summary: Licensing performed a Buildings and Grounds walkthrough. The facility was cited 911.6 for issues identified during the visit.

raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
~=a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 12/4/2024

Home Visit Date: 12/4/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulation Number: 900.911.6

Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.
Finding Description: See narrative for buildings issues noted today.

Action Due Date: 2024-12-23

Action Due Description: Pictures of rectified issues will be sent to licensing on or before 12/23/24.

Comply Date:

Action Due Description: Pictures of rectified issues will be sent to licensing on or before 12/23/24.

Regulations Needing Technical Assistance:

Regulation Not Applicable:

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

Regulations Not Correctable:

Narrative:
Buildings & Grounds conducted. Census: 20

Classroom | staff/client ratio: 3:10

Classroom 2 staff/client ratio: 2:8

Shower areas clean and sanitary. Outside room 67 baseboard trim needs to be glued down. Room 62 wall
covering picked away and broken, needs to be replaced. Hole in wall in front of toilet in bathroom of room 4.
Almost all Boys Hall 2 bathroom ceiling tiles either missing or broken. All of these identified issues today
will be corrected on or before 12/23/24. Pictures of rectified issues will be sent to licensing. Grounds clean
and free of safety hazards.

MAR checked for:

All initialed and up to date.

Provider Comments:

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

CCL Staff Signature :

Provider Signature :

Jnlan)

i]
vy

www.arkansas.gov/dhs

Serving more than one million Arkansans each year

Date: 12/4/2024

Date: 12/4/2024

Page 3 of 3


state: AR

facility_name: Delta Family Services

summary: A resident was transported to the emergency room after swallowing a dry wall screw.

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: 025679
Date of Incident: 11/21/2024
Date Received: 11/22/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: Client, swallowed a dry wall screw
(about 1 1/2 inches long) she possibly obtained from another room. At 6:10pm,
reported she swallowed the screw. She was transported to ER, leaving our facility at 6:30pm
with 2 DFC staff. She was admitted to ER. At approximately (5:30-6:00pm ish). At 9:30pm,
eloped from the hospital. Police were notified. She was brought back to the hospital
by police at approximately 9:40pm. At this time, she remains in the ER at Ashley County
Medical Center, in Crossett, where they are attempting to have her placed in an acute
facility. However, at this time, the acute hospital is refusing to accept due to the screw.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/22/24-Reviewed for licensing concerns. 2 phone calls had today
with Misty Winters and Joshua Brooks of Delta. Hospital x-ray did indeed indicate that
client had swallowed a screw. Misty Winters speculated client had obtained the screw from
a broken door handle (later determined to be inaccurate). 11/22/24-Recieved email from
facility that client was discharged 11/22/24. 11/22/24-Spoke with Joshua Brooks of Delta
who reported that no door handle was broken, and no one could say with certain where
client obtained the screw.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A Buildings & Grounds follow up was conducted to inspect previous deficiencies.

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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 10/17/2024
Home Visit Date: 10/17/2024
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Buildings & Grounds follow up conducted to inspect previous noted deficiencies.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

All sharp or raised edges on all plywood in all rooms below 6 ft. has been sanded down. Many rooms and
bathrooms have added plywood to cover previously identified holes. All added plywood has been painted to
match. Some paper towel dispensers have been removed and replaced with plywood. Loose wallpaper has
been covered with latus strips. New door ordered and installed for separating door. New light covers installed
in several rooms. Light switch cover plate replaced in two rooms. Missing baseboards replaced. Broken corner
panel replaced. New floor and ceiling tiles installed. Additionally, Director and Maintenance did a thorough
walkthrough and fixed other identified issues which were observed during today's visit.
Provider Comments:
CCL Staff Signature : Date: 10/17/2024
Provider Signature : Date: 10/17/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: No deficiencies were cited during the Inspection of Care (IOC) conducted on 09/23/24.

raw_content:
Observations:
AFMC staff reviewed the final document request form with the Administration at the completion of
the on-site Inspection of Care. The provider signed the acknowledgement of manual requirements that
were made available in the provider’s policy and procedures. AFMC staff explained that these findings
were preliminary and there was still an off-site portion to be completed.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in the classroom setting on the school unit and in their
rooms on the units. Clients were engaged in schoolwork and activities. Staff were calmly interacting with clients
and providing a therapeutic environment that was conducive for learning and treatment therapies.
Medication Pass:
No active FFS Medicaid clients received medications during medication pass. Due to the observation of non-
Medicaid clients not being complaint with the HIPAA minimal necessary rule, no medication pass was
observed. AFMC RN visited with the facility’s medication nurse who was able to show AFMC RN the facility
policies and procedures regarding medication administration, count, reconciliation, and handling of controlled
substances, and medication discrepancies.
The tour of the medication room was completed with the facility’s medication nurse. The medication room was
clean and well-organized in a way to provide safety in medication administration. There was a vial of tuberculin
skin test found to be open in the medication refrigerator. The vial was not labeled with the date it was opened or
with the initials of the nurse who opened it. This was reported immediately to the Administrator. The
Administrator reported back to AFMC staff that they talked with the Director of Nursing who stated the staff
nurse had already reported the opened, unlabeled vial and had removed it from the medication room refrigerator.
No other issues were noted during the medication room tour.
Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Delta Family Health and Fitness Center For Childre – Hamburg, AR – IOC Report 2 | P ag e

doc_type: IOC Report


summary: Children’s Records reviewed. All items present in hardcopy file except for daily/nightly observations, which were present in a separate file.

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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 8/21/2024
Home Visit Date: 8/21/2024
Purpose of Visit: Children’s Records
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Children's Records Reviewed for:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

All items present in hardcopy file except for daily/nightly observations which were present in a separate file.
Provider Comments:
CCL Staff Signature : Date: 8/21/2024
Provider Signature : Date: 8/21/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
August 6, 2024
Dean Hill, Administrator
Delta Family Health And Fitness Center For Childre
815 E St Louis
Hamburg, AR 71646
Dear Mr. Hill:
A Complaint Investigation survey was conducted on July 30, 2024. We are pleased to inform you that
no deficiencies were cited during the survey and that your facility was in compliance with the
requirements of 42 CFR Part 483, Subpart G, Requirements for Psychiatric Residential Treatment
Facilities. Your certification remains in effect unless terminated due to non-compliance with program
requirements or voluntary withdrawal from the program.
We have enclosed form CMS 2567, “Statement of Deficiencies and Plan of Correction” for the July 30,
2024 Complaint Investigation survey conducted at your facility for participation in the Medicaid
program. CMS 2567 is enclosed, indicating your facility's compliance status. Please sign and date
the 2567 and email to: Theresa.Forrest@dhs.arkansas.gov.
If you have any questions please contact your reviewer at 501-320-6235.
Sincerely,
DPSQA/Office of Long Term Care
Survey and Certification Section
tf
cc: DRA
Dean Hill - Delta Family Health And Fitness Center For Childre - 08/06/2024- (AOLTC - PRTF No Def) Page 1]

PRINTED: 08/06/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L112 B. WING _____________________________ 07/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
815 E ST LOUIS
DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDRE
HAMBURG, AR 71646
(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 #AR00033801 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:16F411 Facility ID: 3009 If continuation sheet Page 1 of 1

doc_type: Complaint Survey


summary: A resident was found in the bathroom with a pair of pajama pants wrapped around her neck.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022889
Date of Incident: 7/29/2024
Date Received: 7/30/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
On 07.29.2024, approximately 18:18, observed laying
on the floor of her bedroom writing in a note pad. She slid the note pad to
had written a letter stating that she wished she had not lived. She had written the
letter to her sister, stating she was upset the sister was being adopted. A few minutes later, a
peer informed that had stated she wanted to kill herself. as she
is still in training, took the note to another Behavior Coach. Another client yelled that
had gone in the bathroom with a towel to kill herself. got assistance from
2 other and was sitting on the toilet with a pair
of pajama pants wrapped around her neck. The 3 BC's restrained in order to
remove the cloth. Nurse was notified when they saw the pajamas on her
neck. contacted psychiatrist, who then ordered the client be placed on Self
Harming Precautions and 1:1 with a staff member until ordered otherwise.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 7/30/24-Reviewed for licensing concerns. Facility sent nursing note
and witness statements. Client is on Suicide Precautions, 1:1 precaution until further
notice.


