summary: A resident and staff member were involved in a verbal altercation that turned physical. The staff member was terminated. The facility was cited 905.4.g and 109.1.g 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: 7/18/2023
Date Received by DCCECE: Perimeter Behavioral of Forrest City
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: Upon further video review of incident previously reported on 7/19, it
was noted that client and staff were involved in a verbal altercation that turned physical.
Action taken: Written statements were obtained from staff.
. Staff termination pending (he has been removed from the
schedule) Clinical Director to retrain 3-11 staff on verbal de-escalation/TBRI Life Value
Terms. Texas Caseworker ( ) notified. Guardianship: Texas, CPS
Interim Action Narrative: Written statements were taken
. Staff member involved has been removed from the schedule pending the
outcome of the investigation. Clinical Director will retrain 3pm to 11pm staff on verbal de-
escalation.
Maltreatment Narrative: Reported again on 7/27/2023, call accepted. Referral #
Licensing Narrative: Licensing Specialist reviewed complaint for licensing concerns.
Licensing Specialist will inquire about camera footage. 7/20/2023, Licensing Specialist
informed that camera footage is available. Licensing Specialist will inquire if was
accepted and the name of the staff member involved. 7/21/2023- Program Coordinator
emailed the facility to determine the status of the staff and gather further information
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

regarding the altercation that took place between the resident and staff. Licensing Specialist
will schedule day and time to review camera footage. Licensing Specialist informed that Mr.
Jackson (clinical director) will begin the training for the 3-11 shift on Wednesday, July 26,
2023 and will run the training until Wednesday, August 4, 2023. 7/26/2023, Licensing
Specialist reviewed camera footage. 7/27/2023, Licensing Specialist inquired about
notification. Licensing Specialist informed that Clinical Director called the incident in to the
Licensing Specialist reported incident to
Licensing Specialist informed because of new system a referral number
would be emailed. call accepted, referral number emailed # 8/8/2023,
Licensing Specialist received training roster. 9/1/2023, Licensing Specialist inquired about
assigned investigator. Licensing informed that staff ( ) is no longer employed with
the facility. 9/5/2023, Licensing Specialist informed of investigator and true finding.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 7/26/2023
Home Visit Date: 7/26/2023
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 was observed charging toward resident that could have caused bodily harm.
Action Due Date: 7/19/2023
Action Due Description: Staff was terminated.
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 109. 1 .g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Staff member's actions toward resident was unprofessional.
Action Due Date: 7/19/2023
Action Due Description: Staff member was terminated.
Comply Date:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 10:00 am to 11:00 am
Census: 59
AMENDED 7/27/2023
Licensing received a complaint on 7/18/2023 for ELS Case #015170.
Licensing Specialist reviewed camera footage for reported complaint on 7/18/2023 for ELS Case #05170. The
incident took place on the 300 Hall.
Licensing Specialist observed five (5) staff members in the hallway of the 300 Hall. Ratio 5:1, due to resident
also being in the hallway near the entrance doorway.
Licensing Specialist later observed staff and resident by 300 Hall door, ratio 2:1. It appeared that staff were
holding the resident back. Licensing Specialist observed resident break away from staff and head toward the
Program Manager’s office. Licensing Specialist observed staff block resident from entering the Program
Manager’s office.
While staff had resident against the wall, Licensing Specialist observed what appeared to be a male staff
member charge toward the resident and proceeded to swing at him. Staff was observed trying to separate the
resident and the male staff member.
Facility will be cited for R905.4.g, the actions of the male staff member toward the resident could have caused
physical injury or threat of bodily harm.
AMENDMENT: Facility will be cited for R109.1.g, the actions of the male staff member toward the
resident was unprofessional.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

Licensing Specialist was informed that male staff member has been terminated. Licensing Specialist observed
documentation (Corrective Action Form) where staff was terminated. Other staff involved will be retrained on
mandated reporting, verbal de-escalation/TBRI Life Value Terms.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


state: AR

facility_name: Perimeter Behavioral of Forrest City

summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of having a foreign object in his ear.

raw_content:
AR KAN S A &
DEPARTMENT OF

+4 HUMAN
<a¥ SERVICES

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: 7/18/2023

Date Received by DCCECE: 7/19/2023

Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing

Report Description: Per staff report the resident complained of having a foreign object in his
ear. Resident was examined by the APRN. The APRN made a referral for the resident to go
out to FCMC for evaluation and treatment due to foreign object was found, and no
abnormalities noted. All proper notifications have been made. Guardianship i

BEE Mothe:

Interim Action Narrative: Resident was assessed by the APRN and referred to FCMC for
further evaluation.

Maltreatment Narrative:

Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.

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

doc_type: Notice of Incident


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of bruising, swelling, and pain to his left elbow from doing cartwheels.

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: 7/17/2023
Date Received by DCCECE: 7/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date and time of incident: 07/17/23 15:00PM Per
staff report the resident was doing cartwheels in the gym and landed on his left hand/wrist
and later noticed bruising, swelling and pain to his left elbow. Resident was examined by
the nurse on duty and had full range of motion but reported pain upon bending his arm up
and down. The APRN made a referral for the resident to go out to FCMC for an x-ray of his
left arm. The resident x-ray findings were no acute fracture or dislocation of the left forearm.
All proper notifications have been made. Guardianship: , Adopted Mother
Interim Action Narrative: Resident was assessed by nursing and APRN referred him to
FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray of his left hand after a peer threw a chair at him.

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: 7/16/2023
Date Received by DCCECE: 7/17/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident: 07/16/23 17:35 PM Per
staff report the resident complained of left-hand (thumb) pain after a peer threw a chair at
him. The APRN made a referral for the resident to go out to FCMC for an x-ray of his left
hand. The resident x-ray findings were no acute abnormality of the left hand. All proper
notifications were made. Guardianship: DHS-AR
Interim Action Narrative: Resident was assessed by nursing and referred by the APRN to
FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray due to complaints of left foot pain and swelling from an injury sustained while playing in the gym.

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: 7/13/2023
Date Received by DCCECE: 7/17/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: DOB Date time of incident 7/13/23 10:45
AM Peer staff report the resident injured his foot while playing in the gym. The nurse did
her assessment and put in a consult for him to be seen by the APRN. The APRN made a
referral for the resident to go out to FCMC for an x-ray of his left foot due to complaint of
left foot pain and swelling. The resident x-ray finding is no acute fracture or dislocation. All
proper notifications were made. Guardianship: DHS-AR
Interim Action Narrative: Resident was assessed by nursing. APRN referred resident to
FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was informed of incident via email. 7/17/2023,
Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray due to complaining of right-hand pain from hitting a wall in anger after an altercation with a peer.

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: 7/13/2023
Date Received by DCCECE: 7/17/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident: 7/13/2023 10:00 AM Per
staff report the resident complained of right-hand pain after hitting the wall in anger after an
altercation with a peer. The APRN made a referral for the resident to go out to FCMC for an
x-ray of his right hand. The resident x-ray findings were no acute fracture or dislocation. All
proper notifications were made. Guardianship: , Grandmother
Interim Action Narrative: Resident was assessed by nursing. APRN referred resident to
FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was informed of incident via email. 7/17/2023,
Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation of blood loss from a self-harm injury.

