summary: A resident reported that a staff member allowed multiple patients to engage in a physical altercation against him. The facility was cited for missing restraint documentation and failure to protect a resident from verbal and physical abuse from peers and staff as a result of this incident. A staff member was terminated.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 032030
Date of Incident: 08/01/2025
Date Received: 08/12/2025
Facility Name: Millcreek of Arkansas PRTF
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Under Review
DPSQA - Incident & Accident - OLTC
Report Description: Patient reported that a staff member
allowed multiple patients to engage in a physical altercation against him.
denies the allegation and reports that he was actively engaged in separating the
patients during the physical altercation. was placed on administrative leave
pending the results of the investigation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


state: AR

facility_name: Millcreek Behavioral Health / Habilitation Center, Inc.

summary: A resident was sent to the emergency room after complaining of shortness of breath and wheezing.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 031781
Date of Incident: 07/31/2025
Date Received: 08/01/2025
Facility Name: Millcreek of Arkansas PRTF
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Complete
DPSQA - Incident & Accident - OLTC
Report Description: The patient was sent to for
shortness of breath and wheezing as per request.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident reported that a staff member called him a “bitch” and his mother a “hoe”. The resident also reported that after the verbal confrontation, another staff member grabbed him by his shirt and swung him between two beds. The complaint was UNFOUNDED by Licensing.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 7/15/2023
Date Received by DCCECE: Millcreek of Arkansas PRTF
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: AR Mandated Reporter Portal Accepted Investigation:
Patient reported that during 2nd shift of 7/14/2023, staff member
engaged in a verbal confrontation with him, calling him a "bitch" and his mother
a "hoe". also reported that after this verbal confrontation, staff member
grabbed him by his shirt and swung him between two beds.
The report was ACCEPTED for investigation. Referral ID:
Interim Action Narrative: Staff was placed on suspension pending termination by the
facility
Maltreatment Narrative: AR Mandated Reporter Portal Accepted Investigation:
Patient reported that during 2nd shift of 7/14/2023, staff member
engaged in a verbal confrontation with him, calling him a "bitch" and his mother
a "hoe". also reported that after this verbal confrontation, staff member
grabbed him by his shirt and swung him between two beds.
The report was ACCEPTED for investigation. Referral ID:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing received report from facility 7/17/23 of an AR Mandated
Reporter Portal Accepted Investigation:
Patient reported that during 2nd shift of 7/14/2023, staff member
engaged in a verbal confrontation with him, calling him a "bitch" and his mother
a "hoe". also reported that after this verbal confrontation, staff member
grabbed him by his shirt and swung him between two beds.
The report was ACCEPTED for investigation. Referral ID:
Received email from facility 7/17/23 that client 's DOB is and he is in Parent
Custody.
Received email from facility 7/17/23: Both and were placed
on administrative leave 07.15.23, pending the results of internal and external investigations.
Phone call made 7/17/23 to Chris Butler of Millcreek to clarify that client made this
complaint on 7/15/23 to direct care staff and Chris Butler of Millcreek reported this to the
7/15/23. Chris Butler stated there is video (no audio) of Rock
Hill Day Room of client interacting with staff. stated that the incident occurred
around 4 or 5PM. Video has been reviewed by Chris Butler from 3PM-8PM. stated
during an interview with Chris Butler that the verbal confrontation with
occurred in the laundry room and the physical confrontation occurred in the bedroom, both
which have no camera footage. Visit scheduled for 7/18/23.
Email sent and phone voice message left 7/17/23 to Investigator Gregoria Garcia for
permission to visit facility.
7/18/23- Licensing Specialist and investigator will coordinate to review camera
footage and interview the witnesses together today 7/18/23.
Facility visited 7/18/23 regarding complaint that client was verbally cursed by staff
and physically assaulted by staff Investigator
Tonyetta Flint met at facility. Ms. Flint indicated that during the interview with client
indicated a verbal confrontation occurred with over clothes not getting
dried. indicated threw him in his bedroom. Camera footage reviewed (no
audio) of Rock Hill the evening of 7/14/23 from 4PM-8PM. can be seen sitting watching
TV for the most part, occasionally getting up to address peers and staff. At 6:50PM, what
appears to be a verbal confrontation occurs between and staff over a basket of
laundry which staff then are seen holding. Client was identified as a client
who may have heard this conversation. At no time during this video can be seen
physically touching
Rock Hill clients and interviewed. stated that staff goes by
the name " ". stated that "throws us across the room". replied no when
asked if any female staff had ever cursed or been physical with him. stated that staff
"flicked me in the mouth...twisted my arm...pushed me down on the court". stated
that no female staff had ever cursed or been physical with him. stated that he had seen

"grab a kid by his arm...nothing bad". stated that no female staff had ever cursed
or been physical with him. stated that "twists arms" and replied that had
twisted his. stated does this until it hurts, and he is unable to get away from the
hold. stated that no female staff had ever cursed him or been physical with him.
Chris Butler of Millcreek stated after interviewing clients today staff
suspension will move to termination.
Licensing is not prepared to make a finding at this time.
Licensing made a separate report ref# regarding the
allegations made by three of the clients interviewed today. Assigned investigator is LaSonya
Goffin.
8/31/23- Maltreatment case closed as unsubstantiated.
Received email 9/1/23 from Christie Aaron of Millcreek that staff was terminated
7/21/23 and staff is no longer employed by Millcreek. Received email from
Christie Aaron of Millcreek 9/5/23 that staff last day of employment at
Millcreek was 7/14/23.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 7/18/2023
Home Visit Date: 7/18/2023
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 7/18/23 regarding complaint that client was verbally cursed by staff and physically
assaulted by staff . DCFS Investigator Tonyetta Flint met at facility. Ms. Flint indicated that during the interview
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