summary: A resident eloped during a trip to the Ankle and Foot Clinic in Little Rock. The resident returned to the facility on 7/26/2024.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022790
Date of Incident: 7/24/2024
Date Received: 7/25/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description:
and another client had gone to Little Rock for a medical
appointment at the Ankle and Foot Clinic with DFC received a call
from on 07.24.2024 @ 1350. We were informed had eloped from
her care, while at the Ankle and Foot Clinic. She noted she had contacted the police, and
would return the other client when she finished speaking with police. At this time, there has
been no report of finding
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/25/24-Reviewed for licensing concerns. Facility visited and further
conversation of incident had. Facility will notify licensing if/when client returns to
facility. 7/26/24-Received email from facility that was in route to facility ETA 4:30AM.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the emergency room after taking several medications she had been cheeking. The facility was cited for 907.2 as a result of this incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022734
Date of Incident: 7/22/2024
Date Received: 7/22/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: About 8:30am, we had to send a client, to the
Emergency Room. Staff attempted to get her up, she was groggy and couldn't wake up for
very long. We found out she had been cheeking medication, and took several medications. I
have talked to her, she noted she did this because she wanted to get high, denied suicidal
ideation or attempt. She had cheeked medication Saturday and Sunday, and took the pills
about 11:00am yesterday. She is on med watch in ICU at this time. We are working on
sending her to Acute Care if possible.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/22/24-Reviewed for licensing concerns. Email sent to facility to
send licensing their Nursing Policy on checking clients when administering medication.
Phone call made to facility. and is of
Delta stated that nurses adhere to the policy of checking clients for cheeking meds. Client
has history of cheeking medication before arriving at Delta. Client's room was searched
after incident. A peer told staff she hides them (meds) in her Bible. The bible was
searched and there was a spot in between the pages that had blue dye as if from medication.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

is currently in ICU and stable. 7/23/24- discharged from Hospital to Pinnacle Point
Acute. Hospital Discharge sent to licensing and reviewed. Phone call made to DON
of Delta to clarify discharge.
is which would yield this. Delta
MAR Policy sent to licensing and reviewed which includes checking client's mouths to
ensure they are not cheeking medication. 7/25/24-Facility visited and cited 907.2. Nursing
Inservice provided to licensing that moving forward all medication passes are to be swept
with gloved hand all around inside of cheeks and inside of mouth, tongues and lips rolled
out.


summary: Officers responded to the facility in reference to a resident taking medications she had been pocketing. Officers assisted as Pro Med Ambulance Service evaluated and transported the resident to the hospital.

raw_content:
Incident #__24-00113 Hamburg Police Dept Report Date __ 07/22/24

Page 10f 2 Incident Report Report Time 2:34 PM
Status Exception Clearance Date Reporting Officer ORI/Agency
Active Not Applicable 885 Carter, Nicole AR0020200

Assigned Officer Entered By Approving Officer
Admin

Assisting Officers

Complainant

SSN/ID/TIN Title DOB Age Sex |Resident Status
U Unknown
Race Unknown Ethnicity DL (#, ST)
Unknown ;

Work Phone Other Phone Personal Cell Work Gell

US Citizen Legal Alien Doc Type Immig Doc # Nationality

Yes
Home Address Employer

Hamburg, AR 71646
ime Latest Possible Date Time
Description Fel/Misd |Att/Comp Loc

POSSIBLE OVERDOSE [Misd__ [Completed

815 E St Louis St (Dfc)

Earliest Possible Dale
07/22/2024

# |Statute/Code
MO

Location Types 13 Hway/Road/Alley 37 Abandoned/Condemned 48 Industiial Site Bias Motivation Codes

43 Lesbian, Gay, Bisexual,

14 Hotel/Motel Structure 49 Military Installation ANTI *
01 Air/Bus/Train Terminal 15 Jail/Prison 38 Amusement Park 50 Park/Playground - 23 Protestant or Transgender, Mixed
02 Bank/S&L 16 Lake/Walerway 39 Arena/Siadium/Fair 51 Rest Area 11 White 24 Islamic (Muslim) Group (LGBT)
03 Bar/Night Club 17 Liquor Store grounds/Coliseum 52 School - 12 Black or African 25 Other Religion ic pesercesated
04 Church/Synag/Tempie 18 Parking LovGarage 40 ATM Separaie from Bank College/University American 26 Multi-religious group 54 BNE DE bili
05 CommercialOf Bldg 19 Rental Storage 41 Auto Dealership 53 School - 13 American Indian or — 27 Atheist/Agnostic 5 Disability
06 Construction Site Facility New/Used Elementary/Secondary Alaska Native 31 Arab 52 Mental Disability
07 Convenience Store 20 Residence/Home — 42 Camp/Campground 54 Shelter - 14 Asian 32 Hispanic or Latino 81 Male
08 DepVDiscount Store 21 Restaurant 44 Daycare Facility Mission/Homeless 15 Multi-races, Group 33 Not Hispanic or & Female i
09 Drug Str/Dr Off/Hosp 23 Service/Gas Station 45 Dock/Wharf/Freight/ 55 Shopping Mall 16 Native Hawaiian or —_Lalino transgender -
10 Fieid/Woods 24 Specialty Stare Modal Terminal 56 Tribal Lands Other Pacific Islander 41 Gay (male) 72 Gender Non-Conforming
11 Govt/Public Bldg 25 Unknown/Other 46 Farm Facility 57 Community Center 21 Jewish 42 Lesbian & None
12 Grocery/Supermarkel 47 Gambling 58 Cyberspace 22 Catholic 99 Unknown

Facility/Casino/Race Track

Suspected Of Using Criminal Activity Types Weapon Type(s) 20 Knife/Cutting Instr 65 Fire/incendiary Device
i ivi ivali ichi i lunt Object 70 Drugs/Narc/Sieeping Pills
B Buying/Receiving C Cultivating/Manuf/Publishing 11 Firearm (Auto) 308! i igs/Nar ping
None P Poseosbingiconcesting O Operaling/Promoting/Assisting 12 Handgun (Auto) 35 Molor Vehicle 85 Asphyxiation
D Distributing/Selling T Transport/lmporyTransmit 13 Rifle (Auto) By Sieg Weapons = es
ioiting Chi Isi i 14 Shotgun (Auto be sa
E Exploiting Children U Using/Consuming bs spol a in) 60 Explosives Ca Nona

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

Victim #1

Name Contact Name
Delta Family Center
Business Address Business Phone
815E St Louis ST,Hamburg, AR 71646 8708534224
Victim Type Injury Type Aggravated Assault/Homicide Circumstances Relationship To Suspect
Business None, #1 N/A

None
Justifiable Homicide Circumstances Taken to: (Hospital Name)

None
Injury Description

Copyright Relativity Inc.© - RPS(Relalivity Public Safety)
Printed : 07/22/24 2:53:48 PM

Incident #__24-00113 Hamburg Police Dept Report Date __ 07/22/24
Page 2 of 2 Incident Report Report Time 2:34 PM

Di Age Sex [Resident Siatus
14 F Unknown
Racé White Ethnicity DL (#, ST)
Unknown
Work Phone Other Phone Personal Cell Work Cell

US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes

Home Address Employer
815 E St Louis ST,Hamburg, AR 71646

Work Address Occupation

Narrative - Carter, Nicole - 07/22/24 2:49:33 PM (Initial)

ON 07-22-24 AROUND 9:08 | WAS DISPATCHED TO DELTA FAMILY CENTER AT 815 EAST ST LOUIS
STREET IN HAMBURG IN REFERENCE TO A CHILD AT THE FACILITY POSSIBLY TAKING MEDS SHE HAD
BEEN POCKETING INSTEAD OF TAKING THEM THE LAST FEW DAYS.

ONCE | ARRIVED | MADE CONTACT WITH THE STAFF AT DELTA FAMILY CENTER AND THEY STATED THAT
AT 8:00 AM THEY NOTICED 14 YEARS OLD) WAS NOT WAKING UP AND WHEN THEY
DONE THE STERNUM RUB AND SHE WOKE UP BUT WOULD GO RIGHT BACK TO SLEEP.

PRO MED AMBULANCE SERVICE ARRIVED AND LOADED HER UP AND TOOK HER TO ASHLEY COUNTY
MEDICAL CENTER AND A STAFF MEMBER RODE IN THE AMBULANCE WITH THEM.

IT IS UNKNOWN AT THIS TIME WHAT MEDICATION OR HOW MUCH SHE HAD TAKEN SOMETIME DURING
THE NIGHT.

