTENDSSCHOOLATTHEFACILITY
10/27/2024:18:10:05tkelleyNarrative:UNKSOCIALMEDIA
10/27/2024:18:09:57tkelleyNarrative:UNKIFFRIENDORRELATIVEPICKEDHIMUP
10/27/2024:18:09:38tkelleyNarrative:ISNOTFROMHERE
10/27/2024:18:09:33tkelleyNarrative:UNKDESTINATION
10/27/2024:18:09:28tkelleyNarrative:NOALTMODE
10/27/2024:18:09:19tkelleyNarrative:NONOTE
10/27/2024:18:09:11tkelleyNarrative:NOPHONE
10/27/2024:18:09:04tkelleyNarrative:NOSERVICEANIMAL
10/27/2024:18:08:50tkelleyNarrative:NURSESSTATIONHASAPICAVAILABLE,CALLERDOESNOTHAVEACCESS
10/27/2024:18:08:33tkelleyNarrative:ENGISPRIMARY
10/27/2024:18:08:29tkelleyNarrative:UNKPERSONALBELONGINGSAREMISSING
10/27/2024:18:08:17tkelleyNarrative:NOC1
10/27/2024:18:08:11tkelleyNarrative:NOINJURIESKNOWN
10/27/2024:18:08:03tkelleyNarrative:TAKESMEDS,UNKWHICHONES,UNKMED
10/27/2024:18:07:47tkelleyNarrative:NOTHINGWITH
10/27/2024:18:07:36tkelleyNarrative:UNKSHOES
10/27/2024:18:07:33tkelleyNarrative:GRAYSHIRTREDWRITINGJEANSUNKSHORES
10/27/2024:18:07:18tkelleyNarrative:NOSMTS
10/27/2024:18:07:10tkelleyNarrative: SHORTBLKHAIRWITHWAVES,POSSBROEYES
LIGHTCOMPLEXION
10/27/2024:18:06:06tkelleyNarrative:LASTSEENTODAYJUSTAFEWMINUTESAGO
10/27/2024:18:05:51tkelleyNarrative:UNKWHERE LIVES,ISARESIDENTHERE
10/27/2024:18:05:44tkelleyNarrative:NOSPECCONSIDERATIONS
10/27/2024:18:05:26tkelleyNarrative:SEENBYCALLER
10/27/2024:18:05:22tkelleyNarrative:LASTSEENAMINUTEAGO,THEREWERESTAFFMEMBERSFOLLOWING
10/27/2024:18:04:53tkelleyNarrative:SUBJRANAWYFROMPINEYRIDGE
10/27/2024:18:04:03tkelleyNarrative: SUBJGRAYSHIRTREDWRITINGJEANS
10/27/2024:18:03:48tkelleyNarrative:THROUGHTHEPLOTOFMEXICANRESTAURANT
10/27/2024:18:03:36tkelleyNarrative:CHILDELOPEDEASTTOWARDSCROSSOVER
Page: 2 of 2

Public Records Exemptions
Enclosed please find a copy of the response documents for your public
records request. The following information is provided to explain the
process employed to review and produce the response documents.
Reason Description Pages
2
1 of 1


summary: A resident complained of pain after punching a wall. An x-ray was ordered.

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: 025007
Date of Incident: 10/24/2024
Date Received: 10/28/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/24/24 at approximately 1851
) became angry regarding a situation with peers, so the resident punched the
wall, which resulted in her having pain in her right hand. Resident had pain in her right
hand. X-Ray ordered on 10/25/24. No other pain or injury resident placed on assault
precautions. X-ray occured in house on 10/25/2024 and was
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/29/2024 - Licensing reviewed the report and requesting nursing
notes for the incident. 11/13/2024 - Licensing received nursing notes, reviewed, and
uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident swallowed a Lego. An x-ray was ordered.