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: 7/7/2023
Date Received by DCCECE: Perimeter Behavioral of Forrest City
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was referred to Forrest City
Medical Center (FCMC) for medical reasons. The physician at FCMC referred resident to
LeBonhuer for further pediatric care and supervision. Resident returned back to the facility
on 7/8/2023 with orders to monitor and give medication if needed.
Interim Action Narrative: Resident was taken to FCMC and referred to LeBonhuer for
further pediatric care and supervision.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received incident via email. 7/11/2023, Licensing
Specialist reviewed provider reported incident for licensing concerns. Licensing Specialist
inquired about guardianship and reason for resident needing medical attention. Licensing
Specialist informed that resident had loss of blood from a self-harm injury. 7/12/2023,
Licensing Specialist will inquire about a safety plan for resident. 7/18/2023, Licensing
Specialist reached out to facility regarding safety plan for resident. Licensing Specialist
informed Clinical Director was out of office. 7/24/2023, Licensing Specialist reached out to
the Clinical Director regarding the safety plan for the resident. 7/26/2023, Licensing
Specialist informed that resident's safety plan was increased for resident to decrease self-
harm. Resident has a bedroom to himself.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of pain in his pelvis.

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: 7/6/2023
Date Received by DCCECE: 7/7/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
7/6/2023 8:08am Please describe the incident: Per staff report the resident complained of
pain in his pelvis. The resident did not disclose why his pelvis is hurting to the APRN.
Actions Taken: The APRN made a referral for the resident to go out to FCMC for an X-Ray
of his pelvis The resident X-Ray findings are no acute fracture or dislocation. All proper
notifications have been made. Guardianship: AR Foster Care
Interim Action Narrative: Resident was assessed by the APRN and sent to FCMC for an x-
ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of foot pain.

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: 7/6/2023
Date Received by DCCECE: 7/7/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
7/6/2023 8:08am Please describe the incident: Per staff report the resident complained of
pain in his Rt foot, the resident stated he woke up and his foot was hurting. Actions Taken:
The APRN made a referral for the resident to go out to FCMC for an X-Ray of his Rt ankle
and foot. The resident X-Ray findings are no acute fracture or dislocation. All proper
notifications have been made. Guardianship: AR Foster Care
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray of his ankle and foot after an altercation with a peer.

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: 7/6/2023
Date Received by DCCECE: 7/7/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 7/6/2023 7:30am Please describe the incident: Per staff report the resident
complained of pain in his nose, the resident hit his nose after being in physical altercation
the previous day with a peer. Actions Taken: The APRN made a referral for the resident to
go out to FCMC for an X-Ray of his Rt ankle and foot. The resident X-Ray findings are no
acute fracture or dislocation. All proper notifications have been made. Guardianship: MN
Private Placement
Interim Action Narrative: Resident was referred to FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire about x-ray findings. 7/11/2023, Licensing
Specialist informed that resident's x-ray findings were: no acute fracture or dislocation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of pain from hitting his foot on a wall while playing dodgeball.

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: 6/28/2023
Date Received by DCCECE: 6/29/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 6/28/2023 11:25am Please describe the incident: Per staff report the resident
complained of pain in his Rt foot, the resident hit his foot and toe on the wall while in the
gym playing dodgeball with his peers. Actions Taken: The APRN made a referral for the
resident to go out to FCMC for an X-Ray of his Rt ankle and foot. The resident was placed
on no physical activity restriction until his X-Ray results were resolved. The resident X-Ray
findings are no acute fracture or dislocation. All proper notifications have been made.
Guardianship: AR Foster Care
Interim Action Narrative: Resident was assessed and referred to FCMC for further
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray of his right elbow after falling while playing basketball.

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: 6/23/2023
Date Received by DCCECE: 6/26/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 6/23/2023 6:10pm Please describe the incident: Per staff report during the
resident?s routine visit with the facilities APRN, the resident complained that he fell on his
right elbow in the gym while playing basketball 8 days ago. There is no direct report of the
resident falling in the gym 8 days ago. Actions Taken: The APRN made a referral for the
resident to go out to FCMC for an X-Ray of his right elbow. The resident was placed on no
physical activity restriction until his X-Ray results were resolved. The resident X-Ray was
negative. The physical activity restrictions were lifted. All proper notifications have been
made. Guardianship: TX DFPS
Interim Action Narrative: Resident was assessed by the APRN and sent to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of pain in his left index finger.

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: 6/23/2023
Date Received by DCCECE: 6/26/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 6/23/2023 7:05pm Please describe the incident: Per staff report during the
resident?s routine visit with the facilities APRN, the resident complained of pain in his left
index finger. The resident did not identify why it was hurting. Actions Taken: The APRN
made a referral for the resident to go out to FCMC for an X-Ray of his left index finger. The
resident was placed on no physical activity restriction until his X-Ray results were resolved.
The resident X-Ray findings are still pending. The resident remains on no physical activities
until results return. All proper notifications have been made. Guardianship: TX DFPS
Interim Action Narrative: Resident was assessed by the APRN and referred to FCMC for
further evaluation. He was placed on no physical activity restriction pending his x-ray
results.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will follow-up with the facility regarding resident's x-ray
results. 6/28/2023, Licensing Specialist informed resident's x-ray indicated no acute
fracture or dislocation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of pain in his right hand.

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: 6/23/2023
Date Received by DCCECE: 6/26/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 6/23/2023 6:20pm Please describe the incident: Per staff report during the
resident?s routine visit with the facilities APRN, the resident complained of pain in his right
hand. Actions Taken: The APRN made a referral for the resident to go out to FCMC for an
X-Ray of his right hand. The resident was placed on no physical activity restriction until his
X-Ray results were resolved. The resident X-Ray findings are still pending. The resident
remains on no physical activities until results return. All proper notifications have been
made. Guardianship: AR Foster Care
Interim Action Narrative: Resident was assessed by the APRN and referred to FCMC for
further evaluation. He was placed on no physical activity restriction pending his x-ray
results.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will follow-up with facility regarding resident's x-ray results.
6/28/2023, Licensing Specialist informed resident's x-ray indicated no acute fracture or
dislocation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of right hand pain from punching a wall.

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: 6/17/2023
Date Received by DCCECE: 6/19/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 6/17/2023 8:24pm Please describe the incident: Per staff report the resident came
to nurses' station and complained of pain in the right hand after punching the wall due to
being upset with staff. Actions Taken: The resident was taken to the nurse's station and
assessed. The resident was then assessed by the APRN. The APRN referred the resident to
FCMC for further evaluation. The resident was diagnosed with: contusion of the Rt hand
with a splint. The resident was placed on self-harm precautions which will evaluated within
72 hours (about 3 days) for safety. All appropriate notifications have been made.
Guardianship: AR Foster Care
Interim Action Narrative: Resident was assessed by the nurse and APRN. He was referred
to FCMC for further evaluation. Resident was placed on self-harm precautions.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after he was hit in the eye with a basketball while playing in the gym.