Copyright Relativity Inc. © - RPS(Relalivity Public Safety)
Printed : 07/22/24 2:53:48 PM

Incident #__24-00113 Hamburg Police Dept Report Date __07/22/24

Page 1 of 2 Incident Report Report Time 2:34 PM
Status Exception Clearance Date Reporting Officer ORI/Agency
Active Not Applicable 885 Carter, Nicole
Assigned Officer Entered By | Approving Officer
Assisting Officers
Complainant

SSN/ID/TIN Title | Name DOB ‘Age Sex [Resident Status |
U Unknown
Race Unknown Ethnicity DL (#, ST)
Unknown ,
Work Phone Other Phone Personal Cell Work Cell
US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes

Home Address

Employer

Work Address Occupation

Offenses

Incident Location Zone
815E St Louis St (Dfc) Hamburg, AR 71646 pre
Earliest Possible Date Time Latest Possible Date Time
07/22/2024 07/22/2024 09:10

 [BtatuterCode[osecron «disc JABUComp [Loc[Bias

1 1982 POSSIBLE OVERDOSE |Misd_ | Completed

MO Method Of Entry
nla 0

Location Types 13 Hway/Road/Alley 37 Abandoned/Condemned 48 Industrial Site Bias Motivation Codes

43 Lesbian, Gay, Bisexual,

14 Hotel/Motel Structure 49 Military Installation ANTI ‘
01 Air/Bus/Train Terminal 15 Jail/Prison 38 Amusement Park 50 Park/Playground 7 23 Protestant or Transgender, Mixed
02 Bank/S&L 16 Lake/Walerway 39 Arena/Stadium/Fair 51 Rest Area 11 White 24 Islamic (Muslim) Group (LGBT)
03 Bar/Night Club 17 Liquor Store grounds/Coliseum 52 School - 42 Black or African 25 Other Religion pe oe
04 Church/Synag/Tempie 18 Parking LovGarage 40 ATM Separate from Bank College/University American 26 Multi-reiigious group een bi
05 CommerciaOff Bldg 19 Renlal Storage 41 Auto Dealership 53 School - 13 American Indian or — 27 Atheist/Agnostic ys Disabllity
06 Construction Site Facility New/Used Elementary/Secondary Alaska Native 31 Arab 52 Mental Disability
07 Convenience Store 20 Residence/Home — 42 Camp/Campground 54 Shelter - 14 Asian 32 Hispanic or Latino 61 Male
08 Dept/Discount Store 21 Restaurant 44 Daycare Facility Mission/Homeless 15 Multi-races, Group 33 Not Hispanic or oe Female 4
09 Drug Sti/Dr Off/Hosp 23 Service/Gas Siation 45 Dock/Wharf/Freight! 55 Shopping Mall 16 Native Hawaiian or Latino ransgender ;
10 Field/Woods 24 Specialty Store Modal Terminal 56 Tribal Lands Other Pacific Islander 41 Gay (male) 72 Gender Non-Conforming
11 Govt/Public Bldg 25 Unknown/Other 46 Farm Facility 57 Community Center 21 Jewish 42 Lesbian 88 None
12 Grocery/Supermarket 47 Gambling 58 Cyberspace 22 Catholic 99 Unknown

Facility/Casino/Race Track

Suspected Of Using Criminal Activity Types Weapon Type(s) 20 Knife/Cutting Instr 65 Fire/Incendiary Device
; ivi ivati fecha i Blunt Object 70 Drugs/Narc./Sieeping Pills
B Buying/Receiving C Cultivating/Manuf/Publishing 11 Firearm (Auto) 30 ips BS AICS CePIng
None P Possessing/Concealing O Operating/Promoting/Assisting 12 Handgun (Auto) 35 Motor Vehicle 85 Asphyzxiation
D Distributing/Selling T Transpor/Importl Transmit 13 Rifle (Auto) io poreons Weapons ela i
E Expioiti hil ing/t i 14 Shoigun (Auto) noon: ure)
ploiting Children U Using/Consuming ieee rh eee 60 Explosives 98 None

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

Victim #1

Name Contact Name
Delta Family Center
Business Address Business Phone
815 E St Louis ST,Hamburg, AR 71646 8708534224
Victim Type Injury Type Aggravated Assault/Homicide Circumstances Relationship To Suspect
Business None, None #1 N/A

Justifiable Homicide Circumstances Taken to: (Hospital Name)

None

Injury Description

Copyright Relativity Ine. © - RPS(Relalivity Public Safely)
Printed : 07/22/24 2:53:54 PM

Incident # _24-00113 Hamburg Police Dept Report Date __ 07/22/24
Page 2 of 2 Incident Report Report Time 2:34 PM
SSNAD/TIN Title gu at= Age Sex |Resident Status
14 F Unknown
Race White Ethnicity DL (#, ST)
Unknown ,

US Citizen Legal Alien Doc Type Immig Doc # Nationality

Yes
Home Address Employer

815 E St Louis ST,Hamburg, AR 71646

eee ee

Narrative - Carter, Nicole - 07/22/24 2:49:33 PM (Initial)

ON 07-22-24 AROUND 9:08 | WAS DISPATCHED TO DELTA FAMILY CENTER AT 815 EAST ST LOUIS
STREET IN HAMBURG IN REFERENCE TO A CHILD AT THE FACILITY POSSIBLY TAKING MEDS SHE HAD
BEEN POCKETING INSTEAD OF TAKING THEM THE LAST FEW DAYS.

ONCE I ARRIVED | MADE CONTACT WITH THE STAFF AT DELTA FAMILY CENTER AND THEY STATED THAT
AT 8:00 AM THEY NOTICED EN 14 YEARS OLD) WAS NOT WAKING UP AND WHEN THEY
DONE THE STERNUM RUB AND SHE WOKE UP BUT WOULD GO RIGHT BACK TO SLEEP.

PRO MED AMBULANCE SERVICE ARRIVED AND LOADED HER UP AND TOOK HER TO ASHLEY COUNTY
MEDICAL CENTER AND A STAFF MEMBER RODE IN THE AMBULANCE WITH THEM.

IT IS UNKNOWN AT THIS TIME WHAT MEDICATION OR HOW MUCH SHE HAD TAKEN SOMETIME DURING
THE NIGHT.

Copyright Relativity Inc. - RPS(Relalivity Public Safety)
Printed : 07/22/24 2:53:54 PM

doc_type: Police Report


summary: Personnel Records reviewed. All items present in files. No citations.

raw_content:
521 Visit Compliance Report

Licensee: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill I!
Record Visit Date: 6/18/2024

Home Visit Date: 6/18/2024

Purpose of Visit: Personnel Records

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Personnel Records reviewed for:

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

ARKANSAS
) DEPARTMENT OF

|\-7 HUMAN
» "2 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

y

Page 1 of 2

All items present in files.

Provider Comments:

CCL Staff Signature :

A

Date: 6/18/2024

rani)

YW) ||

“hy YZ

Provider Signature : Date: 6/18/2024

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


summary: A resident was found in her bedroom attempting to pull a pair of pants around her neck.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021295
Date of Incident: 5/15/2024
Date Received: 5/16/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: 05.15.2024 @ 1910 Client was placed on 2:1 with staff due to
threats to harm herself earlier in the day. @1910, she went to her room, got under the covers
and was making movement under the covers. Staff asked what she was doing and she
stated, "nothing." She straightened her body out, 2 staff went in room and pulled covers
back, had taken off her pants attempting to pull up to her neck. Client was placed in
a personal restraint so the pants could be removed. Client continued on 2:1 (two clients to
one staff).
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 5/16/24-Reviewed for licensing concerns. Phone call made to Delta to
ascertain client . Email sent for nursing note.
Nursing note received and reviewed. Client remains on 1:2 suicide watch (one staff/two
clients), COBS- 24-hour Continuous Observation, AB1-Agressive Behavior, and Eye
Contact.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was found in the bathroom with a sheet wrapped around her neck.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021278
Date of Incident: 5/15/2024
Date Received: 5/15/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: 05.15.2024 @ 11.57a Client was told to wash her hands
and line up for lunch. Staff felt she was in the bathroom too long, and went to the bathroom
to check on her. Staff found her on the floor with a sheet wrapped around her neck. She did
not require any medical attention and was placed on 2:1 (two clients, one staff).
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 5/16/24-Phone call made to Nurse at Delta. Nursing note
requested via phone and email. . was
immediately placed on and continues to be on 1:2 suicide watch (one staff/two clients),
COBS- 24-hour Continuous Observation, AB1-Agressive Behavior, and Eye Contact. Staff
are discussing possible acute placement today, but no final decision has been made at this
time. Nursing note sent to licensing and reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing conducted an after hours visit. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 5/9/2024

Home Visit Date: 5/9/2024

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

ARKANSAS
) DEPARTMENT OF

> HUMAN
~=a' SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

After hours visit conducted from 5:30AM-6:30AM. Census: 18. Staff/client ratio: 4:18. Night Nurse | |
HE immediately let licensing specialist in the front door.

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

Page 1 of 2

Hall 1 staff/client ratio: 1:5
Hall 2 staff/client ratio: 1:7
Hall 3 staff/client ratio: 1:6

All staff alert, awake, attentive and night visual check logs were observed. Clients were still sleeping.

Hall 6, Room#68 was vacant. The bathroom door was seen to have 4 holes that had been fixed with flex seal
caulking. , | with maintenance was consulted whom stated that plywood could be used to fit over door.

MAR checked for:

All initialed and up to date.