with client , indicated a verbal confrontation occurred with over clothes not getting dried.
indicated threw him in his bedroom. Camera footage reviewed (no audio) of Rock Hill the evening of 7/14/23 from
4PM-8PM. can be seen sitting watching TV for the most part, occasionally getting up to address peers and staff. At
6:50PM, what appears to be a verbal confrontation occurs between and staff over a basket of laundry which staff
, then are seen holding. Client was identified as a client who may have heard this conversation. At no time
during this video can be seen physically touching .
Rock Hill clients , , , and interviewed. stated that staff goes by the name " ". stated
that "throws us across the room". replied no when asked if any female staff had ever cursed or been physical with
him. stated that staff "flicked me in the mouth...twisted my arm...pushed me down on the court". stated that no
female staff had ever cursed or been physical with him. stated that he had seen "grab a kid by his arm...nothing
bad". stated that no female staff had ever cursed or been physical with him. stated that "twists arms" and
replied that had twisted his. stated does this until it hurts, and he is unable to get away from the hold.
stated that no female staff had ever cursed him or been physical with him.
of Millcreek stated after interviewing clients today staff suspension will move to termination.
Licensing is not prepared to make a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 8/22/2023
Provider Signature : Date: 8/22/2023
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: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 9/5/2023
Home Visit Date: 9/5/2023
Purpose of Visit: Revisit Complaint
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
8/31/23-Case#015132. Maltreatment case closed as unsubstantiated. Facility visited 9/5/23 and findings 521 issued.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Received email 9/1/23 from Christie Aaron of Millcreek that staff was terminated 7/21/23 and staff is no
longer employed by Millcreek. Received email from Christie Aaron of Millcreek 9/5/23 that staff last day of
employment at Millcreek was 7/14/23.
Provider Comments:
CCL Staff Signature : Date: 11/1/2023
Provider Signature : Date: 11/1/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident injured his finger while playing football.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 030825
Date of Incident: 06/27/2025
Date Received: 06/30/2025
Facility Name: Millcreek of Arkansas PRTF
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Complete
Report Description:
Patient was playing football with a group of peers and hurt his finger.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

ARKANSAS DEPARTMENT OF HUMAN SERVICES
STATEMENT OF DEFICIENCIES STATE VENDOR NUMBER: DATE SURVEY COMPLETED
AND PLAN OF CORRECTION
Total # of Page(s):
NAME OF PROVIDER OR SUPPLIER PHYSICAL STREET ADDRESS, CITY, STATE, ZIP
ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER’S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE
INFORMATION) APPROPRIATE DEFICIENCY)
ADMINISTRATOR/DESIGNEE DATE
Survey.
1/1


summary: A parent complained that her daughter was being taken to her home without her permission and requested to speak to someone about the complaint process.

raw_content:
R
Notice of Incident
Case Number: 030696
Date of Incident:
Date Received: 6/24/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: My daughter is being taken to my home in without my permission
today from a stay at Millcreek Behavioral Health in Arkansas. I would like to discuss the complaint
process or other processes needed to report the he horrible experience my family and my daughter
has endured the here the last couple of months. Nobody should have to go through this. I?ve called
the numbers provided on the admission paperwork, and other numbers provided through those
calls, but I haven?t reached the right person. I?m hoping you can help me. Thank you,
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

ARKANSAS DEPARTMENT OF HUMAN SERVICES
STATEMENT OF DEFICIENCIES STATE VENDOR NUMBER: DATE SURVEY COMPLETED
AND PLAN OF CORRECTION
Total # of Page(s):
NAME OF PROVIDER OR SUPPLIER PHYSICAL STREET ADDRESS, CITY, STATE, ZIP
ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER’S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE
INFORMATION) APPROPRIATE DEFICIENCY)
ADMINISTRATOR/DESIGNEE DATE
Survey.
1/1


summary: A resident was sent for an x-ray after injuring her toe at the splash pad.

raw_content:
R
Notice of Incident
Case Number: 030507
Date of Incident: 6/13/2025
Date Received: 6/16/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient
reported to the while she was on an off-campus trip that she hurt her middle toe on the right
foot at the splash pad. stated she tripped over another peer. The patient was transported
to , and x-rays were taken.
Patient was returned to facility, and the toe will be
buddy taped.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for evaluation after complaining of pain due to being “slammed” by a peer.

raw_content:
R
Notice of Incident
Case Number: 030469
Date of Incident: 6/12/2025
Date Received: 6/13/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient
reported he was in a physical altercation with another peer. reported he was "slammed" by a
peer. The patient reported back pain to the nursing staff, and he was transported to where
he received
Patient was returned to the facility without any special instructions. This incident
has been .
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Complaint # AR00038949 and #AR00037200 were in compliance.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
June 19, 2025
Brady Serafin, Administrator
Habilitation Center, Llc
P.O. Box 727
Fordyce, AR 71742
Dear Mr.Serafin:
A Complaint Investigation Survey was conducted on June 11, 2025. We are pleased to inform you that
no deficiencies were cited during the survey and that your facility was in compliance with the
requirements of 42 CFR Part 483, Subpart G, Requirements for Psychiatric Residential Treatment
Facilities. Your certification remains in effect unless terminated due to non-compliance with program
requirements or voluntary withdrawal from the program.
We have enclosed form CMS 2567, “Statement of Deficiencies and Plan of Correction” for the June
11, 2025 Complaint Investig. survey conducted at your facility for participation in the Medicaid
program. CMS 2567 is enclosed, indicating your facility's compliance status. Please sign and
date the 2567 and email to breanna.marengo@dhs.arkansas.gov.
If you have any questions please contact your reviewer at 501-320-6280.
Sincerely,
for Jeff Rosenbaum
Breanna Marengo, RN QA Reviewer
DPSQA/Office of Long Term Care
Survey and Certification Section
bbm
cc: DRA
Brady Serafin - Habilitation Center, Llc - 06/19/2025- (AOLTC - PRTF No Def) Page 1]

doc_type: Complaint Survey


summary: A resident was transported for an x-ray after hitting the wall while upset.

raw_content:
R
Notice of Incident
Case Number: 030415
Date of Incident: 6/10/2025
Date Received: 6/11/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient got
upset and hit the wall with his left hand. Patient was transported to
for an x-ray.
. Patient was transported back to the facility with orders for a splint
on the left hand.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for treatment of a laceration after an altercation with a peer.

raw_content:
R
Notice of Incident
Case Number: 030338
Date of Incident: 6/6/2025
Date Received: 6/9/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient was
involved in an altercation with another peer and received a laceration to left eyebrow. Patient was
transported to and received . The
. Patient was returned to facility without any special
precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident complained of finger pain from recreational activities.

raw_content:
R
Notice of Incident
Case Number: 030266
Date of Incident: 6/5/2025
Date Received: 6/5/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient
complained of finger pain after taking part in the outside activity of the waterslide. Patient was
transported to for an x-ray of his right 5th digit. Patient's x-ray
showed and patient was returned to the facility with no restrictions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for evaluation after she reported knee pain from dancing.