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: 6/16/2023
Date Received by DCCECE: 6/19/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
6/16/2023 5:27pm Please describe the incident: Per staff report the resident came to nurses'
station and complained that he was hit in the Lt eye with a basketball while playing in the
gym. Actions Taken: The resident was taken to the nurse's station and assessed. The
resident was then assessed by the APRN. The APRN referred the resident to FCMC for
further evaluation. The resident was diagnosed with: encounter for screening unspecified.
The resident did not return with any new orders or prescriptions. All appropriate
notifications have been made. Guardianship: AR Private Placement
Interim Action Narrative: Resident was assessed by the nurse. APRN assessed and referred
resident to FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to perform a buildings and grounds walkthrough and to review children’s records and personnel files. 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: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Helena Coplin
Record Visit Date: 6/15/2023
Home Visit Date: 6/15/2023
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 1:30 pm to 2:00 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Census: 57
Licensing Specialist completed buildings and grounds on the following areas: courtyard, gym, dining room,
classroom hall, Stations 1 and 2.
Classroom #318 was empty. Classroom #317, ratio 5:12 and Classroom #319 ratio 3:8. Residents and staff in
the classrooms were working on arts and crafts. In the gym, ratio 4:10, residents and staff were playing
basketball.
The courtyard was clean and free of debris. Licensing Specialist noticed orange cones on the courtyard that
are used for Velocity Airplane Activities. Ms. Coplin (Director of Quality and Risk Management) informed
the Licensing Specialist that the residents are enjoying the Velocity Airplane Activities.
Licensing Specialist smelled the aroma of cleaning products in the dining room area (cafeteria), Stations 1 and
2. All bathrooms, day areas, and hallways were clean. Licensing Specialist was greeted with cool air on both
Stations 1 and 2.
Licensing Specialist reviewed MARs for the following residents:
All initialed and up to date.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

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

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Helena Coplin
Record Visit Date: 6/15/2023
Home Visit Date: 6/15/2023
Purpose of Visit: Personnel Records
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 2:00 pm to 2:45 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing Specialists reviewed five (5) personnel files:
(Youth Care Worker/Mental Health Tech) 3/20/2023
(PRN Youth Care Worker/Mental Health Tech) 4/17/2023
(Youth Care Worker/Mental Health Tech) 4/17/2023
(Youth Care Worker/Mental Health Tech) 4/3/2023
(Youth Care Worker/Mental Health Tech) 3/6/2023
Personnel files reviewed complied with the minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
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: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Helena Coplin
Record Visit Date: 6/15/2023
Home Visit Date: 6/15/2023
Purpose of Visit: Children’s Records
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 2:45 pm to 4:00 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing Specialist reviewed five (5) children files:
All children’s files reviewed complied with the minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: All deficiencies were corrected, and no new deficiencies were found during the revisit conducted on 6/2/2023.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
June 2, 2023
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
Dear Ms. Lockhart:
During the Revisit survey conducted on June 2, 2023, your facility was found to be in compliance with
program requirements. Please email the signed CMS 2567 Theresa.Forrest@dhs.arkansas.gov.
If you have any questions, please contact your reviewer: Theresa Forrest, LPN 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: 06/02/2023
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
04L115 B. WING _____________________________ 06/02/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(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 June 2, 2023, for all
deficiencies cited on April 25, 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:DK9Q14 Facility ID: 3012 If continuation sheet Page 1 of 1

doc_type: Revisit Survey


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of stomach pain.

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: 5/28/2023
Date Received by DCCECE: 5/31/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
5/28/2023 11:34am Please describe the incident: Per staff report the resident came to nurses'
station and complained of stomach pain. Actions Taken: The resident was taken to the
nurse's station and assessed. The resident was then assessed by the APRN. The APRN
referred the resident to FCMC for further evaluation. The resident was diagnosed with:
All appropriate notifications have been made. Guardianship:
Private Placement
Interim Action Narrative: Resident was assessed by the nurse and APRN. It was ordered for
resident to have further evaluation at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was notified of incident on 5/30/2023 and
provided documentation from FCMC. 5/31/2023, Licensing Specialist reviewed provider
reported incident. No licensing concerns noted.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after a physical altercation with two of his peers.

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: 5/28/2023
Date Received by DCCECE: 5/31/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time
of incident: 5/28/2023 4:15pm Please describe the incident: Per staff report the resident was
in a physical altercation with two other residents. The resident presented with a swollen
nose. Actions Taken: The resident was taken to the nurse's station and assessed. The
resident was then assessed by the APRN. The APRN referred the resident to FCMC for
further evaluation. The resident was diagnosed with: Contusion of the nose. The resident X-
Ray presented negative. The resident has been restricted from his peer. The resident was
also placed on assault precautions which will be re-evaluated within 72 hours (about 3 days)
for safety. All appropriate notifications have been made. Guardianship Foster Care
Interim Action Narrative: Resident was assessed by the nurse and APRN. APRN referred
resident to FCMC for further evaluation. Residents were placed on peer restrictions and
assault precautions.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist was notified of incident via email and provided
documentation from FCMC. 5/31/2023, Licensing Specialist reviewed provider reported
incident. Licensing Specialist inquired about the altercation. Licensing Specialist informed
that the altercation in the dayroom on Station 1. There is no camera footage due to the
camera being broken. A request has been submitted for the camera to be repaired. The
residents were separated by staff. All residents involved in the altercation were placed on
assault precautions and peer restrictions. 6/1/2023, Licensing Specialist reviewed provider
reported incident for licensing concerns.


summary: A resident eloped from the facility by pushing open a hallway exit door. The resident was located by Forrest City Police Department and returned to the facility.

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: 5/21/2023
Date Received by DCCECE: 5/22/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
5/21/2023 11:34am Please describe the incident: Per staff report the resident came out of his
room, walked to the end of the hallway pushed open the exit door with his shoulder and
proceeded to elope from the facility. Actions Taken: Camera observation was conducted on
5/22/2023. The resident is observed entering the hallway and standing at his assigned room
door until the staff opens his door. The resident waited until one staff member walked of the
hall to check the restroom for availability. Once the resident seen the staff member walk off
the hall, he proceeded to the backdoor. The resident pushed the door with his shoulder one
time and exited the facility. Staff followed the resident until he was out of sight. Forrest City
Police Department was contacted, given a picture, and description of what the resident was
wearing. The resident was found by the FCPD and returned to the facility at 12:50pm on
5/21/2023. The resident was taken to the nurse?s station where a body check and vital signs
were completed. The resident did not present with any visible injuries or complaints of pain.
The resident was placed on elopement precautions for safety. The resident will be re-
evaluated in 72 hours (about 3 days) for safety. All proper notifications have been made.
Guardianship: Private Placement
Interim Action Narrative: Staff followed resident and FCPD were called. Resident was
found by FCPD and returned to the facility. He was assessed and body checked by nursing.
Resident was placed on elopement precautions for safety. Camera footage reviewed.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: 5/22/2023- Licensing emailed the facility to find out if the door the
resident eloped from has been repaired and the census. 5/23/2023- Licensing received an
email from Helena Coplin stating the following: "The child to staff ratio was 15:3. The exit
door is not usually unlocked. A staff member exited and re-entered the building earlier
throughout the morning. We are re-educating staff not to exit or enter through the
residential unit door unless it is an emergency."


summary: Officers were dispatched in response to a report of a runaway juvenile.

raw_content:
CES - Command Log

CFS # CFS2318930

Call Taker CALANDRA HENDERSON
Location
Location Details
Primary Incident Code RUNAWAY : Runaway

Mod Report Needed

Priority 1

Use Caution No

Primary Disposition | Handled By Officer / Deputy
Beat

Zone Forrest City Police Department
Call Time 05/21/23 11:35:11

Completed Time 05/21/23 11:55:03

Reporters

EMPLOYEE (Initial Reporter
Sex

DOB
Address
Report Time
How Reported
From Phone
Contact Phone (870) 633-3200
Comments

05/21/23 11:35:11

Other Names

Vehicles

Responders

514 (Primary) 514 - FRYER, TAMEKA
515 515 - KEYS, PHILLIP

Response Times
Assigned 05/21/23 11:36:22 *

Enroute 09/21/23 11:36:22
Arrived 05/21/23 11:40:10
Leaving

Arrived At

Completed 05/21/23 11:55:03

IR / External Agency Numbers
FCPD2023048p6

Officer Addenda

Printed on June 20, 2023

1521 ALBERT ST, FORREST CITY, AR 72335 (Woodridge Behavioral Center)

FCPD (Primary)
FCPD (Primary)