Provider Comments:

CCL Staff Signature : Date: 5/9/2024

>
lpn 4)

// 7

Provider Signature : Date: 5/9/2024

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


summary: A resident alleges a staff member poked her ring into the resident’s arm during a personal restraint, approximately a year ago. The resident alleges a second staff member twisted her arm during a restraint on 4/24/24. This complaint was UNFOUNDED by Licensing.

raw_content:
Licensing Narrative: 5/28/24-Reviewed for licensing concerns. Phone call made to Delta
and ascertained that client disclosed the above
5/24/24 and facility was made aware of Saturday 5/25/24 when an
arrived at Delta and stated Licensing was notified by facility at this time.
There is no video of alleged incident as video DVR does not go back to 4/24/24. Staff
was working at facility when phone call was made. Nurse was
informed that both staff named in alleged incident would need an approved ICA from
licensing before being allowed to continue working. Nurse stated she would contact
of Delta as soon as possible regarding this. Client remains at
facility. Phone call made to
and granted permission for licensing to contact and facility regarding this incident. A
second component of this report is that client while at
Delta. Visit scheduled for 5/28/24. 5/28/24-Facility visited. Client interviewed. No
citations. No finding at this time.

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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 6/27/2024
Home Visit Date: 6/27/2024
Purpose of Visit: Revisit Complaint
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
This is to document that Case#021509 has been investigated and determined to be unfounded.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Provider Comments:
CCL Staff Signature : Date: 6/27/2024
Provider Signature : Date: 6/27/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was transported to the emergency room and then to acute care after cutting herself with metal from a paper towel dispenser.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 020176
Date of Incident: 3/28/2024
Date Received by DCCECE: 3/28/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: I haven't gotten the critical incident done yet, but wanted to let you all
know we had a situation. One of our clients, took the metal from the paper
towel dispenser, and cut herself up pretty good. All superficial, but numerous cuts. Police
and Ambulance are here, and she is being sent to ER, then acute. DHS Supervisor has been
notified.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 3/29/24-Phone call made to Delta to ascertain client DOB:
/ / Email sent to facility to notify licensing if/when client returns to
Delta from acute and what safety plan will be.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that her roommate got into the resident’s bed, attempted to kiss her, and pulled her shirt up to feel her breast. The complaint was UNFOUNDED by Licensing. The facility was cited 110.12 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
Notice of Serious Incident
Case Number: 019884
Date of Incident: 3/11/2024
Date Received by DCCECE: 3/17/2024
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Dual
Report Description: On 03/13/2024, around 7pm, client reported to staff,
Heather Kilcrease, "roommate was right next to her bed last
night during the night when she turned around. stated then kissed her on the
cheek, got in her bed with her then asked is she wanted to have sex" stated "NO" and
put her covers over her head. stated peer tried to kiss her on the mouth, pulled shirt
up and felt her breast. stated "I just I cant go through this tonight again." Clients were
separated that night (03.13).
, came to meet with on 03.14.2024
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 3/18/24-Licensing reviewed complaint for licensing concerns. Email
sent to facility to ascertain why licensing was not notified by the next business day. Phone
call made to who granted permission for licensing to
contact facility regarding complaint. Phone call made to Delta to determine client
DOB and guardianship. Visit scheduled for 3/18/24 to watch video for supervision
concerns. 3/18/24-Facility visited in response to complaint that A/V received unwanted
sexual advances from a peer. This was reported to have happened right after bedtime, in
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

client bed. A/O was roommate. Clients were immediately separated after
reported this. A/O has been assigned to her own room.
following client disclosing this incident to staff. The incident was not
reported to licensing until 3/17/24. Facility cited 110.12: The agency shall notify the
Licensing Unit by the next business day when a report of
Per facility report, a power surge 3/7/24
damaged the cameras for Hall 1 where the alleged incident occurred. The cameras are still
out and facility is waiting on cameras to be fixed or replaced. Licensing and Dean Hill of
Delta looked at camera view for 3/11/24 and 3/12/24 when alleged incident occurred. Both
of these dates for Hall 1 were blacked out/blank. Print preview for Proxiguard night checks
reviewed for 3/11/24 and 3/12/24 between 8PM-12AM. All checks conducted according to
print out within 30 minutes. Client interviewed. reported that the alleged incident
occurred in between staff checking on her room. reported that staff check on her room
15, 20 and "sometimes 30" minutes. Staff Misty Winters reported this incident to licensing
late. Staff Winters is aware that are to be reported to
licensing by the next business day. Additional conversation had with staff Winters and Dean
Hill of Delta regarding importance of licensing regulation 110.12. Email received from staff
Winters that she had no valid reason for reporting this late other than she got busy and
forgot. Licensing is not prepared to make a finding on complaint at this time.


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 911.6 for a loose toilet seat, torn wallpaper, and droopy ceiling tiles.

raw_content:
_ ARKANSAS
) DEPARTMENT OF

«| 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: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 3/8/2024

Home Visit Date: 3/8/2024

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulation Number: 900.911.6
Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.

Finding Description: Room 67 had a loose toilet seat, Room 68 bathroom had a torn hole in wallpaper, and
Room 70 had two droopy ceiling tiles.

Action Due Date: 2024-03-08
Action Due Description: Deficiencies fixed during today's visit.

Comply Date:

Action Due Description: Deficiencies fixed during today's visit.

Regulations Needing Technical Assistance:

Regulation Not Applicable:

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

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted from 9:30AM-10:30AM. Census: 19

Hall 6 observed to be clean, safe and in good repair except for Room 67 had a loose toilet seat, Room 68
bathroom had a torn hole in wallpaper, and Room 70 had two droopy ceiling tiles. Facility cited 911.6: All
buildings and furnishings shall be clean, safe and in good repair. Maintenance notified during today's visit.
Torn wallpaper was where a soap dispenser had been but was recently torn down. Replaced during today's
visit. Ceiling tiles replaced during today's visit. Toilet seat was tightened during today's visit. Grounds clean
and free of safety hazards. Bathrooms and shower area clean and sanitary with functioning sinks, showers and
toilets.

MAR checked for:

All initialed and up to date.

Background checks review completed for all employees.

Provider Comments:

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

CCL Staff Signature : Date: 3/8/2024

AVA
WV

}

Provider Signature : Date: 3/8/2024

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


summary: Licensing visited the facility to conduct an annual policies review and a personnel background checks 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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 2/1/2024
Home Visit Date: 2/1/2024
Purpose of Visit: Agency Checklist
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Annual Review/Policies/PRTF checklist completed. All items accounted for.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Background checks reviewed for 20 personnel files. All background checks accounted for.
Provider Comments:
CCL Staff Signature : Date: 2/1/2024
Provider Signature : Date: 2/1/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Officers were dispatched to the facility in response to a juvenile assaulting a staff member.

raw_content:
Incident #__23-00256 Hamburg Police Dept Report Date __ 12/28/23
Page 4 of 3 Incident Report Report Time 9:10 AM
Status Exception Clearance Date Reporting Officer ORI/Agency
Active Not Applicable 881 Burgess, Johnathan ARO0020200
Assigned Officer Entered By | Approving Officer
Admin
Assisting Officers
Lonipiainant
SSN/ID/TIN Title DOB Age Sex |Resident Status
U Unknown
Race Unknown Ethnicity DL (#, ST)
Unknown ,

Home Phone Work Phone Other Phone

US Citizen
Yes

Home Address

Personal Cell Work Cell

Nationality

Legal Alien

Doc Type Immig Doc #

Employer

Work Address

Offenses

Occupation
Incident Location
Hwy 82E (Dfc) Hamburg, AR 71646

Earliest Possible Date e Latest Possible Date Time
12/19/2023 13:38 12/19/2023 13:38
TJStetutetCode [Description ———SSSCSCSCSC~S*~S~SSC*i Mi JAWComp lve ins [Won ATs
SATTERY _aRO DEGREE / PURPOSE OF CAUSING NuuRY, causes muuRY [Misd_[Compieted] 26] 88 99 ___|