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: 024840
Date of Incident: 10/19/2024
Date Received: 10/21/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/19/24 at approximately 1635 was on the east unit
playing with legos. He placed a lego in his mouth and refused to spit it out upon staff
direction. He ran up to the nurses station and stated "I am going to swallow it" and then
proceeded to swallow the lego. APRN notified and a liquid diet for 72 hours was ordered
and an abdominal xray was ordered. The xray occured on 10/20/24 and the results were:
. . Nursing educated resident
on the importance of not ingesting objects not meant for consumption. Resident mildly
receptive to education.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: The report was reviewed by Licensing 11/13/2024 - Licensing
specialist will inquire of the precautions the resident was placed for his actions. Facility
response received: "Yes we supervise the residents and the nurse spoke with the resident.
Justin the CEO and I had a conversation of mitigation and decided that in the long run ? it
was therapeutic for residents."
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An inspection of the Facility’s policies was conducted for the annual review. No deficiencies cited.

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: Piney Ridge Treatment Center
Facility Number: 203
Licensee Address: 2805 E ZION RD
FAYETTEVILLE AR 72703
Licensing Specialist: Jarred Parnell
Person In Charge:
Record Visit Date: 10/16/2024
Home Visit Date: 10/16/2024
Purpose of Visit: Agency Review
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
An inspection of the Facility's policies was conducted for the annual review. The following was reviewed for
the facility:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

a. Personnel policies;
b. Volunteer policy;
c. Student intern policy;
d. Admission policy;
e. Intake policy;
f. Behavior Management policy: Corporal punishment is prohibited for all residential licenses.
g. Crisis Management policy;
h. Child Maltreatment/Mandated Reporter policy: according to Arkansas law, including procedures to ensure
that alleged, suspected, or witnessed incidents of maltreatment are reported to the Child Maltreatment Hotline
and documented as required by these or other applicable rule or laws;
i. Child Exploitation policy;
j. Visitation policy;
k. Family Therapy or Therapeutic Pass policy
l. Admission Health Assessments policy (
m. Public Safety policy (sexual rehabilitative programs only); and
n. Target Population and Admission, Exclusion, and Discharge Criteria policy
Security camera policies were reviewed as part of the inspection. The facility has an updated fire inspection,
health inspection, board of directors information, and organization chart.
Provider Comments:
CCL Staff Signature : Date: 10/16/2024
Provider Signature : Date: 10/16/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident swallowed a battery and a bottle cap. An x-ray was ordered.

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: 024734
Date of Incident: 10/14/2024
Date Received: 10/15/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/14/24 at approximately 1300
) was on the educational outing at Farmland Adventure. Staff saw the resident put
what appeared to be a small battery into his mouth and a bottle cap into his mouth. The
resident refused to give it up when asked and swallowed the item. When arriving back at the
facility, he refused a pocket search and wand search and ran past staff at first but eventually
was searched. APRN ordered an x-ray and placed the resident on clear liquid diet until the
results of x-ray was back. In house x-ray showed . The resident
was placed on precautions to be reassessed in 24 hours.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/16/2024 - The report was reviewed by licensing, licensing specialist
will inquire if the resident picked up the items on the outing. Facility responded that they
believe the resident picked up the items on his outing.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident climbed a fence and eloped from 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: 024555
Date of Incident: 10/5/2024
Date Received: 10/7/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/5/24 Resident
climbed the fence and eloped while outside, staff tried to intervene but Resident was able to
jump the fence, staff had eyes on Resident for while and lost sight of him, Fayetteville police
called at 1405, AOC made aware, and guardian called and notified at 1420, Resident was
found by the outside gym and was brought back to the facility at 1525 by Piney staff, skin
assessment and gown search completed, Resident sustained two abrasions to his right hand
while climbing the fence, wound care completed and Resident placed on elopement
precautions X 24 hrs. Resident will process with his primary therapist.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/8/2024 - The provider reported incident was reviewed by the
licensing specialist. Licensing specialist will follow up with the facility in regards to nursing
notes and staff intervention with a follow up visit under inspection #081011. The facility has
removed the awning to prevent future incidents where residents can climb the awning and
scale the fence. Supervision was discussed and it was noted staff saw the resident and
attempted to stop the resident with verbal redirection. Physical restraint was not used for
safety concerns and the resident was out of reach. 10/10/2024 - Facility response received :
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

"So related to elopement ? it depends on situation to the decision of how to intervene."
Facility staff provided a copy of elopement polices and procedures for dealing with
elopements. Documents were reviewed, and uploaded to ELS


summary: The Fayetteville Police Department came to the facility and arrested a resident. Related to PRLU portal entry 024360 (9/28/24 Peer Altercation).