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown

05/21/23 11:35)11 | HENDERSON, CALANDRA | New CFS

05/21/23 11:36|22 | HENDERSON, CALANDRA | 514, 515 | Enroute

Page 1 of 2

05/21/23 11:37:38 | HENDERSON, CALANDRA | CALLER ADVISED THAT ONE OF THEIR JUVENILES RAN
AWAY .ADVISED THAT SUBJECT RAN INTO WOODS.W/M WEARING BLUE SWEATSHIRT/BLUE SHORTS
05/21/23 11:40:10 | HENDERSON, CALANDRA | 514 | On Scene

05/21/23 11:42:23 | MORGAN, SYDNEY | 515 | On Scene

05/21/23 11:45:34 | MORGAN, SYDNEY | 514 | Clear Alarms

05/21/23 11:49:25 | MORGAN, SYDNEY | 515 | Clear Alarms

05/21/23 11:50:36 | HENDERSON, CALANDRA | 515 | On Scene

05/21/23 11:54:23 | HENDERSON, CALANDRA | EVENT#2305210015

05/21/23 11:55:03 | HENDERSON, CALANDRA | 514, 515 | Complete

Received At
Location ;
Accuracy

Page 2 of 2

CES - Command Log Printed on June 20, 2023

CFS # CFS2318933
Call Taker CALANDRA HENDERSON
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (Woodridge Behavioral Center)

Location Details

Primary Incident Code PATROL : Patrol Activities
Mod Non Emergency Fire/Medical
Priority 3

Use Caution No

Primary Disppsition — Handled By Officer / Deputy
Beat

Zone Forrest City Police Department
Call Time 05/21/23 12:06:05

Completed Time 05/21/23 13:00:56

Reporters

FCED (Initial Reporter

Sex

DOB

Address

Report Time | 05/21/23 12:06:05
How Reported

From Phone

Contact Phone

Comments

Other Names|

Vehicles

Responders
FCE1 (Primary) — FCFD, Engine CO 1 FCFD (Primary)
FCE2 FCFD, Engine Co 2 FCFD (Primary)
513 (Primary) 513 - WILLIAMS, JERRY FCPD

Response Times

Assigned 05/21/23 12:06:16 *
Enroute 05/P1/23 12:06:16
Arrived 05/21/23 12:08:06
Leaving

Arrived At

Completed 05/21/23 13:00:56

IR / External Agency Numbers
FCFD 202300648

Officer Addenda

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown
05/21/23 12:06:d5 | HENDERSON, CALANDRA | New CFS

Page 1 of 2

05/21/23 12:06:16 | FCFD, Engine Co 1 | FCE21 | Enroute

05/21/23 12:46:38 | HENDERSON, CALANDRA | SETTING UP DRONE FOR RUNAWAY JUVENILE
05/21/23 12:07:10 | HENDERSON, CALANDRA | 513 | Enroute

05/21/23 12:48:06 | FCFD, Engine CO 1| FCE1 | On Scene

05/21/23 12:98:31 | HENDERSON, CALANDRA | FCFD ADVISED THAT THEY WILL BE SETTING UP BY CHURCH

05/21/23 12:
05/21/23 12:

Received At
Location
Accuracy

‘35 | HENDERSON, CALANDRA | 513 | On Scene

:31 | FCFD, Engine Co 2 | FCE2 | Enroute

:28 | MORGAN, SYDNEY | FCE1 | Clear Alarms

59 | MORGAN, SYDNEY | 513 | Clear Alarms

22 | HENDERSON, CALANDRA | FCFD ADVISED SUBJECT WAS WALKING NORTH ON KITTLE

:24 | HENDERSON, CALANDRA | FCFD ADVISED GLENGERRY/KITTLE RD
:15 | HENDERSON, CALANDRA | 513 ADVISED HAVE JUVENILE IN CUSTODY
:21 | HENDERSON, CALANDRA | B/M 12754

‘40 | HENDERSON, CALANDRA | E/M 12755@1245

:29 | MORGAN, SYDNEY | 513 | Clear Alarms

:46 | HENDERSON, CALANDRA | ENTRY REVISED - E/M 12755@1245

:48 | FCFD, Engine CO 1 | FCE1 | Available

‘56 | HENDERSON, CALANDRA | 513, FCE2 | Complete

Page 2 of 2

FORREST CITY Call For Service

PARTMENT Event Detail Page

Event #

Print Date
2305210017 06/20/2023

County ST FRA State AR

REPORTING PARTY INFORMATION
ut QFFICER WILLIAMS 556
Pe Se ee

RESPONSE INFORMATION

Total Consumed

Minutes of all
one | otic SSSOSC~*& és t

Dispatch Ti

a
CALL DETAILS

| Call Type 46 FIELD INTERVIEW CONTACTS Priority

Description :
JUVENILE

Disposition © CALL CLEARED EMD Code
Comments

is

in mon UT

doc_type: Police Report


summary: Licensing received a complaint that the air conditioner in the classroom was broken. The complainant stated that management is aware but haven’t repaired it. The facility was cited 911.15.f and given technical assistance for 911.10 as a result of this complaint.

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: 5/10/2023
Date Received by DCCECE: 5/16/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Caller stated that the air conditioner in the classroom is broken. Caller
stated management is aware and they have not repaired it.
Interim Action Narrative: If temp is above 75, the residents shall be relocated until the ac is
working properly in the classrooms.
Maltreatment Narrative:
Licensing Narrative: Program Manager Litzsey visited facility and spoke with CEO
Lockhart regarding the complaint. Building Manager provided Program Manager with an
update on the repairs of the air conditioner by contractor, Store Services.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after jamming his fingers while playing basketball.

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: 5/8/2023
Date Received by DCCECE: 5/9/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 5/8/2023 5:10pm Please describe the incident: Per staff report the resident
reported to the nurse that he jammed his fingers while playing basketball in the gym.
Actions Taken: The resident was taken to the nurse's station and assessed. The resident was
then assessed by the APRN. The APRN referred the resident to FCMC for further
evaluation. The resident was diagnosed with: No acute fracture or dislocation. The proximal
and distal carpal rows are adequately aligned. The soft tissues are grossly unremarkable. All
proper notifications have been made. Guardianship Private Placement
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 5/10/2023- Licensing reviewed this incident for any licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation due to complaining of head pain after falling while playing basketball.

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: 5/8/2023
Date Received by DCCECE: 5/9/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
5/8/2023 6:01pm Please describe the incident: Per staff report the resident fell while in the
gym playing basketball and complained of head pains Actions Taken: The resident was
taken to the nurse's station and assessed. The resident was then assessed by the APRN.
The APRN referred the resident to FCMC for further evaluation. The resident was
diagnosed with: . All
proper notifications have been made. Guardianship Private Placement
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 5/9/2023- Licensing received the notification of this incident and
reviewed it for any licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation due to complaining of finger pain and swelling after hitting his peer.