raw_content:
R
Notice of Incident
Case Number: 030251
Date of Incident: 6/4/2025
Date Received: 6/4/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient was transported
to for x-rays after reporting to nursing staff that her left knee was
hurting after she had been dancing. Patient
Patient was able to return to the facility with no restrictions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for an x-ray after reporting ankle pain from landing wrong while coming down a waterslide.

raw_content:
R
Notice of Incident
Case Number: 030252
Date of Incident: 6/4/2025
Date Received: 6/4/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient reported to
nursing staff that her right ankle was hurting after attending an outside activity which was playing on
a waterslide. Patient was transported to for x-rays of the ankle.
Patient's . Follow up care will be provided
through the PCP.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Multiple deficiencies were noted during the Inspection of Care (IOC) conducted on 6/2/25.

raw_content:
June 17, 2025
Habilitation Center, LLC
1810 Industrial Dr
Fordyce, AR 71742-7110
Arkansas Foundation for Medical Care (AFMC) performs Inspections of Care (IOC) reviews of the Behavioral
Health Agencies for the Division of Provider Services and Quality Assurance with the Arkansas Department of
Humans Services. The Arkansas Department of Human Services Division of Behavioral Health Services Licensure
Standards for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report
An incident occurred at the following service site that prompted an order for an additional review. Upon review
of the policies relevant to the incident, the findings are noted below:
Habilitation Center, LLC
Provider Medicaid ID:
Onsite Inspection Date: June 2, 2025
Onsite Inspection Time: 9:02 AM
A summary of the inspection, policies reviewed, and findings are noted below.
Inspection of Care Summary
Health and Safety-Policy Review
This additionally ordered inspection was triggered by a complaint against Habilitation Center, LLC regarding a
client’s medications, late or missing labs, significant weight gain, the development of prediabetes or diabetes, and
the lack of physical activity. Based on the nature of the incident, the following were reviewed and interviews
conducted:
• Client file of the alleged victim
• Staff interviews
• Client/guardian interviews
• Employee File Review
Observation:
Upon arrival at the facility, AFMC staff were promptly greeted at the entrance by a Habilitation Center, LLC
receptionist in the main lobby. AFMC staff signed the visitor log. AFMC staff were immediately taken to a
conference room where they were met by the Chief Executive Officer, Director of Risk Management, Director of
Clinical Services, and the Chief Nursing Officer. AFMC staff were given the completed and signed consent form
listing approval for access to the AFMC portal. Facility staff were given the Document Request Form, and AFMC
staff discussed the requirements for the Inspection of Care.
AFMC staff reviewed the final document request form with the Chief Executive Officer, Director of Risk
Management, and the Director of Clinical Services at the completion of the on-site Inspection of Care and the

provider signed the acknowledgement of manual requirements that were not made available in the provider’s
policy and procedures. AFMC staff explained that these findings were preliminary, and there was still an off-site
portion to be completed.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, the following deficiencies were
noted:
Regulation Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: HR records did not indicate that all direct Upon review of employee SR020485, it was
42 CFR 482.130, care personnel are currently certified in observed that no certification in
42 CFR 483.376 cardiopulmonary resuscitation (CPR). cardiopulmonary resuscitation (CPR) was
included.
Medicaid IP Sec. 2: There is no documentation that all direct The provider lacked evidence of professional
215.220, 218.000 care personnel hold current licenses, as licenses for one of the reviewed professionals.
42 CFR 441.156 required by their position and profession
and/or licensing authority.
Personnel Records – Licenses, Certifications, Training:
There was a total of 50 personnel records reviewed, eleven (27%) professionals and 39 (25%) paraprofessionals.
During the review of the personnel records, the following deficiencies were noted:
Rule Found Deficient Credential Validated Personnel Record Reviewer Notes
Number
Medicaid IP Sec. 2: CPR training - IP Acute SR020485 No File Received
221.804.C
Act 806 of 2023
A.C.A. 9-28-130 (d)(1)(C)
Medicaid IP Sec. 2: Professional License or SR020492 No File Received
215.220, 218.000 Certificate - IP Acute
Act 806 of 2023
A.C.A 9-281302(d)(1)(C)
Medicaid IP Sec. 2: Child Maltreatment SR020487 Expired
241.100.B Check - IP Acute
Act 806 of 2023
A.C.A. 9-28-1302(d)(1)(C)
Clinical Review Deficiencies:
AFMC was provided with the alleged victim’s file for review.
The provider uploaded records which were then reviewed for compliance with licensure standards. Based on the
review of clinical components of licensure requirements, the following deficiencies were noted:
Record Rule Reviewer Notes
Number
RR0040322 Medicaid IP Sec. 2: The Group Therapy Notes and the Family Therapy Notes did not
204.100 document the setting in which the services were provided.
RR0040322 Medicaid IP Sec. 2: The Individual Therapy Notes, Group Therapy Notes, and Family
204.100 Progress Notes did not document the client's progress. However,
the Group Therapy Notes for the month of May were documented
in different forms and did have the patient's progress documented.
RR0040322 Medicaid IP Sec. 2: The provider lacked evidence that the Individual Plan of Care was
218.100 developed in consultation with the recipient and his or her
Habilitation Center, LLC – Fordyce, AR – IOC Report 2 | P a g e