5-13-203A(1)
Method Of Entry
n/a

43 Lesbian, Gay, Bisexual,

1
MO

Bias Motivation Codes

13 Hway/Road/Alley 37 Abandoned/Condemned 48 Industrial Site

Location Types

14 Hotel/Motel Structure 49 Military Installation 3
01 Air/Bus/Train Terminal 15 Jail/Prison 38 Amusement Park 50 Park/Playground ANTI- 23 Protestant or Transgender, Mixed
02 Bank/S&L 16 Lake/Walerway 39 Arena/Stadium/Fair 51 Rest Area 11 White 24 Isiamic (Muslim) Group (LGBT)
03 3ar/Night Club 17 Liquor Store grounds/Coliseum 52 School - 12 Black or African 25 Other Religion 44 Heterosexual
04 Church/Synag/Temple 18 Parking Lot/Garage 40 ATM Separale from Bank College/Universily American 26 Multi-religious group 2 Soerert an
05 Commercial/Off Bidg 19 Rental Storage 41 Auto Dealership 53 School - 13 American Indian or 27 Atheist/Agnostic hys Disability
06 Construction Site Facility New/Used Elementary/Secondary Alaska Native 31 Arab 52 Mental Disability
07 Convenience Store 20 Residence/Home — 42 Camp/Campground 54 Shelter - 14 Asian 32 Hispanic or Latino 81 Male
08 Depi/Discount Store 21 Restaurant 44 Daycare Facility Mission/Homeless 15 Multi-races, Group 33 Not Hispanic or 62 Femaie
09 Drug Str/Dr Off/Hosp 23 Service/Gas Station 45 Dock/WharfiFreight! 55 Shopping Mall 46 Native Hawaiian or — Latino 71 Transgender ;
10 Field/Woods 24 Specialty Store Modal Terminal 56 Tribal Lands Other Pacific Isiander 41 Gay (male) 72 Gender Non-Conforming
11 Govt/Public Bldg 25 Unknown/Other 46 Farm Facility 57 Community Center 21 Jewish 42 Lesbian 88 None
12 Grocery/Supermarket 47 Gambling 58 Cyberspace 22 Catholic 99 Unknown

Facility/Casino/Race Track

20 Knife/Cutting Instr 65 Fire/Incendiary Device

Suspected Of Using Criminal Activity Types Weapon Type(s)

B Buying/Receiving C Cultivating/Manuf/Publishing 11 Firearm (Auto) 30 Blunt Object 70 Drugs/Narc./Sleeping Pills
None P Possessing/Concealing O Operating/Promoting/Assisting 12 Handgun (Auto) 35 Motor Vehicle 85 Asphyxiation
D Disiributing/Selling T Transport/imporvTransmit 13 Rifle (Auto) bs ieee! Weapons Po nes
E Expioiting Child: ing! i 14 Shotgun (Auto) c Inknown,
ploiting Children U Using/Consuming be oe un (Austo) 60 Explosives oh None

| Intentional Abuse & Torment
S Sexual Animal Abuse

A Simpie/Gross Neglect
F Organized Abuse

Copyright Relalivity Inc.© - RPS(Relalivity Public Safety)
Printed : 02/09/24 12:41:54 PM

Incident #__23-00256 Hamburg Police Dept Report Date __ 12/28/23
Page 2 of 3 Incident Report Report Time 9:10 AM
Victim #1 ve —_— ee

SSN/ID/TIN Title | Name ; D Age Sex  |Resident Status
Kesee, Lashundra Monquie 33 F Unknown
Race Black / African Ethnicity
American Unknown
tiome Phone Work Phone Other Phone Personal Cell Work Cell
US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes

Work Address Occupation

Victim Type Injury Type Aggravated Assault/Homicide Circumstances Relationship To Suspect
Individual None, None #1 N/A
Justifiable Homicide Circumstances Taken to: (Hospital Name)

None

Injury Description

Title DOB Age Sex |Resident Status
| | M_| Unknown

Ethnicity DL #, ST) i

Hispanic/Latino ,

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

Home Address Employer
Debastian Co Dhs ,,

Work Address

Narrative & Statements

Suspect#1
SSN/ID/TIN

=
oa

Race Unknown

m
|
2

Occupation

Narrative - Burgess, Johnathan - 12/19/23 9:23:33 AM (Initial)

ON DECEMBER 19, 2023 AT APPROXIMATELY 1:38 PM, | WAS DISPATCHED TO DELTA FAMILY CENTER
ON HWY 82 EAST WHERE THEY HAD A JUVENILE SUBJECT DETAINED ON THE GROUND. WHILE IN ROUTE
| SPOKE WITH CHIEF OLIVER AND THE JUVENILE INTAKE OFFICER JASMINE TANKSLEY. UPON ARRIVING
| PLACED THE SUBJECT INTO CUSTODY AND DE-ESCALATED THE SITUATION. | THEN STEPPED OUTSIDE
AND CONTACTED MRS. TANKSLEY_AGAIN WHO STATED THAT SHE WOULD LOOK FOR A DETENTION
CENTER TO PLACE

| THEN RE-ENTERED THE BUILDING AND STOOD BY WITH THE SUBJECT. WHILE STANDING IN THE
ENTRANCE TO DFC | SPOKE WITH LASHUNDRA MONQIUE KESEE AND GOT HER INFORMATION. MANY OF
THE WORKERS WERE SPEAKING STATING WHAT HAPPENED. THEY ADVISED THAT
GRABBED MRS. KESEE SHIRT AND WAS PUSHING HER AROUND. THE WORKERS ADVISED THAT BEFORE
HE COULD PUNCH MRS. KESEE, THEY TOOK HIM TO THE ROUND AND RESTRAINED HIM. THE JUVENILES
CASE WORKER WHO WAS STILL ON SCENE. THE CASE WORKER ADVISED THAT THEY WOULD TAKE THE
SUBJECT BACK TO WHERE HE WAS PREVIOUSLY PLACED. THE STAFF WERE SPEAKING AMONGST
THEMSELVES STATING SEVERAL THINGS THAT WERE VISIBLY UPSETTING THE CHILD AND HAD THE
POTENTIAL TO RE-ESCALATE THE SITUATION.

| THEN CONTACTED MS. TANKSLEY WHO ADVISED THAT | COULD TAKE EE TO THE POLICE
DEPARTMENT. | THEN TRANSPORTED EE TO THE PD. WE THEN WAITED FOR MRS.
TANKSLEY TO CALL WITH A PLACEMENT. MRS. TANKSLEY CONTACTED ME AND ADVISED THAT THEY
COULD NOT PLACE EJ AND THAT DELTA FAMILY CENTER AD FILLED OUT AN AFFIDAVIT

Copyright Relativity Inc.© - RPS(Reialivity Public Safety)
Printed : 02/09/24 12:41:54 PM

Incident # 23-00256 Hamburg Police Dept Report Date __ 12/28/23 _
Incident Report Report Time 9:10 AM

Page 3 of 3
Narrative - Burgess, Johnathan - 12/19/23 9:23:33 AM (Initial)

OVER THE INCIDENT. | ADVISED MRS. TANKSLEY THAT | WOULD BE COMPLETING A REPORT TO ATTACH
WITH THE AFFIDAVIT. | THEN REMANDED INTO THE CUSTODY OF HIS CASE WORKER,

WHO THEN TRANSPORTED HIM BACK TO SEBASTIAN COUNTY. AFTER THE JUVENILE AND THE CASE
WORKER HAD LEFT, | CONTACTED MRS. TANKSLEY AND ADVISED HER THAT THE JUVENILE WAS IN THE

CUSTODY OF DHS.

Copyright Relativity Inc.© - RPS(Retalivity Pubiic Safety)
Printed : 02/09/24 12:41:54 PM


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 911.6 and 912.4 as a result of the review.

raw_content:
ARKANSAS
) DEPARTMENT OF

\}v7 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: Delta Family Health and Fitness for Children

Facility Number: 172

Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill I!
Record Visit Date: 12/7/2023

Home Visit Date: 12/7/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulation Number: 900.911.6

Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.
Finding Description: Torn/missing tile behind toilet in room 23.

Action Due Date: 2023-12-07

Action Due Description: Maintenance notified during today's visit. Tile will be replaced by the end of business
day 12/7/23.

Comply Date:

Action Due Description: Maintenance notified during today's visit. Tile will be replaced by the end of business
day 12/7/23.

Regulation Number: 900.912.4

Regulation Description: The bathroom shall be clean and sanitary.

Finding Description: Bathroom in room 25 had strong urine odor and stain behind toilet.

Action Due Date: 2023-12-07

Action Due Description: Housekeeping scheduled for afternoon of 12/7/23 at which time issue will be addressed.

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

Comply Date:

Action Due Description: Housekeeping scheduled for afternoon of 12/7/23 at which time issue will be addressed.

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted from 10:00AM-11:30AM. Census: 20

Classroom | staff/client ratio: 2:7

Classroom 2 staff/client ratio: 6:12

All sleeping areas furnished, clean, safe and in good repair. Shower areas clean and sanitary. Each sleeping
room has individual bathrooms. One bathroom in room 23 on Boy's Hall had torn/missing tile behind the
toilet. Facility cited 911.6. One bathroom in room 25 on Boy's Hall had strong urine odor and stain behind
toilet. Facility cited 912.4. Cafeteria clean and sanitary. Grounds clean and free of safety hazards.

MAR checked for:

All initialed and up to date.

Video camera footage reviewed for the early morning hours of 12/4/23 and 12/5/23.