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: 5/4/2023
Date Received by DCCECE: 5/5/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 5/4/2023 7:38am Please describe the incident: Per staff report the resident was in a
physical altercation with a peer. The resident complained of pain in the Rt 5th digit with
swelling from hitting his peer. Actions Taken: The resident was taken to the nurse's station
and assessed. The resident was then assessed by the APRN. The APRN referred the
resident to FCMC for further evaluation. The resident was diagnosed with: No acute
fracture or dislocation. The proximal and distal carpal rows are adequately aligned. The soft
tissues are grossly unremarkable. The resident was placed on peer restriction and assault
precautions for safety. The precautions will be re-evaluated within 72 hours (about 3 days)
for safety. All proper notifications were made. Guardianship TX CPS
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC. He was
placed on peer restriction and assault precautions.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist reviewed provider reported incident. No licensing
concerns noted.


summary: Multiple deficiencies were noted at the revisit performed on 4/25/2023. A Corrective Action Plan was submitted and approved.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
May 9, 2023
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
IMPORTANT NOTICE - PLEASE READ CAREFULLY
Dear Ms. Lockhart:
On December 14, 2022, a Complaint survey was conducted at your facility by the Office of Long
Term Care to determine compliance with Federal requirements for Psychiatric Residential
Treatment Facilities participating in the Medicaid program(s). This survey found your facility
was not in substantial compliance with participation requirements. Please refer to our letter,
dated December 28, 2022.
A revisit was conducted on March 30, 2023, and your facility was still not in substantial
compliance with the following participation requierment(s):
N142 Orders For Use Of Restraint Or Seclusion
A revisit was conducted on April 25, 2023, and your facility was still not in substantial
compliance with the following participation requirement(s):
N142 Orders For Use Of Restraints Or Seclusion
Plan of Correction (PoC)
A Plan of Correction (PoC) for the cited deficiencies must be submitted within 10 calendar days
of receipt of this letter to:
Theresa Forrest, LPN, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 320-6235
email to Theresa.Forrest@dhs.arkansas.gov.
Charlotte Lockhart - Woodridge Of Forrest City, Llc - - (AOLTC - PRTF CNC) Page 1]

A revisit will be authorized after an acceptable PoC is received. A completion date for each
deficiency cited must be included. Your Plan of Correction must also include the following:
1. What corrective action(s) will be accomplished for those residents found to have been
affected by the deficient practice;
2. How you will identify other residents having the potential to be affected by the same
deficient practice and what corrective action(s) will be taken;
3. What measures will be put into place or what systemic changes you will make to ensure
that the deficient practice does not recur; and,
4. Indicate how the facility plans to monitor its performance to make sure that solutions
are sustained. The facility must develop a plan for ensuring that correction is achieved
and sustained. This plan must be implemented, and the corrective action evaluated for its
effectiveness. The plan of correction is integrated into the quality assurance system. At
the revisit, the quality assurance plan is reviewed to determine the earliest date of
compliance. If there is no evidence of quality assurance being implemented, the earliest
correction date will be the date of the revisit; and
5. 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 and Human
Services 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
5800 West 10th Street, Suite 400
Little Rock, AR 72204
Charlotte Lockhart - Woodridge Of Forrest City, Llc - - (AOLTC - PRTF CNC) Page 2]

Phone: 501-661-2201
Fax: 501-661-2165
ADH.HFS@Arkansas.gov
If you have any questions concerning this letter, please contact your reviewer.
Sincerely,
DPSQA/Office of Long Term Care
Survey & Certification Section
tf
cc: DRA
Charlotte Lockhart - Woodridge Of Forrest City, Llc - - (AOLTC - PRTF CNC) Page 3]

PRINTED: 05/09/2023
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
04L115 B. WING _____________________________ 04/25/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(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.
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
{N 142} ORDERS FOR USE OF RESTRAINT OR {N 142}
SECLUSION
CFR(s): 483.358(c)
A physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must order the least
restrictive emergency safety intervention that is
most likely to be effective in resolving the
emergency safety situation based on consultation
with staff.
This ELEMENT is not met as evidenced by:
Based on record review, and interview, the
facility failed to ensure an order for a physical
restraint and a chemical restraint was not
received at the same time for 2 (Clients #1 and
#2) sampled clients. The findings are:
1. Client #1 had diagnoses of Attention Deficit
Hyperactivity Disorder (ADHD) and Post
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:DK9Q13 Facility ID: 3012 If continuation sheet Page 1 of 4

PRINTED: 05/09/2023
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
04L115 B. WING _____________________________ 04/25/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(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 142} Continued From page 1 {N 142}
Traumatic Stress Disorder (PTSD).
a. An Incident Notification Report dated 04/15/23
documented, "...Physical Restraint (Hold) start
1318 [1:18 PM] Stop 1332 [1:32 PM] Emergency
Medication Administration Medication(s)
Administered Thorazine/Benadryl Time Given:
1321 [1:21 PM]..."
b. A Physician Order Physical Restraint
documented, "Order Date: 1323 [1:23 PM] Time
of Order 4/15/23 Order for physical restraint for
up to: 1 hour due to aggression... by [Licensed
Practical Nurse (LPN) #1's]..."
c. A Physician Order Emergency Medication
documented, "Today's Date 4/15/23 Time 1325
[1:25 PM] Order for emergency Medication due to
aggression Medication to be given: Thorazine...
Dose: 50 mg [milligram] Route [Intramuscular]...
by [LPN #1].
2. Client #2 had a diagnosis of Disruptive Mood
Dysregulation Disorder (DMDD).
a. An Incident Notification Report dated 04/16/23
documented, "...Physical Restraint (Hold) start
1305 [1:05 PM] Stop:1313 [1:13 PM] Emergency
Medication Administration Medication(s)
Administered: Benadryl 50 mg/Thorazine 50 mg.
Time given 1305 [1:05 PM]..."
b. A Physician Order Physical Restraint Order
documented, "Order Date 4-16-23 Time of Order
1305 Order for physical restraint for up to 1 hour
due to physical aggression towards staff... by
[Registered Nurse (RN) #1]..."
c. A Physician Order Emergency Medication
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:DK9Q13 Facility ID: 3012 If continuation sheet Page 2 of 4

PRINTED: 05/09/2023
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
04L115 B. WING _____________________________ 04/25/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(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 142} Continued From page 2 {N 142}
documented, "Today's Date 4-16-23 Time 1305
Order for emergency Medication due to phys
[physical] aggression toward staff Medication to
be given Benadryl... Dose: ...50 mg Route: IM...
by [RN #1]..."
3. On 04/25/23 at 12:00 PM, the Surveyor asked
the Chief Executive Officer (CEO) how long
nursing staff should wait between a physical
restraint order and a chemical restraint order.
She stated, "Ten minutes."
4. On 04/25/23 at 1:24 PM, the Surveyor asked
the Director of Nursing (DON) if she did the
nurses inservice. She stated, "Yes." The Surveyor
asked if part of the inservice was that physical
ESI (Emergency Safety Intervention) order and
emergency medicine orders should not be
obtained at the same time. She stated, "Yes. I
had to put that part on there, it was new, since the
last survey."
5. The Nurse Meeting Agenda for 04/13/23
documented, "...Obtaining ESI Orders - 1. Nurse
is notified of initiation of ESI. The Nurse calls
[Physician] to obtain order for the physical ESI. 2.
If the restraint continues for 10 minutes or longer,
The Nurse contacts [Physician] for additional
orders. 3. If order received include emergency
medications, The Nurse is to carry out orders by:
Writing a separate order for emergency
medications to include date, time, & rationale
Administer medication if client continues to be a
danger to self or others... *Physical ESI orders
and Emergency medicine orders should not be
obtained at the same time, therefore the orders
should not have the same times documented for
"time received"."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:DK9Q13 Facility ID: 3012 If continuation sheet Page 3 of 4

PRINTED: 05/09/2023
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
04L115 B. WING _____________________________ 04/25/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(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 142} Continued From page 3 {N 142}
6. A Sign In Sheet for the Nurse Training, dated
4/13/2023, contained both LPN #1's and RN #1's
names and signatures.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:DK9Q13 Facility ID: 3012 If continuation sheet Page 4 of 4

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
May 16, 2023
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, LLC
1521 Albert St
Forrest City, AR 72335
Dear Ms. Lockhart:
On April 25, 2023, we conducted a Complaint Investigation, Follow-Up/Revisit 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 May 15, 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
Charlotte Lockhart - Woodridge Of Forrest City, Llc -- -- (AOLTC-14) Page 1

APOC
05/16/2023
DM


summary: A resident was sent to Forrest City Medical Center for evaluation after receiving multiple direct blows to the face in a physical altercation with a peer.