Act 806 of 2023 parent(s), legal guardian(s), or others in whose care he or she will
A.C.A. 9-28-1302(b)(3) be released after discharged.
The client’s guardian stated in a phone interview that the facility
never called her with any updates or changes to the client’s
Individual Plan of Care.
RR0040322 Medicaid IP Sec. 2: The provider lacked evidence in the Individual Plan of Care of a
218.200 description of the functional level of the client.
Summary of Findings and Resolution:
Below is a summary of the telephone interview with the guardian:
The guardian was contacted via telephone on June 3, 2025, at 8:30 a.m. by AFMC staff to interview her regarding
the circumstances surrounding the complaint. She stated that when she picked up the client on Saturday, August
16, 2024, for a weekend home visit she immediately noticed her daughter visible, uncontrollable shaking in both
hands, both legs, and her head. She also observed the client drooling excessively. She was told by staff this was
normal due to the medications she had been placed on. She stated that the staff acknowledged at the time she was
picking her daughter up that her daughter had these symptoms, but the staff did not state how long the symptoms
had been going on. The guardian stated no one from the facility had contacted her to let her know the client had
been exhibiting tremors, shaking, drooling, or any other side effects from the medication. The guardian stated that
she had been informed that the medications were being administered to the client to help with
. The guardian stated the staff was angry that the client was trying to run off and the medications
were being used to control the client and not proper oversight of the client. The guardian did receive enough
medications to administer for the entire weekend pass, but she did not administer any of the medications to the
client once they left the facility
After leaving the facility, the guardian stated that the client continued to ‘not act right’ and she took her straight
to her primary care physician at in where she saw the physician assistant. A
was drawn and found to be . The clinic sent the client home with the guardian at that time and was
told to go home and monitor the client for changes or worsening in symptoms. Later in the day, the physician
assistant called the guardian and stated that she had consulted with a colleague regarding the client’s condition
and was recommending the guardian to take the client to the emergency room immediately. The guardian took the
client to the emergency room at . Upon arrival to the emergency room the client was
found to have which were diagnosed as
The client was placed on for .
The client remained in for approximately .
Once discharged from , the client was sent home with a to prevent
. There was a concern initially about the client going home on , but her
stabilized in the hospital, so she did not require upon discharge. The client had to check her
levels three to four times daily, which guardian states were traumatizing and had to check due to
being way too high or dropping way too low. Upon discharge from the hospital, the client also had
. All issues have been resolved, and the
client was discharged from the .
The guardian did state that she was not involved in formulating the client’s treatment plan or discharge plans. She
stated that she had to initiate calls to the facility to inquire about what the treatment and discharge plans were. She
stated the only calls she received from the facility were asking for consent for medication changes or when the
client was misbehaving or getting in trouble. The guardian stated that one staff member even asked, “Do you
realize she is a bully?”, in reference to the client. That staff member put the guardian on the phone with the client
so the guardian could “scold her for bad behavior.” The guardian stated that she asked this staff member if they
were aware that the client has a diagnosis of which is the cause for the outburst of behaviors
Habilitation Center, LLC – Fordyce, AR – IOC Report 3 | P a g e

and the reason why the client is receiving treatment. The guardian stated the staff member told her they were not
aware of the diagnosis. The guardian called the case manager to discuss this situation and was told by the case
manager that those things (referring to the ) were on a need to know basis for
staff.
Below is a summary of observations from the chart review of the alleged victim:
• The client was admitted to Habilitation Center LLC on 2024, at . and was discharged
on 2024, after not returning from a with the guardian.
• The client had multiple episodes documented in the nursing notes and staff observation notes detailing
the client’s behaviors that warrant the use of . All documentation was completed
thoroughly and accurately.
• On August 11, 2024, at 7:30 p.m., the night shift nurse (SR020522) documented “Patient on unit taking
medications, this nurse noticed that patient’s hands had tremors while trying to take medications.” No
follow up documentation was noted in the chart regarding tremors, nor was this documented as being
reported to the physician. AFMC staff interviewed facility staff (SR020522) via phone, and they reported
they had sent an email to the physician’s nurse (SR020529) via email and that is the normal practice.
AFMC staff interviewed SR020529, and she reported that she did not recall receiving an email and that
if she did, she would have forwarded it to the physician’s nurse that was providing care to the client.
AFMC interviewed the physician’s nurse (SR020530) that was overseeing the client, and she reported
that she did not recall receiving any information about the tremors.
• AFMC requested to view the emails, and it was reported that ‘corporate policy for email retention is 6
months, so anything older than that would have rolled off.’
Upon review of the physician orders, vital sign sheet, and laboratory values the following observations were
noted:
• Medication Orders:
o On May 23, 2024, at 3:43 p.m., the order was received to continue the following home
medications:
▪
▪
o On June 3, 2024, at 12:45 p.m., the order was received to
.
o On June 13, 2024, at 1:15 p.m., the order was received to
o On June 27, 24, at 1:45 p.m., the following medication orders were received:
▪
▪ .
o On July 2, 2024, at 12:30 p.m., the order was received to
.
o On July 12, 2024, at 1:45 p.m., the order was received to
o On July 26, 2024, at 2:45 p.m., the following medication orders were received:
▪
▪ .
• :
o were drawn as per the physician’s order and
policy. All results were within the .
• Weight gain documentation:
o The client’s weight on admission on , 2024, was
o On June 2, 2024, the client’s weight was .
o On July 5, 2024, the client’s weight was .
o On August 1, 2024, the client’s weight was .
Habilitation Center, LLC – Fordyce, AR – IOC Report 4 | P a g e

o There was no documentation to address the client’s weight gain except a physician order on July
7, 2024, at 2:30 p.m., the order was received to
.
o Due to the weight gain AFMC staff reviewed the physical activity schedule provided to the
clients as well as the daily schedule of what this client participated in. There were 20 days this
client was not identified as being off the unit where appropriate physical activity could take
place. Additionally, there is no indication of what is offered while clients are outside or in the
gymnasium for activities. The facility staff stated they can only offer clients activities but
cannot force them to participate. While onsite AFMC staff observed several groups of clients
outside during activity time, but staff were not observed offering any activities but instead they
were sitting with clients at picnic tables.
o While onsite, AFMC staff nurse looked at the documented monthly weights for the current clients
on Penguin Hall. There were nine clients whose weights were documented on admission, three
days after admission, and monthly thereafter. Of the nine clients the following were noted to have
significant weight gains:
▪ One client had a 22.4 pound weight gain in a 5 month period.
▪ One client had a 15.2 pound weight gain in a 2 ½ month period.
▪ One client had a 23.4 pound weight gain in a 10 month period.
▪ One client had a 58.2 pound weight gain in a 22 month period.
o AFMC staff spoke with the Director of Nursing who provided four week rotating menus for
breakfast, lunch, and dinner. The Director of Nursing explained that if a client receives an 1800
calorie diet the only change from a regular diet is smaller portion sizes and a different snack
such as an apple instead of a prepackaged fudge round. Clients also are offered three snacks per
day in addition to the three meals offered each day.
Additional statements:
• AFMC was unable to retrieve medical records from the PCP or due to not
having a release of information.
• The observations detailed above are not a direct regulation deficiency within the Licensure Standards
for Inpatient Psychiatric Services for Under 21; however, they are significant to the complaint and client
care.
Respectfully
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Habilitation Center, LLC – Fordyce, AR – IOC Report 5 | P a g e