12/3/23
Hall 1 night visual checks conducted at 12:48AM, 1:04AM and 1:23AM

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

Hall 2 night visual checks conducted at 12:45AM, 1:00AM and 1:18AM
Hall 6 night visual checks conducted at 12:46AM, 1:00AM and 1:13AM

12/4/23

Hall 1 night visual checks conducted at 1:20AM, 1:32AM and 2:02AM
Hall 2 night visual checks conducted at 1:16AM, 1:30AM and 1:49AM
Hall 6 night visual checks conducted at 12:25AM, 12:44AM and 1:02AM

All night visual checks conducted within 30 minutes.

Provider Comments:

CCL Staff Signature : Date: 12/7/2023
‘| AV LA
Provider Signature : Date: 12/7/2023

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


summary: During a video review, a staff member was observed grabbing a resident’s neck and slamming him to the floor during a restraint. The facility was cited 905.10 as a result of this incident.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/13/2023
Date Received by DCCECE:11/17/2023
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Licensing
Report Description: Footage of the restraint was reviewed today, 11.17.2023 at 2.00pm. Upon
reviewing a physical restraint completed on client , 11/13/2023, 12.50pm --
13.10pm, it was observed Behavior Coach , did not utilize proper restraint
procedures. He intervened solo, grabbed his neck and slammed him on the floor. The
critical incident indicated threw the desk, but this did not occur, as observed in
review of video today. He laid the desk over on the floor and was no danger to self or others.
Interim Action Narrative: Staff placed on suspension pending
investigation.
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/17/23 that footage of
a restraint was reviewed 11.17.2023 at 2.00pm. Upon reviewing a physical restraint completed
on client , 11/13/2023, 12.50pm -- 13.10pm, it was observed Behavior
Coach , did not utilize proper restraint procedures. He intervened solo,
grabbed his neck and slammed him on the floor. The critical incident indicated
threw the desk, but this did not occur, as observed in review of video today. He laid the desk
over on the floor and was no danger to self or others. Phone call made to Delta 11/20/23 to
determine that client is private placement and DOB is . Facility visited 11/21/23
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

in response to provider reported incident that staff had possibly used or initiated
an inappropriate hold with client . Video reviewed from 11/13/23 from approximately
12:50PM-1:00PM. Client is seen sitting in a desk, periodically getting up with an object
(later identified by CPI Instructor Josh Brooks to be a highlighter marker). After what
appears to be a brief exchange between staff and walks towards ,
grabs his ( 's) left arm, uses his (staff's) left arm, palm flat on client's back and guides
client to the ground. This was observed in real time and did not appear to using
excessive force. Other staff are present for entire incident and are seen immediately
assisting in hold by securing 's extremities. After incident, appears to calm
down without further incident. CPI Instructor Josh Brooks observed video during today's
visit as well. When asked what could have been done differently, Mr. Brooks indicated that
the other clients could have been removed from the area and client given time to calm
down. Facility cited 905.10 for staff initiating physical restraint whilst client was not, at that
point, a threat to himself, other people or property. At no time during video reviewed today,
did there appear to be reasonable cause to suspect child maltreatment. Staff will
be retrained on initiation/intervention of holds and level of holds. Staff is
currently on suspension. Staff will complete training before returning to work.


summary: Licensing visited the facility to review video for the early morning hours of 11/3/23 and 11/4/23. The facility was cited 907.6 for issues identified during the review.

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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 11/6/2023
Home Visit Date: 11/6/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulation Number: 900.907.6
Regulation Description: Supervision during sleeping hours shall include a visual check on each child at least
every thirty (30) minutes.
Finding Description: 37 minutes in between two night checks observed in video.
Action Due Date:
Action Due Description:
Comply Date:
Action Due Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Facility visited and camera footage reviewed for the early morning hours of 11/3/23 and 11/4/23.
11/3/23:
Hall 1 night visual checks conducted at 12:22AM, 12:44AM and 1:03AM.
Hall 2 night visual checks conducted at 1:13AM, 1:29AM and 1:46AM.
Hall 6 night visual checks conducted at 2:06AM, 2:21AM and 2:32AM.
11/4/23:
Hall 1 night visual checks conducted at 1:14AM, 1:29AM and 1:46AM.
Hall 2 night visual checks conducted at 1:47AM, 1:58AM and 2:22AM.
Hall 6 night visual checks conducted at 2:39AM, 3:02AM, 3:39AM and 4:01AM. 37 minutes in between
checks. Staff observed awake and moving throughout hallway but did not walk the full length of the hallway
to conduct checks for a 37-minute interval.
Facility cited 907.6: Supervision during sleeping hours shall include a visual check on each child at least
every thirty (30) minutes.
Provider Comments:
CCL Staff Signature : Date: 11/6/2023
Provider Signature : Date: 11/6/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: Dean Hill II
Record Visit Date: 11/6/2023
Home Visit Date: 11/6/2023
Purpose of Visit: Agency Checklist
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited from 9:30AM-12:00PM. Annual Review/Policy PRTF checklist completed.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

All items on Annual Review/Policy PRTF checklist accounted for.
Provider Comments:
CCL Staff Signature : Date: 11/6/2023
Provider Signature : Date: 11/6/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to conduct a buildings and grounds review. The facility was cited 911.6 for issues identified during the review.

raw_content:
Delta Family Health and Fitness for Children
815 EAST SAINT LOUIS STREET
HAMBURG AR 71646

ARKANSAS
DEPARTMENT OF

DN 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

Clayton DeBoer
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 172

Date of Visit: 10/19/2023
Visit Type(s): Monitor Visit
Time: 10:30 AM - 11:30 AM

Regulation# 9.911 .6
Result : Non-Compliant
Action Due Date : 10/19/2023

Date Corrected:

Action Due : Maintenance began working to replace ceiling tiles during today's visit.

Comment : Hall 6, room 4 had water spots on ceiling tiles. Hall 2 had broken/sagging ceiling tile.

Visit Comment :

Buildings & Grounds conducted from 10:30AM-12:00PM. Census: 20

Classroom | staff/client ratio: 2:8

Classroom 2 staff/client ratio: 3:12

All sleeping areas clean, safe and in good repair except Hall 6, room 4 had water spots on 3 tiles. Hall 2, room
27 had one tile broken/sagging. Bathrooms clean and sanitary with functioning sinks and toilets. Shower area
clean and sanitary with functioning showers and hot water. Maintenance was notified and began to replace

broken and stained ceiling tiles during today's visit.

Page 1 of 2

Grounds well-kept and free of safety hazards.

MAR checked for:

All initialed and up to date.

Video reviewed for the early morning hours of 10/15/23 and 10/16/23.

10/15/23: Hall 1 night visual checks conducted at 1:12AM, 1:26AM and 1:42AM
Hall 2 night visual checks conducted at 1:15AM, 1:28AM and 1:44AM
Hall 6 night visual checks conducted at 1:03AM, 1:24AM and 1:43AM
10/16/23: Hall 1 night visual checks conducted at 1:06AM, 1:16AM and 1:42AM
Hall 2 night visual checks conducted at 1:19AM, 1:34AM and 1:41AM
Hall 6 night visual checks conducted at 1:25AM, 1:44AM and 2:00AM

All night visual checks viewed conducted within 30 minutes.

CCL Staff Signature : Date: 10/19/2023
Provider Signature : Date: 10/19/2023
ar

Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.

Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.

Page 2 of 2


summary: Complaint #AR00030833 was not in compliance, all or in part, with deficiencies cited at N128 and N132. A revisit was conducted on 12/13/23, for all deficiencies cited on 10/11/23. All deficiencies have been corrected, and no new noncompliance was found.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
October 20, 2023
Dean Hill, Administrator
Delta Family Health And Fitness Center For Childre
815 E St Louis
Hamburg, AR 71646
Dear Mr. Hill:
On October 11, 2023 a Complaint Investigation survey was conducted at your facility by the Office of
Long Term Care to determine if your facility was in compliance with Federal requirements for
Psychiatric Residential Treatment Facilities participating in the Medicaid (Title XIX) Program. This
survey found that your facility had deficiencies requiring correction/substantial correction prior to a
revisit as specified in the attached CMS-2567.
Plan of Correction
A POC must be submitted within 10 calendar days of you receipt of the Statement of
Deficiencies. Failure to submit a POC may result in termination. Include a completion date for each
deficieny cited.
Theresa Forrest, LPN, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 3206235
email to Theresa.Forrest@dhs.arkansas.gov.
Your Plan of Correction must also include the following:
a. Address how the corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
b. Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
c. Address what measures will be put into place or systemic changes will be made to ensure that the
deficient practice will not recur;
d. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop plan for ensuring that correction is achieved and sustained. This plan must
be implemented, and the corrective action evaluated for its effectiveness.
Dean Hill - Delta Family Health And Fitness Center For Childre - - (AOLTC - PRTF OTC) Page 1]