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: 4/23/2023
Date Received by DCCECE: 4/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 4/23/2023 9:02am Please describe the incident: Per staff report the resident was in
a physical altercation with multiple peers. Actions Taken: The resident was taken to the
nurse's station and assessed. The resident obtained multiple direct blows to the face. The
resident was then assessed by the APRN. The APRN referred the resident to FCMC for
further evaluation. The resident was diagnosed with:
The resident is not to participate in any physical
activities until further notice. The resident has been peer restricted from all peers involved
in the physical altercation. The resident was also placed on assault precautions which will
be re-evaluated within 72 hours (about 3 days) for safety. All appropriate notifications have
been made. Guardianship Foster Care
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation. He will not participate in any physical activities until further notice.
Resident was placed on peer restriction and assault precautions.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 4/25/2023- Program Coordinator visited the facility and reviewed the
camera footage. Resident was taken to the emergency room and treated for his injuries.
Resident was peer restricted, placed on assault precautions, and moved to another unit.
Nursing body check paperwork reviewed, and a copy of the hospital discharge paperwork
was received.


summary: A resident was sent to Forrest City Medical Center for evaluation of a busted lip after a physical altercation with a peer.

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: 4/23/2023
Date Received by DCCECE: 4/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time
of incident: 4/23/2023 9:27am Please describe the incident: Per staff report the resident was
in a physical altercation where he obtained a busted upper lip on the inside of mouth
Actions Taken: The resident was taken to the nurse's station and assessed. The resident was
then assessed by the APRN. The APRN referred the resident to FCMC for further
evaluation. The resident was diagnosed with: . The
resident has been restricted from his peer. The resident was also placed on assault
precautions which will be re-evaluated within 72 hours (about 3 days) for safety. All
appropriate notifications have been made. Guardianship Foster Care
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation. He was placed on peer restriction and assault precautions.
Maltreatment Narrative:
Licensing Narrative: 4/25/2023- Program Coordinator visited the facility and reviewed the
camera footage. Staff appear to intervene quickly as the fight occurred inside of a resident's
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

bedroom. No direct camera footage of the fight is available. A copy of the ESI packet was
received from the facility, along with the nursing body check, restraint order, and a medical
screening exam.


summary: A resident was sent to Forrest City Medical Center for evaluation after injuring his thumb playing basketball.

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: 4/23/2023
Date Received by DCCECE: 4/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 4/23/2023 7:54pm Please describe the incident: Per staff report the resident rolled
injured is Lt thumb playing basketball. Actions Taken: The resident was taken to the
nurse's station and assessed. The resident was then assessed by the APRN. The APRN
referred the resident to FCMC for further evaluation. The resident was diagnosed with: No
acute fracture or dislocation. Soft tissues are grossly unremarkable. No other interventions
necessary. All appropriate notifications have been made. Guardianship Foster Care
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: 4/24/23- Program Coordinator reviewed the incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after rolling his ankle while in the gym.

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: 4/22/2023
Date Received by DCCECE: 4/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 4/22/2023 8:10pm Please describe the incident: Per staff report the resident rolled
his Lt ankle while in the gym. Actions Taken: The resident was taken to the nurse's station
and assessed. The resident was then assessed by the APRN. The APRN referred the
resident to FCMC for further evaluation. The resident was diagnosed with: No acute
fracture or dislocation. The ankle mortise is intact. Soft tissues are unremarkable. No other
interventions necessary. All appropriate notifications have been made. Guardianship
Foster Care
Interim Action Narrative: Resident was assessed by nursing and taken to FCMC for further
evaluation.
Maltreatment Narrative:
Licensing Narrative: 4/24/23- Program Coordinator reviewed the incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident alleged that a staff member walked into his room and choked him.

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: 4/21/2023
Date Received by DCCECE: 4/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type:
Incident Type: Maltreatment
Report Description: Residents Name/DOB: Date/Time of
incident: 4/21/2023 8:00pm Please describe the incident: Per staff report the resident alleged
to the nurse that around 8pm walked into his room and choked him.
Actions Taken: The resident was taken to the nurse's station and assessed. The resident did
not have any visible injuries. A written statement was collected from the resident and the
employee. The was called by the nurse and accepted here is the
referral number: . Camera observation was conducted on 4/24/2023 at 10:28am.
is observed walking onto the 300-Hall at 8:25pm, is then observed
walking into multiple resident's rooms conducting quality checks. is then
observed walking to the end of the hall to room 302. He is observed walking into the room
at 8:26pm with (2) witnesses and . He then exits the room at
8:27pm. The employee has been suspended pending further investigations. The resident will
be seen by his therapist to address any additional issues of concerns. All appropriate parties
have been notified. Guardianship Private Placement
Interim Action Narrative: Staff member has been suspended pending investigation.
Resident will process with therapist. The facility requested an ICA for the staff to continue
working with no direct or unsupervised contact with the residents on 4/25/23. Licensing
approved the ICA o
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative: Per staff report the resident alleged to the nurse that around 8pm
walked into his room and choked him.
Licensing Narrative: 4/25/2023- Program Coordinator visited the facility and reviewed
camera footage. Statements from staff L. Barton, staff G. Hall, staff D. Williams and
resident reviewed. Nursing notes were obtained and reviewed. Helena Coplin will
send the witness statement from staff Davenport when she returns to work and email it to
the Program Coordinator. 4/25/2023- Licensing received the ICA for staff to continue
working with no direct or unsupervised contact with the residents. 4/27/23-Licensing
approved the ICA for staff and emailed the facility. 5/4/2023- Licensing again asked for a
copy of the witness statement of Ms. Davenport. The facility reports they will email it to the
Program Coordinator. 5/8/2023-Licensing requested the facility watch the video again to
determine if at any point the staff returns back inside the resident's bedroom past 8:30pm.
The facility confirmed that the staff did not return to the resident's bedroom after the nurses
brought the resident back to the bedroom. 5/9/2023- Program Coordinator received a copy
of the witness statement for K. Davenport and reviewed it. 5/10/2023- Program Coordinator
followed up with the investigator to determine if any new information has been found after
interviews with the A/V's roommates. The Program Coordinator called Helena Coplin with
the agency and requested copies of the training records for the A/O, his hire date, and any
records pertaining to disciplinary actions and or complaints made against him by residents.
Helena reported that their were not complaints or disciplinary actions and she will have
their HR send a copy of the A/O hire date along with his training records. Additionally, the
Program Coordinator and Helena discussed potential training that the staff will have
if/when he returns to work with the residents to include, but not limited to, SAMA and
Conscious Discipline. 5/24/2023- Licensing received notification that the maltreatment
investigation was closed as unsubstantiated. The Program Coordinator notified the Program
Manager to determine if the ICA for the staff could be lifted by the Licensing Unit so he
could return to normal job duties, pending retraining on appropriate de-escalation
techniques. 6/1/2023, Licensing Specialist requested documentation when staff has been
retrained. Licensing Specialist received documentation of training.


summary: Licensing visited the facility to complete a review of educational records within the children’s records. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Chelsea Vardell
Person In Charge:

Record Visit Date: 4/12/2023

Home Visit Date: 4/12/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Licensing visit completed from 12:30PM-3:15 PM

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

Current facility census is 51

Program Coordinator completed a review of educational records within the children's records of three

residents including 1 i. Records showing the update
to IEPs for all three children occurring every 9 weeks were provided to the Program Coordinator.