doc_type: IOC Report


summary: A complaint received alleged concerns with the facility’s cleanliness, lack of supervision that leads to altercations between residents, and staffing ratio concerns. The complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 030176
Date of Incident: 6/1/2025
Date Received: 6/1/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Av is a 13yo who currently resides at Millcreek Behavioral Health. AO
are staff members at Millcreek Behavioral Health Habilitation Center. I work for Texas
DFPS and recently received a concern from a Texas CASA (guardian ad litem) for the
resident. Resident was placed at the Millcreek Behavioral Health habilitation center on
3/17/2025. The concerns are that there is chemical restraint used at the facility, and that the
CASA was not allowed to see the youth or the youth's living quarters during an on-site visit.
There are concerns with the facility's cleanliness, the facility's lack of supervision that leads
to altercations between the residents, and a staffing ratio concern.
Interim Action Narrative:
Narrative:
Licensing Narrative: 6/2/25-Reviewed for licensing concerns. Visit scheduled for this week
depending on car availability. 6/3/25-No state car. Visit scheduled for 6/4/25. Phone call
made to the CASA worker and a voicemail was left requesting a return call. 6/4/25-Facility
visited. No citations. Complaint unfounded. 6/4/2025, case and documentation reviewed.
Resident inteviewed and living quarters observed. Complaint unfounded by licensing,
Approved by Program Coordinator. Case complete.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Mitzy Reynolds
Record Visit Date: 6/4/2025
Home Visit Date: 6/4/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited from 9:30AM to 11:30AM for Licensing Complaint Case #030176received on 6/1/2025.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Census: 159.
Staff to resident ratio sheets for the month of May 2025 provided to Licensing and reviewed. Resident 1
resides in Pebble Creek. Staff to resident ratio ranged from 3:13 to 3:17, all within ratio. All chemical
restraints for Resident 1 requested. No documentation could be provided due to Resident 1 was not given a
chemical restraint for his duration at facility.
Pebble Creek, Resident 1's sleeping quarters and living day area observed to be clean, safe, and in good repair.
Bathroom was clean and sanitary with functioning sink, shower, and toilet. Client rights and emergency
diagram observed.
Resident 1 interviewed who voiced no concerns other than wanting to know why he couldn't have his MP3
player. He stated that some staff were nice, and that he felt safe around all staff and felt comfortable telling
them if he felt unsafe. Resident 1 stated that he recently went on an outing where he saw a baby alligator and
got to eat sushi. He stated that in 5 days he is discharging and going back to Texas. Resident 1 was reminded
by facility administration the rules of MP3 player which he seemed receptive to.
Licensing regulations reviewed:
905.11: Chemical restraint shall be used only if ordered by a physician. A chemical restraint is an emergency
behavioral intervention that uses pharmaceuticals by topical application, oral administration, injection, or
other means to modify a child's behavior. Prescribed treatment medications that have a secondary effect on the
child's behavior are not considered a chemical restraint.
907.3:Staff to child ratio shall be at least one to six (1:6) during waking hours and one to eight (1:8) during
sleeping hours.
911.6:All buildings and furnishings shall be safe, clean, and in good repair.
912.1-6:The facility shall provide a bathroom for the children which is clean and sanitary with an adequate
supply of hot and cold running water, soap, towels, and tissue. There shall be separate bath and toilet facilities
for males and females. There shall be a separate toilet, bathtub or shower, and sink for each six (6) children.
Licensing complaint Case #030176has been investigated and determined to beunfoundedas evidenced by:
Staff to client ratio for Resident 1's cottage was within ratio. No buildings concerns observed in Resident 1's
sleeping quarters, living quarters or bathroom. No chemical restraint has been administered on Resident 1 for
his duration at facility.
***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

Provider Comments:
CCL Staff Signature : Date: 6/4/2025
Provider Signature : Date: 6/4/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was transported for evaluation after she reported knee pain from falling.

raw_content:
R
Notice of Incident
Case Number: 030181
Date of Incident: 5/30/2025
Date Received: 6/2/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient reported
while on a home pass she tripped and fell on her right knee. Patient was taken to
of the right knee. Patients and patient
was returned to facility without any special instructions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that she took an unknown medication provided to her by a peer.

raw_content:
R
Notice of Incident
Case Number: 030184
Date of Incident: 5/31/2025
Date Received: 6/2/2025
Facility Name: Millcreek of Arkansas PRTF
Report Description: Patient
reported she had taken unknown medication which was supposedly provided by another peer.
Patient was transported to for a number of which all
resulted negative for any medications. Patient was sent back to facility with the recommendation of
suicidal precautions, which was done.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for assessment and x-ray after complaining of left foot pain to the nursing staff.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 030128
Date of Incident: 5/29/2025
Date Received: 5/29/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Pt was
transported to of the left foot after complaining of
pain to the nursing staff. Patients the patient returned to the
facility to resume normal activities.
Interim Action Narrative: Resident x-rayed.
Narrative:
Licensing Narrative: 5/30/25-Reviewed for licensing concerns. Received email that x-ray
was completed 5/28/25, not 5/29/25.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for assessment after reporting a recreational injury to nursing staff.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 030130
Date of Incident: 5/28/2025
Date Received: 5/29/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient was
transported to after reporting a
recreational injury to nursing staff. Patient's ,
and patient was returned to facility to resume normal activities.
Interim Action Narrative: Resident x-rayed.
Narrative:
Licensing Narrative: 5/30/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for an x-ray after reporting finger pain from a recreational injury.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 030129
Date of Incident: 5/28/2025
Date Received: 5/29/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient )
was transported to of the right third digit after
reporting finger pain due to a recreational injury. Patient's
. Patient returned to the facility
to resume normal activities.
Interim Action Narrative: Resident x-rayed.
Narrative:
Licensing Narrative: 5/30/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A complaint received states that staff will not let the resident go to the bathroom when she wants and makes her wait at least 2 hours between bathroom breaks. The report also alleges that staff does not believe the resident has panic attacks and did not believe she was injured when she fell off the monkey bars. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 030026
Date of Incident: 5/22/2025
Date Received: 5/22/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Millcreek staff will not allow the AV to go to the bathroom when she
wants to go and makes her wait a minimum two hours between bathroom breaks. Staff does
not believe that AV has panic attacks and this will cause her to have micro seizures with the
panic attacks. Also, two to three months ago the AV fell off the monkey bars and
and staff did not believe the AV. It is believed staff made the AV wait till the next
day to get her out because the AV has a history of over exaggerating.
Interim Action Narrative: Staff 1 placed on administrative leave pending investigation.
Narrative:
Licensing Narrative: 5/22/25-Received licensing complaint. Reviewed for licensing
concerns. Email sent to for further information. Email received back from
Resident is -Portion of complaint involving hurt arm
from falling off monkey bars reviewed, . According to report from facility
4/17/25, resident fell off the monkey bars 4/12/25 and did not report pain until 4/16/25 at
which time she was x-rayed. Nursing notes from 4/12/25 will be requested. 5/27/25-
History and Physical 6/14/24 day after admission 6/13/24 reviewed. No mention of micro
seizures or panic attacks. Nursing notes reviewed which indicate resident did complain of
pain "10/10" 4/12/25 following falling off the monkey bars. Resident given
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