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: 024556
Date of Incident: 10/4/2024
Date Received: 10/7/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/4/24 at approximately 1430, the Fayetteville police department
came and arrested related to PRLU portal
entry 024360. He was taken to Washington Co JDC and was discharged from PRTC.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/8/2024 - The provider reported incident was reviewed by the
licensing specialist. Licensing reviewed and uploaded nursing notes, hospital discharge
documentation and after care guide, reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident injured her ankle while running around outside. An x-ray was ordered.

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: 024562
Date of Incident: 10/3/2024
Date Received: 10/7/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: In the evening of 10/3/24
was running around the court outside and accidentally twisted her ankle. She reports having
pain around her ankle and upon further assessment, she currently has a swollen red ankle.
was advised to decrease physical activity to avoid pain and further damage to her
ankle. In addition, she was also given ibuprofen to help with the inflammation and pain in
her ankle. A nurse followed up on 10/4/24 to assess injury again and the resident saw the
APRN who ordered an x-ray. The x-ray occured in house on 10/5/24 and the results
No additional orders at this time.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/8/2024 - The provider reported incident was reviewed by the
licensing specialist. Licensing requested nursing notes and hospital discharge paperwork
from the facility. A follow up visit was conducted at the facility under inspection #081011 to
discuss the reported incident. Facility staff will provide nursing notes for the incident.
10/9/2024 - Provider nursing notes received, reviewed, and uploaded to ELS
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Two residents eloped from the facility by climbing onto an awning and through a fence.

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: 024507
Date of Incident: 10/3/2024
Date Received: 10/4/2024
Facility Name: Piney Ridge Treatment Center
Facility Number: 203
Incident Type: Licensing
Report Description: On 10/03/2024 two residents;
resident in custody, and
resident in custody both climbed onto the awning and climbed through the
fence in the area near the cell phone tower. They were on the awning at 1845 and then left
our property at approx 1912, the police were called at 1916. Staff had eyes on the residents the
entire time and was able to get to walk back to the property rather quickly.
stayed off the property but in the sight of staff for approx 30 minutes. We called the police
back to let them know we were with the residents and able to get them back inside without
any issues. Both residents are on RTU and elopement precautions x 24 hours. Staff were
with them the entire time outside trying to process with residents and were already outside
the fence waiting on them so the residents were never out of staff sight.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10/7/2024 - The provider reported incident was reviewed by the
Licensing specialist. The facility has removed the awning in order to prevent residents from
climbing the fence in the future.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Staff advised dispatch that two residents left the facility by climbing a fence.

raw_content:
Incident Report
Print Date/Time: 10/21/2024 07:57 Fayetteville Police Department
Login ID: aarcher ORI Number: AR0720100
Incident: 2024-00069364
Incident Date/Time: 10/3/2024 7:16:23 PM Incident Type: MISSING PERSON
Location: 4253 N CROSSOVER RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (313)303-4040 Source: 911
Report Required: No Priority: 1-High
Prior Hazards: No Status: In Progress
LE Case Number: Nature of Call:
Unit/Personnel
Unit Personnel
418 418-HARRIS
441 441-IBARRA
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller VASINA, STEPHANIE 4253 N CROSSOVER RD Unknown Female
FAYETTEVILLE AR 72703
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:418
Disposition Count Date/Time
03NORPT 1 10/03/2024 19:21
Unit:441
Disposition Count Date/Time
03NORPT 1 10/03/2024 19:22
03NORPT 1 10/03/2024 19:45
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 2

Public Records Exemptions
Enclosed please find a copy of the response documents for your public
records request. The following information is provided to explain the
process employed to review and produce the response documents.
Reason Description Pages
2
1 of 1