The Program Coordinator discussed with the Education Director Paulette Cartwright what the facility's
process is to ensure each child's IEPs are met and how they provide these documents to other agencies,
individuals, and school after the child is discharged.

The Program Coordinator also discussed the facility's current license and capacity for their programs. The
facility reports they currently accept up to 52 PRTF children with 15 being out of state only. They can admit
up to 14 children into the SRU program. The Program Coordinator discussed how the facility's current
licenses only reflects the total capacity for both programs and not individual capacities. The facility CEO
reports that she will discuss the desired capacity for each program with upper management and respond to
licensing by 4/19/23.

Provider Comments:

CCL Staff Signature : Date: 4/12/2023
Provider Signature : Date: 4/12/2023

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


summary: A resident was sent to Forrest City Medical Center for evaluation after slipping and falling while playing football.

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: 4/3/2023
Date Received by DCCECE: 4/4/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type: Residential
Incident Type: Licensing
Report Description: on 4/3/2023 at 5:15pm. Foster
Care Per staff report the resident was outside playing football when he slipped and fell. The
resident was taken to the nurse's station and assessed. The resident was then assessed by
the APRN. The APRN referred the resident to FCMC for further evaluation. The resident
was diagnosed with a . The resident returned with one new
medication. The resident will not be permitted to engage in any physical activities until
further notice. Nursing and staff will continue to monitor the residents progress while in
school and the milieu.
Interim Action Narrative: Resident was assessed by the nurse and sent to FCMC for further
evaluation. He will not participate in physical activities until further notice.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident and
documentation from Forrest City Medical Center. Resident diagnosis with sprain
unspecified site of left knee, initial encounter. No licensing concerns noted.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident tampered with a smoke detector, triggering the fire alarm, and eloped from the facility. The resident was found by Forrest City Police Department and returned to the facility.

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: 4/2/2023
Date Received by DCCECE: 4/3/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type: Residential
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 4/2/2023/ 2:14pm Please describe the incident: Per staff report the resident
tampered with the smoke detector triggering the fire alarm and eloped from the facility.
Actions Taken: The resident tampered with the smoke detector in the hallway. Once
tampered with the smoke detector it triggered the fire alarm unlocking the facility doors.
The resident ran down 300-Hall towards the cafeteria and out of the residential lobby. Staff
tried to stop the resident and pursed him while on campus grounds. The resident
successfully eloped from the facility grounds. FCPD was notified and continued to search
for the residents while in the community. The resident was found by FCPD and brought
back to campus at 3:55pm. The resident was assessed by the nursing department and
appeared to be alert and oriented. The resident did not have any complaints of pain or
injury. The resident was placed on elopement precautions and unit restriction. The
precautions will be re-evaluated in 72 hours (about 3 days) for safety. Staff and nursing will
continue to monitor the resident's interactions while in the milieu. Guardianship: Private
Placement
Interim Action Narrative: The FCFD and FCPD were called. Upon returned, resident was
assessed by the nurse. Resident was placed on elopement precautions and unit restriction.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist reviewed provider reported incident.. Licensing
Specialist will follow-up with facility regarding a solution for the smoke detectors being
triggered by the residents. 4/12/23- Program Coordinator visited the facility, discussed the
incident, and reviewed the camera footage.


summary: Licensing provided technical assistance on 102.3.h and 110.9.

raw_content:
a A RK AWS ASE
DEPARTMENT OF

) }-7 HUMAN
a “Tf SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Kendra Rice
Person In Charge:

Record Visit Date: 3/30/2023
Home Visit Date: 3/30/2023

Purpose of Visit: Technical Assistance Request Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Number: 1. 102. 3 -h

Regulation Description: The following policies of the agency shall be current and available to all employees of
the agency and the Licensing Specialist:

Findings Description:

Action Due Date:

Action Due Description:
Comply Date:

Sub Regulation Description:
Regulation Number: 1. 110.9

Regulation Description: Any owner/operator, employee, foster parent, or volunteer in a child welfare agency
shall immediately notify the Child Abuse Hotline if he or she has reasonabie cause to suspect that a child has

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

CCL Staff Signature : Ue Date: 3/30/2023
Provider Signature+ | Date: 3/30/2023

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was sent to Forrest City Medical Center for evaluation after a physical altercation with a peer.

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: 3/29/2023
Date Received by DCCECE: 3/30/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type: Residential
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of
incident: 3/29/2023/ 5:45pm Please describe the incident: Per staff report the resident while
in the gym the resident was in physical altercation with a peer. Actions Taken: The resident
was taken to the nurse's station and assessed. The resident presented with a small knot on
the left side of his head. The resident presented with steady gain, skin intact, and denied
any pain or discomfort. The resident was also assessed by the APRN. A referral was made to
transport the resident to FCMC for further evaluation. The resident returned with no new
order and was diagnosed with . The
resident and his peer were both placed on assault precautions and peer restriction to limit
contact. Precautions will be re-evaluated in 72 hours (about 3 days) for safety. Guardianship:
Private Placement
Interim Action Narrative: Resident was assessed by nursing. Resident and peer were placed
on assault precautions and peer restriction.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist reviewed provider reported incident. Licensing
Specialist will follow-up with facility on the altercation, nursing notes, witness statements,
and camera footage. 4/3/2023, Licensing Specialist informed staff intervened by separating
the residents. The ratio at the time of this incident, 2:12. 4/12/23- Program Coordinator
visited the facility and reviewed camera footage of the incident. The resident was attacked
by his peer while playing basketball and staff intervened quickly. The resident was taken for
follow up medical care and placed on peer restriction while the aggressor was placed on
assault precautions. No further issues have occurred between these two residents since the
date of the incident.


summary: Residents eloped from the facility after tampering with a smoke detector and causing all the facility doors to unlock. The facility was cited 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
Notice of Serious Incident
Date of Incident: 3/25/2023
Date Received by DCCECE: 3/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type: Residential
Incident Type: Licensing
Report Description: Residents Name/DOB: ,
Date/Time of incident: 3/25/2023/ 8:28am Please describe the
incident: Per staff report the resident?s eloped from the facility grounds after tampering with
a smoke detector in his room causing all the facility doors to unlock. Actions Taken:
Camera review was conducted on 3/27/2023 at 11:00am. Two residents are observed going
into room 104. The resident exited the room and a peer entered. As the peer entered about
30 seconds later the fire alarm was triggered. Staff are observed lining the resident up and
exiting the building to the courtyard. While waiting in the courtyard for the building the be
cleared. Two residents ( and are observed getting out of line and walking
towards the building. A third resident ( is also observed getting out of line from
the far right and running towards his two peers. All three residents ran inside of the building
down 100-Hall to the exit. Staff are observed following the residents from the courtyard to
the building and to 100-hall out of the exit. FCPD was called and gave the residents
description. The residents were found by the FCPD on 3/276/2023 around 9:30am. At the
first point of contact all three residents had knives on them, the residents procured the
knives after eloping from the facility. 2 of them ( and dropped their
knives and the police were able to obtain them. The third resident, who is took
off running in the middle of an open field. The resident then held the knife to his throat
threatening to kill himself. The police were able to subdue the resident and retrieve the
weapon. was taken to Forrest City ED for further evaluation. The resident has
now been transferred to Perimeter West Memphis Acute for homicidal ideation and suicide
gesture. and were both sent out to the FCMC on 3/26/2023 for further
evaluation. Both residents returned with no new orders. Both residents have been placed on
a safety plan and elopement precautions. The residents will remain on precautions until
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched in response to 3 residents running away from the facility.