4/13/25 and reported pain "5/10". Resident seen 4/15 and continued to complain of pain.
4/15/25 Dr. ordered for 4/16/24. Resident 4/16/25.
A Splint was placed for
support and transferred back to the facility. 5/14/25-Follow up removed splint and x-ray
noted healing. 5/28/25-Facility visited. Licensing complaint unfounded.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Mitzy Reynolds
Record Visit Date: 5/28/2025
Home Visit Date: 5/29/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited from 9:45AM -11:00AM in response toCase #030026. Census: 158.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Nursing notes, physician notes, initial medical assessment, and MAR provided to licensing and reviewed.
Resident 1 fell off the monkey bars on 4/12/25, she was seen by nursing, given Ibuprofen, and reported a pain
level of 10/10. Resident 1 was seen by nursing on 4/13/25, given Ibuprofen, and reported a pain level of 5/10.
Resident 1 was seen by nursing on 4/15/25 and a physician order was given for an x-ray scheduled for
4/16/25. X-ray completed on 4/16/25 which indicated an acute nondisplaced fracture of the proximal-mid right ulnar
diaphysis, arm placed in a splint. Resident 1 seen for follow up x-ray on 5/14/25 which indicated healing and splint removal
on 5/28/25. Resident 1 still had arm wrapped up when interviewed during today's visit. Initial medical assessment yields no
diagnoses of micro-seizures or panic attacks.
Resident 1 interviewed. When asked, Resident 1 indicated that if she needs to use the bathroom, she asks staff, and they let
her go. Resident 1 indicated she has never had an issue with staff allowing her to use the restroom. When asked what a
micro-seizure was Resident 1 stated she did not know and had never heard that word before. Resident 1 did state she has
panic attacks sometimes when other residents are placed in a hold. When asked about Staff 1, Resident 1 stated she was "a
little nice" except for when Staff 1 "gets in my business." Resident 1 stated she felt safe around Staff 1 and facility staff in
general. She stated she felt safe telling staff if she felt threatened or unsafe.
Licensing regulation907.2reviewed: Childcare staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child's age,
individual differences and abilities, surrounding circumstances, hazards, and risks.
Licensing complaintCase #030026has been investigated and determined to beUnfoundedas evidenced by: Resident 1 was
routinely seen by nursing and assessed for pain until x-ray was scheduled. Resident 1 reported no issues with being allowed to
use the restroom. Resident 1 was unaware of what a micro-seizure was and had no complaints regarding such.
***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.
Provider Comments:
CCL Staff Signature : Date: 5/29/2025
Provider Signature : Date: 5/29/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A complaint received alleges that a resident has been overmedicated by the facility, causing adverse health side effects.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029702
Date of Incident: 5/12/2025
Date Received: 5/12/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Report received and attached to this case. Allegations of a resident
being overmedicated causing adverse health side effects.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5/20/25-Facility visited and the following items provided to licensing:
Physician orders and notes, nursing notes, MAR, all lab reports and facility medication
policy regarding medications that require bloodwork and/or monitoring. 6/2/2025-
Information was sent for a medical opinion.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A guardian reported that a resident had been sexually assaulted by a peer while at the facility. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029323
Date of Incident: 4/26/2025
Date Received: 4/28/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: A/V is a . A/O is unknown (unknown1; no age provided in
demographics, below referred to as a minor peer at Millcreek). Care Coordinator was
informed on April 4/28/2025 via guardian, that resident had been sexually assaulted while
at Millcreek Behavioral Health by another child receiving treatment there. Guardian stated
that on Saturday 4/26/2025 resident called "hysterical" claiming that another resident at
Millcreek had put his mouth on the resident's private, given him a bruise on his buttock and
had woken up to the peer kissing him on the cheek. Guardian also says that the other
resident had tried to insert himself into the resident's but that the peer wasn't physically
able to, and the resident was able to defend himself to get the other resident off of him. The
guardian says the resident has been coached to lie about what has happened and that after
she called with concerns, she was only allowed to speak with the resident via speaker phone.
The guardian indicated lying by the provider, Millcreek, and has had concerns about his
treatment for about 2 weeks, but after this particular incident the guardian picked the
resident up and had him discharged.
Interim Action Narrative: Residents assigned separate bedrooms from previous alleged
incident. Resident 2 (A/O) placed on sexually acting out precautions.
Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing inquired about which program resident was in. Facility
informed licensing PRTF and that he discharged him on /2025. 4/30/15-Phone call
had with for further information. Phone call had with of Millcreek for
further information. Visit scheduled for today at 10:00AM.
Visit scheduled for Millcreek this afternoon. 4/30/25-Facility visited. No citations.
Complaint unfounded.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Mitzy Reynolds
Record Visit Date: 4/30/2025
Home Visit Date: 5/1/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited from 1PM-2:30PM in response toCase#29323. Census: 161.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Licensing had previously attended interviews with Resident 1 (A/V) and Resident 1's guardian. It was
determined by interviews that alleged incident occurred at "midnight" 4/25/25-4/26/25. Resident 1 stated that
Resident 2 (A/O) "army crawled" across the unit from his (Resident 2)'s room into his room (Resident 1).
Resident 1 drew a diagram of how this happened. When asked Resident 1 stated that staff were "sleeping
under the cameras...they always are sleeping with their heads on their desks". Resident stated this happened at
"midnight" the night before he called his mom.
Resident 1's guardian, mom, stated that Resident 1 reported to her on the phone alleged incident occurred the
night before he called her 4/26/25.
Video reviewed of Deerfield Hall from 4/25/25 at 11:50PM to 4/26/25 at 12:20AM. At no time is any resident
seen crossing the unit. Resident 1 and Resident 2's rooms identified in video. There is no way a resident could
have crossed the unit out of camera view. Both staff are seen alert, attentive and moving the entire video.
Resident 2 had already been assigned a separate bedroom from Resident 1 from a previous incident. Resident
2 had been placed on sexually acting out precautions as a precautionary measure. Sexually acting out
precautions document provided to licensing and reviewed which indicates staff maintain the same level of
supervision but immediately intervene in the event of any sexual behavior. Resident 1 has since discharged
from the facility on 4/26/25.
Licensing regulations reviewed:907.2: Childcare staff shall be responsible for providing the level of
supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility,
taking into account the child's age, individual differences and abilities, surrounding circumstances, hazards
and risks. Resident 2 was separated from Resident 1. Resident 2 was put on sexually acting out precautions.
907.3:Staff to child ratio shall be at least one to six (1:6) during waking hours and one to eight (1:8) during
sleeping hours. Deerfield staff/child ratio at time of alleged incident 2:9.907.5:All childcare shift staff counted
in the staff child ratio shall remain awake at all times. Both staff observed in video awake, attentive and
moving.
Licensing complaintCase#29323has been investigated and determined to beUNFOUNDEDas evidenced by
interviews and video review.
***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 5/1/2025
Provider Signature : Date: 5/1/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was transported to the hospital for a CT scan. The hospital recommended the resident be placed on seizure protocols.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029095
Date of Incident: 4/17/2025
Date Received: 4/18/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient
had a seizure Thursday evening at the facility. The patient was transported to
performed a CT without contrast and
patient was cleared to return to the facility. The hospital recommended the patient be
placed on seizure protocols per facility protocol and follow up with primary care doctor
within the next week.
Interim Action Narrative: Resident taken to hospital, treated, and aftercare plan in place.
Narrative:
Licensing Narrative: 4/18/25-Reviewed for licensing concerns. Safety plan in place.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A complaint received alleges that a resident has been overmedicated multiple times by the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029005
Date of Incident: 4/15/2025
Date Received: 4/15/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: had been a resident at Millcreek Behavioral Health. He is now
back in at . has been overmedicated multiple times by
the facility. is on . It is believed that was
overmedicated on his . When staff arrived to get
could not stay awake and appeared to be in some type of (over) medicated induced
condition. Upon arriving at , he was almost unconscious. had
trouble waking him up-, but he was more coherent the next morning. He was not given his
medications the previous night. staff took to
to have him medically cleared. His presentation and behavior were concerning. He
had significantly difficulties walking and communicating with staff. When staff return from
the hospital, they informed us that did not test positive for any illegal drugs. The
doctor at the hospital informed staff that was presenting the way he was because of
his prescription medications. received a copy of the bloodwork today and
according to the bloodwork On Friday March 7th he
was transported to for their walk-in clinic to be evaluated and assigned to a
psychiatrist. was assigned to for management of his
psychotropic medication. He has his initial appointment on Tuesday at 12:00
pm. He has additionally, been assigned to for case management at
. He saw for a wellness
examination. He had bloodwork while at . We are still waiting for the results. I
spoke with about the bloodwork for the hospital being and he
stated that he did not know how the got into his system. Unfortunately, the
bloodwork does not have the amount of in his system. He is functioning some
better than when he first arrived at
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 4/15/2025- Licensing contacted the facility to determine the discharge
date of the resident. The resident discharged from Millcreek PRTF on /2025. 4/16/25-
Facility visited. Facility provided MAR, physician orders and restraint packets with
physician orders to licensing. 6/2/2025-Request was made for a medical opinion.