e. Include dates when corrective action will be completed. The corrective action completion dates
must be acceptable to the State. Your facility is ultimately accountable for its own compliance. The
plan of correction will serve as the facility’s allegation of compliance. Unless otherwise stated on the
PoC, the last completion date will be the date of alleged compliance.
Informal Dispute Resolution
In accordance with 42 CFR § 488.331, you have one opportunity to question deficiencies through an
informal dispute resolution (IDR) process. To obtain an IDR, you must send your written request to
Health Facility Services, Arkansas Department of Health within ten (10) calendar days from receipt of
the Statement of Deficiencies. The request must state the specific deficiencies the facility wishes to
challenge. The request should also state whether the facility wants the IDR to be performed by a
telephone conference call, record review, or a face-to-face meeting.
An incomplete informal dispute resolution procedure will not delay the effective date of any
enforcement action or the requirement for timely submission of an acceptable plan of correction.
Informal dispute resolution in no way is to be construed as a formal evidentiary hearing. It is an
informal administrative process to discuss the findings.
Please submit your request to:
IDR/IIDR Program Coordinator
Health Facilities Services
th
5800 West 10 Street, Suite 400
Little Rock, AR 72204
Phone: 501-661-2201
ADH.HFS@Arkansas.gov
If you have any questions, please contact your Reviewer.
Sincerely,
DPSQA/Office of Long Term Care
Survey & Certification Section
tf
cc: DRA
Dean Hill - Delta Family Health And Fitness Center For Childre - - (AOLTC - PRTF OTC) Page 2]

PRINTED: 10/20/2023
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
04L112 B. WING _____________________________ 10/11/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
815 E ST LOUIS
DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDRE
HAMBURG, AR 71646
(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 AR00030833 was not in compliance,
all or in part, with deficiencies cited at N128 and
N132.
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
N 128 PROTECTION OF RESIDENTS N 128
CFR(s): 483.356(a)(3)
Restraint or seclusion must not result in harm or
injury to the resident and must be used only-
This ELEMENT is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure a physical restraint was
implemented without injury for Client #1. The
findings are:
Review of the Restraint Order Form dated
9/15/2023 for Client #1 noted the client attempted
to hit staff with a closed fist and was at risk of
harm to self or others. A telephone order to place
Client #1 in a physical hold up to one hour for
physical aggression towards staff was initiated at
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:B2TW11 Facility ID: 3009 If continuation sheet Page 1 of 4

PRINTED: 10/20/2023
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
04L112 B. WING _____________________________ 10/11/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
815 E ST LOUIS
DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDRE
HAMBURG, AR 71646
(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 128 Continued From page 1 N 128
7:15 PM and ended at 7:19 PM.
The RN (Registered Nurse) Assessment for
Behavior Management and/or Emergency Safety
Interventions report dated 9/15/2023 showed at
8:10 PM Client #1 had bruising to the left side of
the face on the cheek area, a cut on his lip and a
raised area to the left side of temple area.
On 10/9/23 at 2:45 p.m., the Surveyor with the
Director of Education watched the video of the
restraint incident on 9/15/23. The restraint was
not visible on the video due to being in the client's
room.
On 10/10/23 at 9:22 a.m., the Surveyor asked the
Director of Nursing (DON) how Client #1 got the
bruising to the face and the cut on his lip. The
DON stated, "The lip looked like he might have
tried to bite. There was blood from his ear, it was
a scratch. There was a bruise in the crease of his
face." The Surveyor asked if he had these injuries
prior to the restraint. The DON stated, "Not to my
knowledge."
On 10/10/23 at 2:17 p.m., the Surveyor asked
Client #1 about the restraint incident on 9/15/23.
He stated, "I got slammed. He pushed me and
threw me up on the bed."
N 132 PROTECTION OF RESIDENTS N 132
CFR(s): 483.356(b)
Emergency safety intervention. An emergency
safety intervention must be performed in a
manner that is safe, proportionate, and
appropriate to the severity of the behavior, and
the resident's chronological and developmental
age; size; gender; physical, medical, and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:B2TW11 Facility ID: 3009 If continuation sheet Page 2 of 4

PRINTED: 10/20/2023
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
04L112 B. WING _____________________________ 10/11/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
815 E ST LOUIS
DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDRE
HAMBURG, AR 71646
(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 132 Continued From page 2 N 132
psychiatric condition; and personal history
(including any history of physical or sexual
abuse).
This ELEMENT is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure a physical
hold was performed in a safe manner for Client
#2. The findings are:
A review of the Restraint Order Form dated
9/15/23 showed Clint #2 behavior escalated to
physical aggression and a telephone order was
obtained for a physical hold up to 1 hour with a
start time of 2:40 p.m. and ending at 2:58 p.m.
On 10/9/23 at 2:45 p.m., the Surveyor with the
Director of Education watched the video of the
9/15/23 incident with the restraint. The video
showed Behavior Coach #2 talking with Client #2
who was sitting at a desk in a classroom; then
physical contact between Behavior Coach #2 and
Client #2 occurred, then the two had physical
contact, a desk fell over, and then Behavior
Coach #2 and Client #2 both fell to the ground.
Behavior Coach #2 was then seen placing Client
#2 in a physical hold. The Director of Education
said "He could have been a little less aggressive.
On 10/10/23 at 2:05 p.m., the Surveyor asked
Behavior Coach #3 about the restraint incident
with Client #2 on 9/15/23. She stated, "The hold
itself was just awful. Her face hit the desk. It fell
over on her way down."
On 10/10/23 at 2:27 p.m., the Surveyor asked
Client #2 about the restraint incident on 9/15/23.
Client #2 stated, "He touched me like he was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:B2TW11 Facility ID: 3009 If continuation sheet Page 3 of 4

PRINTED: 10/20/2023
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
04L112 B. WING _____________________________ 10/11/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
815 E ST LOUIS
DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDRE
HAMBURG, AR 71646
(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 132 Continued From page 3 N 132
going to pull me out of the classroom, but I
wouldn't go. He was yanking on my arm. I told
him to quit touching me or I was going to hit him. I
was trying to hit him when he slammed me into
one of the desks. My nose hit it."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:B2TW11 Facility ID: 3009 If continuation sheet Page 4 of 4

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
October 30, 2023
Dean Hill, Administrator
Delta Family Health And Fitness Center For Children
815 E St Louis
Hamburg, AR 71646
Dear Mr. Hill:
On October 11, 2023, we conducted a Complaint Investigation Survey at your facility. You have
alleged that the deficiencies cited on that survey have been corrected. We are accepting your allegation
of compliance and have approved your plan of correction and presume that you will achieve substantial
correction by October 27, 2023.
We will be conducting a revisit of your facility to verify that substantial correction has been achieved
and maintained.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email to
Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
Theresa Forrest, Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
tf
Dean Hill - Delta Family Health And Fitness Center For Childre -- -- (AOLTC-14) Page 1

APOC
10/30/2027
DM

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
December 13, 2023
Dean Hill, Administrator
Delta Family Health And Fitness Center For Children
815 E St Louis
Hamburg, AR 71646
Dear Mr. Hill:
During the Revisit survey conducted on December 13, 2023, your facility was found to be in
compliance with program requirements. Please email the signed CMS 2567 to:
Theresa.Forrest@dhs.arkansas.gov.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email to
Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
DPSQA/Office of Long Term Care
Survey and Certification Section
tf

PRINTED: 12/13/2023
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 ______________________
R-C
04L112 B. WING _____________________________ 12/13/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
815 E ST LOUIS
DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDRE
HAMBURG, AR 71646
(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.
A revisit was conducted on December 13, 2023,
for all deficiencies cited on October 11, 2023. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.
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:B2TW12 Facility ID: 3009 If continuation sheet Page 1 of 1


summary: Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted on 10/02/23.

raw_content:
October 5, 2023
Delta Family Health and Fitness – Center for Children
815 E Saint Louis St
Hamburg, AR 71646-2766
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
Delta Family Health and Fitness – Center for Children
Provider Medicaid ID:
Onsite Inspection Date: October 02, 2023
Onsite Inspection Time: 12:05 PM
A summary of the inspection and any deficiencies noted are outlined below.
Inspection of Care Summary
Facility Tour:
Upon arrival to the facility, AFMC staff was promptly greeted at the main entrance by a Delta Family Health
and Fitness – Center for Children facility staff member. AFMC staff were checked in at the front desk and were
taken to a conference room and met by the Assistant Administrator. AFMC staff was given the completed and
signed consent form listing approval for access to the AFMC portal.
A tour of the facility was completed with the Security Officer of the residential unit. The facility was noted to be
clean and free of clutter. AFMC staff observed several areas of minor damage to walls and floors on the client
units, but no safety concerns were noted. Educational classes were in session. Several staff members were
observed calmly interacting with clients throughout the facility.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, there were no deficiencies noted.
Personnel Records – Licenses, Certifications, Training:
There was a total of eight personnel record(s) reviewed, three (30%) professional and five (26%)
paraprofessional. There were no deficiencies noted during the personnel record review.
Observations:
AFMC staff reviewed the final document request form with the Assistant Administrator, the Director of
Nursing, and the Human Resource Director at the completion of the on-site Inspection of Care. The provider
signed the acknowledgement of manual requirements that were made available in the provider’s policy and
procedures. AFMC staff explained that these findings were preliminary and there was still an off-site portion to
be completed.

Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There were no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client
interviews were conducted.
Program Activity/Service Milieu Observation:
AFMC staff reviewed the final document request form with the Chief Executive Office, the Chief Operations
Officer, and the Risk Manager at the completion of the on-site Inspection of Care. The provider signed the
acknowledgement of manual requirements that were made available in the provider’s policy and
procedures. AFMC staff explained that these findings were preliminary and there was still an off-site portion to
be completed.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being compliant with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies.
Facility nurse was able to verbalize the step-by-step process of medication delivery including the demonstration
of the five rights of medication administration, documentation of medication delivery, verification of client
taking medication including mouth/cheek checks, and how clients are educated about each medication. Facility
nurses also verbalized the process utilized when a client refuses medications. The tour of the medication room
was completed and secure storage of medications including narcotics was the only issue noted.
AFMC staff did note that the facility’s medication policy titled MP5 did state, “All controlled substances are
kept double locked in the medication room or in medication cart stored medication room.” AFMC staff did
discuss with facility administration regarding this policy is not being followed in the practice of the security of
narcotics. Currently, the facility houses the medication cart in the centrally located unlocked workstation where
unauthorized staff and clients may have access to the medication cart. AFMC staff noted several staff members
who are not authorized to have access to medications gaining access into the unlocked workstation during the
inspection to complete various work-related tasks. AFMC staff voiced concern that even though the cart was
locked during inspection if nurse failed to lock the medication cart and walked away that all medications
including narcotics would be unsecure. The facility does have a medication room next to the open nurses’
station but currently the only medications that are stored in the medication room are refrigerated medications.
Clinical Record Review Deficiencies:
There were no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, there were no
clinical record reviews conducted.
Delta Family Health and Fitness – Center for Children – Hamburg, AR – IOC Report 2 | P ag e

Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Delta Family Health and Fitness – Center for Children – Hamburg, AR – IOC Report 3 | P ag e


summary: Licensing and staff met to discuss the progress of the current Corrective Action Agreement made on 3/22/23. Due to recent citations involving the use of inappropriate behavior management by staff, the current CAA will be extended an additional 3 months. Two new requirements were made on the CAA. Staff have been retrained on their restraint hold procedures prior to today’s meeting.

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ARKANSAS
DEPARTMENT OF

DN 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

Delta Family Health and Fitness for Children Chelsea Vardell
815 EAST SAINT LOUIS STREET Donaghey Plaza
HAMBURG AR 71646 P.O. Box 1437

Little Rock, AR. 72203
Facility Visit Compliance Notice

Facility#: 172

Date of Visit: 9/26/2023

Visit Type(s): Corrective Action Visit
Time: 11:00 AM - 12:00 AM

Visit Comment :

Zoom meeting held today between Delta representative Jj jj PRLU staft I ER) anc
HE to discuss the progress of the current Corrective Action Agreement made on 3/22/2023.

Licensing explained that due to recent citations involving the use of inappropriate behavior management by
staff, the current CAA will be extended an additional three months. Two new requirements were made on the
CAA and discussed with Mr. i The facility has already proactively retrained staff on their restraint hold
procedures prior to today's meeting and will provide a copy to the Program Coordinator.

CCL Staff Signature : Date: 9/26/2023
Provider Signature : Date: 9/26/2023

Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.

Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.

Page 1 of 1


summary: A resident accused a staff member of hitting him during a physical hold. The staff member was terminated. The facility was cited 905.4.g and 907.2 as a result of this incident.

raw_content:
Division of Child Care & Early Childhood Education
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
Date of Incident: 9/15/2023
Date Received by DCCECE: Delta Family Health and Fitness for Children
Facility Name: Delta Family Health and Fitness for Children
Facility Number: 172
Incident Type: Dual
Report Description: At approximately 7:30 P.M. 09/15/2023 CT accused
staff of hitting him during a physical hold that happened around 30
minuets earlier. Nurse noted redness and swelling on CT's face. The hotline was then called
and staff went home. Staff will not be coming back to work until a safety
plane for him and CT is in place and has been approved.
Interim Action Narrative: Licensing emailed LaChandra Williams, Dean Hill and Becky
Brooks of Delta 9/18/23 that A/O cannot return to work until an ICA has been approved by
licensing.
Maltreatment Narrative: accused staff of hitting him
during a physical hold that happened around 30 minuets earlier. Nurse noted redness and
swelling on CT's face. Ref# accepted.
Licensing Narrative: Licensing received complaint 9/16/23 that on 9/15/23 client
accused staff of hitting him during a physical hold
that happened around 30 minuets earlier. Nurse noted redness and swelling on CT's face.
The hotline was then called, and staff went home. Staff will not be coming
back to work until a safety plan for him and CT is in place and has been approved.
Licensing emailed LaChandra Williams, Dean Hill and Becky Brooks 9/18/23 to ascertain
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

client date of birth, guardianship, when the Hotline was called, what the
ref# is and if the hotline call was accepted. Client DOB: . Guardianship: AR Foster
Care. Facility visited 9/18/23 in response to complaint that on 9/15/23 staff
physically assaulted client during a restraint. Facility reported this incident to the
Hotline in a timely manner. Nursing note reviewed which states that client
"noted to have bruising and swelling to left side of face following a physical restraint".
Client and roommate interviewed during today's visit. Client stated he
received injuries to his face "because we was fighting". When asked client stated he
was fighting staff When asked client could not remember what exact
movement by staff resulted in him sustaining injuries to his face.
roommate interviewed. Client stated that did not have any injuries to his face
prior to this altercation with staff. Client stated that staff struck "3 times
in the face...with a closed fist... was on the ground on his back and was
on top of him". added that later had blood coming out of his ear. Ms. LaChandra
consulted regarding this incident who confirmed that no CPI restraint should result in the
above-mentioned injuries to client. Facility cited 905.4g: The following disciplinary actions
shall not be used: Physical injury or threat of bodily harm. Staff had called a code
yellow asking for assistance during this incident. Two staff, and
did not assist. Staff did not wait for additional staff to engage client.
Facility cited 907.2: Childcare 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. Licensing complaint is founded. Received
email 11/10/23 that maltreatment complaint was founded. Email sent to facility 11/13/23 to
ascertain employment status of staff . Received email from Misty Winters
of Delta that staff was terminated 11/10/23.

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: Delta Family Health and Fitness for Children
Facility Number: 172
Licensee Address: 815 EAST SAINT LOUIS STREET
HAMBURG AR 71646
Licensing Specialist: Clayton DeBoer
Person In Charge: LaChandra Williams
Record Visit Date: 9/18/2023
Home Visit Date: 9/18/2023
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulation Number: 9. 905. 4 .g
Regulation Description: The following actions shall not be used, including as discipline:
Findings Description: Staff inflicted physical injury to client during a restraint.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 9. 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.
Findings Description: Two staff member failed to assist a third staff member calling a code yellow, asking for
assistance, which resulted in the injury of a client.
Action Due Date:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 9/18/23 in response to complaint that on 9/15/23 staff physically assaulted client during a
restraint. Facility reported this incident to the Hotline in a timely manner. Nursing note reviewed which states
that client "noted to have bruising and swelling to left side of face following a physical restraint". Client and
roommate interviewed during today's visit. Client stated he received injuries to his face "because we was fighting". When
asked client stated he was fighting staff When asked client could not remember what exact movement by
staff resulted in him sustaining injuries to his face. roommate interviewed. Client stated that did
not have any injuries to his face prior to this altercation with staff. Client stated that staff struck "3 times in
the face...with a closed fist... was on the ground on his back and Mr. was on top of him". added that later
had blood coming out of his ear. Ms. LaChandra consulted regarding this incident who confirmed that no CPI restraint
should result in the above-mentioned injuries to client. Facility cited 905.4g: The following disciplinary actions shall not be
used: Physical injury or threat of bodily harm. Staff had called a code yellow asking for assistance during this
incident. Two staff, and did not assist. Staff did not wait for additional staff to engage client.
Facility cited 907.2: Childcare 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. Licensing complaint is founded.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 9/18/2023
Provider Signature : Date: 9/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3