raw_content:
CFS - Command Log Printed on March 28, 2023

CFS # CFS2310098
Call Taker KILEY HOWTON
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (Woodridge Behavioral Center)

Location Details
Primary Incident Code RUNAWAY : Runaway

Mod Report Needed

Priority 1

Use Caution No

Primary Disposition Handled By Officer / Deputy

Beat

Zone Forrest City Police Department

Call Time 03/25/23 08:35:05

Completed Time 03/25/23 10:44:55
Reporters

WOODRIDGE (Initial Reporter)

Sex

DOB

Address

Report Time 03/25/23 08:35:05

How Reported

From Phone

Contact Phone

Comments

| Other Names

Vehicles
Responders
542 542 - HAWKINS, FCPD (Primary)
NATHANIEL
543 (Primary) 543 - MITLEFF, DALTON FCPD (Primary)
544 544 - DIXON, CORBIN FCPD (Primary)

Response Times
Assigned 03/25/23 08:35:48 *
Enroute 03/25/23 08:35:48 *
Arrived 03/25/23 08:35:48
Leaving
Arrived At
Completed 03/25/23 10:44:55

| IR / External Agency Numbers
FCPD202302356 ~

Officer Addenda
Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown

Page 1 of 2

03/25/23 08:35:05 | HOWTON, KILEY | New CFS

03/25/23 08:35:34 | HOWTON, KILEY | ADVISED 3 SUBJECTS HAVE RAN OFF FROM PROPERTY
03/25/23 08:35:48 | HOWTON, KILEY | 543 | On Scene

03/25/23 08:36:52 | HOWTON, KILEY | ADVISED THEY ARE ALL W/M WEARING SHORTS
03/25/23 08:41:30 | HOWTON, KILEY | 542 | On Scene

03/25/23 08:46:08 | HOWTON, KILEY | IN AREA ATL

03/25/23 08:49:32 | LAWS, ALLISON | 544 | Enroute

03/25/23 09:18:36 | HOWTON, KILEY | BACK OUT AT WOODRIDGE

03/25/23 10:02:36 | LAWS, ALLISON | 544 | Available (Location: In Service)

ileal ||ONTON. KILEY a es «> A
ENTERED INTO ACIC

03/25/23 10:44:55 | HOWTON, KILEY | 542, 543 | Complete

CLQ

Requested At
Sent To
Status
Received At
Location
Accuracy

a
Page 2 of 2


summary: Licensing visited the facility to review children’s files. The facility was cited 902.3 for missing records.

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: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Kendra Rice
Person In Charge: Helena Coplin
Record Visit Date: 3/23/2023
Home Visit Date: 3/23/2023

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulation Number: 9. 902. 3

Regulation Description: Each child shall have proof of current immunizations; a letter of exemption in
accordance with the Arkansas Department of Health or a scheduled appointment within one (1) week after
admission.

Findings Description: No copy of social security card or documentation of request.
Action Due Date:

Action Due Description:

Comply Date:

Sub Regulation 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:

Time of Visit: 2:15 pm to 2:30 pm
Census: 56

Licensing Specialist reviewed two (2) children files:

There was no documentation for a social security card on resident || R902.3, social security card was not

received or documented within 30 days of admission.

Provider Comments:

CCL Staff Signature :

Provider Signature :

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

Date: 3/23/2023

Date: 3/23/2023

Page 2 of 2


summary: A resident eloped from facility grounds after pulling down a smoke detector causing all the facility doors to unlock. Before he eloped, he was involved in a physical altercation with another resident. The facility was cited 907.3 for staffing issues identified 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: 3/19/2023
Date Received by DCCECE: 3/20/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type: Residential
Incident Type: Licensing
Report Description: Residents Name/DOB: Date/Time of incident:
3/19/2023/ 7:30pm Please describe the incident: Per staff report the resident eloped from
the facility grounds after pulling down a smoke detector off the wall in his room causing all
the facility doors to unlock. Actions Taken: Camera review was conducted on 3/20/2023 at
12:00pm. The resident is observed standing inside of his doorway playing a game with
various peers in the hall from their assigned room doorways. Staff were present actively
completing quality 15-minute checks. The resident is observed going into his room and then
the fire alarm went off. All residents and staff proceeded to evacuate the building following
the fire alarm protocol. All residents evacuated to the courtyard and lined up on the
basketball court. While on the basketball court awaiting the building's clearance by the
FCFD, the resident was in a physical fight with a peer. During the altercation, the resident
took his shirt off and began fighting. Staff immediately intervened and separated the two
residents fighting. Shortly after several other fights broke out while on the courtyard, staff
intervened immediately and transitioned the youth back inside the facility. While
transitioning back inside the resident ran past the entire group and back onto the 100-hall.
The building was cleared by the FCFD at 7:47pm, but the alarm system was not online,
meaning the facility doors were still unlocked. The resident ran down the hall and out the
exit at 7:50pm. FCPD was called and gave the residents description. Currently the resident
has not been found. FCPD was contacted again today 3/20/2023 at 1:01pm with no recent
updates. The resident's guardian has also filed a missing person's report as of 3/20/2023 at
2:22pm. All proper notifications have been made. Guardianship: DCFS AR Foster Care
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative: Forrest City Police Department were called and resident's
description was provided. A missing report was filed.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was informed of the provider reported incident.
Licensing Specialist will follow-up with the facility. 3/21/2023, Licensing Specialist
informed resident was found this morning and returned to the facility. Resident is in the
processed of being transferred to an acute care facility. Licensing Specialist will contact
FCPD for the reports. Licensing Specialist informed by FCPD they were unable to email
police report. 3/23/2023, Licensing Specialist went to FCPD to request police report and
was informed the cost would be $5. Licensing Specialist contacted Program Coordinator
who requested the police report via email. Licensing Specialist reviewed camera footage.
3/28/2023, Licensing Specialist informed that FCPD had not responded to police report
request.


summary: A resident was sent to Forrest City Medical Center for evaluation of puncture wounds in the palm of each hand he received while attempting to elope from facility grounds.

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: 3/17/2023
Date Received by DCCECE: 3/20/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Facility Type: Residential
Incident Type: Licensing
Report Description: Per staff, , attempted
to elope from the facility by climbing the fence. While trying to climb the fence the resident
received a puncture hole in each palm of hand from the top of fence. Staff immediately
intervened and resident was unsuccessful. Resident was immediately taken to nursing and
assessed. A referral was made by the APRN to sent the resident out to FCMC for further
assessment. The resident was diagnosed with a
The resident was placed on elopement precautions and unit restrictions for the next 72
hours (about 3 days). Those precautions will be reassessed for safety. All proper
notifications were made, and nursing will continue to monitor the resident's progress while
in the milieu and school.
Interim Action Narrative: Resident was assessed by nursing and referred by the APRN to
FCMC for further evaluation. Resident placed on elopement precautions and unit
restriction.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist reviewed provider reported incident. Licensing
Specialist will follow-up with facility. Resident still on elopement precautions to be
reassessed in 72 hours. 3/23/2023, Licensing Specialist visited facility.