summary: A resident tripped while sweeping, causing a laceration to the jaw. The resident was transported to the emergency room for treatment before being released back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028968
Date of Incident: 4/12/2025
Date Received: 4/14/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient
was sweeping when he tripped and hit the right side of his jaw on the broom
handle and this caused a laceration. The patient was transported to
where he was treated with . The patient returned to the facility
with no restrictions.
Interim Action Narrative: Resident taken to hospital and treated.
Narrative:
Licensing Narrative: 4/14/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported pain after falling from the monkey bars. The resident was sent to the emergency room for an x-ray.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029060
Date of Incident: 4/12/2025
Date Received: 4/17/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description:
was sitting on the monkey bars and fell through a hole. On 4/16/25,
was sent out to for an X-ray of the
right forearm, due to having pain.
. A Splint was placed for support and transferred back to the
facility. Nursing will continue to monitor.
Interim Action Narrative: Resident taken to hospital and treated.
Narrative:
Licensing Narrative: 4/17/25-Reviewed for licensing concerns. Phone call made to
of Millcreek who confirmed the incident of resident falling was 4/12/25. The incident
reported to licensing was the X-ray which took place on 4/16/25 due to resident
complaining of pain from the previous incident. This was reported timely.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was referred for an ultrasound of his scrotum due to right testicular pain.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028966
Date of Incident: 4/11/2025
Date Received: 4/14/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient
) was referred to for an ultrasound of his scrotum due
to right testicular pain.
. Otherwise, normal ultrasound of the testicles and epididymides. The patient
was referred back to the facility without any restrictions.
Interim Action Narrative: Resident taken to hospital and treated.
Narrative:
Licensing Narrative: 4/14/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for an x-ray after kicking an object. The x-ray showed no fracture.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028871
Date of Incident: 4/8/2025
Date Received: 4/9/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient ,
) was taken to due to swelling of right
foot after kicking an object. performed x-rays and did not find any new fractures to
the foot. The patient was released back to the facility without any restrictions.
Interim Action Narrative: Resident taken to and treated at hospital.
Narrative:
Licensing Narrative: 4/10/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the Emergency Room for an x-ray after twisting her ankle when she tripped over her shoes.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028825
Date of Incident: 4/5/2025
Date Received: 4/7/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient Pt. walked
backward, entered her room, tripped over her shoes, and twisted her right ankle.
was transferred to the emergency room for an X-ray. The X-ray report reflects
no acute fractures or dislocation of the right ankle but mild soft tissue swelling in the right
ankle area. was transferred back to the facility, and nursing will continue to
monitor.
Interim Action Narrative: Resident taken to hospital.
Narrative:
Licensing Narrative: 4/7/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the Emergency Room after reporting that she swallowed ChapStick and an ink pen.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028749
Date of Incident: 4/2/2025
Date Received: 4/3/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient
was transferred to as a precautionary measure due to
concerns about possible ingestion of foreign objects. The patient self-reported that she had
swallowed ChapStick and an ink pen. The patient received an x-ray at the local hospital and
no foreign objects were noted. released the patient back to
the facility without any restrictions.
Interim Action Narrative: Resident taken to hospital.
Narrative:
Licensing Narrative: 4/3/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct a Buildings and Grounds inspection.  The buildings were clean, safe, and in good repair, except for one pair of shorts with strings found in a resident’s bedroom. The grounds were clean and free of safety hazards. The facility was cited 911.15.f for the strings found in the bedroom.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Mitzy Reynolds
Record Visit Date: 4/1/2025
Home Visit Date: 4/1/2025
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulation Number: 900.911.15.f
Regulation Description: Areas used by children shall be designed, constructed, and furnished to reduce risk of
suicide and assault including, but not limited to:
Finding Description: One pair of drawstring shorts was found with string in them in resident bedroom. String was
removed during today's visit.
Action Due Date: 2025-04-01
Action Due Description: String removed during visit 4/1/25.
Comply Date:
Sub-Regulation Level 1 Description: Children’s personal items that contain cords, pull-ties, strings, or other
parts that could be used to inflict self-injury shall not be left in the child’s room unless the dangerous component
has been removed.
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Millcreek PRTF is a Psychiatric Residential Childcare facility licensed for 167 PRTF beds. Census today:
158. Buildings & Grounds conducted from 11:00AM-1:00PM for Pebble Creek and Pine Ridge.
Pebble Creek was empty, residents outside. Building clean, safe and in good repair. Bathrooms clean and
sanitary with functioning sinks, showers and toilets. Resident rights and emergency diagram observed.
Pine Ridge staff/client ratio: 3:15. Residents were in day area, seemingly about to eat boxed lunch. Building
clean, safe and in good repair except one pair of drawstring shorts was found with string in them in resident
bedroom. String was removed during today's visit. Facility cited 911.15f. Bathrooms clean and sanitary with
functioning sinks, showers and toilets. Resident rights and emergency diagram observed.
Ground clean and free of safety hazards. Several residents outside playing as it was lunchtime.
Group 1 staff/client ratio: 4:22
Group 2 staff/client ratio: 7:23
Group 3 staff/client ratio: 2:3
One resident seen being escorted by one staff.
Fire drill and emergency drills observed during today's visit.
MAR checked for March 2025:
Facility cited911.15fas evidenced by children's personal item that contained cord, pull-ties, strings or other
parts that could be used to inflict self-injury found in residents' bedroom.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.
Provider Comments:
CCL Staff Signature : Date: 4/1/2025
Provider Signature : Date: 4/1/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3

doc_type: Compliance Report


summary: A resident was transported to the Emergency Room after reporting that she brought illegal substances with her upon admission and inhaled them.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028664
Date of Incident: 3/29/2025
Date Received: 3/31/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient
was transferred to as a precautionary measure due to
concerns about possible substance usage. The patient self-reported that she brought illegal
substances with her upon admission to the facility on 02.12.2025 and that she inhaled them.
The patient was drug tested at the hospital, and all tests came back negative for any
substances. released the patient back to the facility without
any restrictions. A contraband search was conducted on the patient and her possessions,
and no contraband was found.
Interim Action Narrative: Resident taken to hospital.
Narrative:
Licensing Narrative: 3/31/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: While working in the cafeteria, a resident was injured by spilling hot water on his right foot. The resident was transported to the Emergency Room for treatment before being released back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028473
Date of Incident: 3/23/2025
Date Received: 3/24/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient is a
patient worker who was assigned to the cafeteria and accidentally spilled hot water on his
right foot. Patient was transferred to where he received
treatment for to his foot. Patient will receive ongoing nursing
care on site and patient was released back to the facility.
Interim Action Narrative: Resident treated at hospital.
Narrative:
Licensing Narrative: 3/24/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain in his right hand after playing football. An x-ray was ordered and showed no fractures.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028472
Date of Incident: 3/21/2025
Date Received: 3/24/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient (Arkansas, Custody,
complained of pain in right hand after playing football. Patient was taken to
x-ray was performed on right hand and no fracture was noted. The patient
was released to return to the facility with no limitations.
Interim Action Narrative: .
Narrative:
Licensing Narrative: 4/16/25-Reviewed for licensing concerns. This report was noticed
late. No notification was provided to specialist.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for an x-ray after injuring his hand by punching a window.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028364
Date of Incident: 3/18/2025
Date Received: 3/19/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was sent to for outpatient x-
rays when a nurse assessment revealed continued bruising to his right hand. The injury was
a result of self-injurious behavior on 3/6/2025, where aggressively punched a window.
. He was
provided a splint and released to return to the facility.
Interim Action Narrative: Resident sent for x-ray and treated.
Narrative:
Licensing Narrative: 3/19/25-Reviewed for licensing concerns. Facility notified licensing
resident's Placement.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident eloped from the facility and stole a truck from a nearby home, crashing the truck in a nearby town. The resident told officers he left the facility because he was being sexually abused by one staff member and physically abused by two other staff members. The facility was alerted to the resident’s absence by police officers approximately an hour after the resident eloped from the premises. The facility was cited 907.3 and 907.2 for supervision issues as a result of this incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028298
Date of Incident: 3/15/2025
Date Received: 3/17/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Av is who resides at Millcreek Behavioral. AOs are
Unknown, Unknown, And Unknown who are staff at Millcreek Behavioral.
Yesterday in the school bathroom. Unknown who is a female staff member forced him to
put his private part into her butt. When he was asked what he meant and if it was in her
butthole, he said ?No, the other hole.? He stated that she has a knife, and he does not
remember how he got his penis into her vagina. who are staff regularly beat
with their fists and hands. The last time it happened was a couple days ago. They
take him down to his room where there are no cameras. He stated that they do leave
bruises, but he currently doesn?t have any. He was asked if he told someone, and he stated
that he is afraid because he doesn?t want to get in trouble because he knows that he will get
beat again. Ultimately, he had enough, and he ran away from the facility. He stole a car and
the wrecked it and is currently at
Interim Action Narrative:
have been put on administrative leave pending licensing investigation.
Narrative:
Licensing Narrative: 3/17/25-Reviewed for licensing concerns. Phone call had with
for further information. Program Manager requested police report from the
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

PD. Licensing Specialist attended interview with resident. 3/18/2025, Program
Coordinator called SO and requested the police report. Incident reported
received and Licensing Specialist informed. reviewed. 3/18/25-Facility visited
with . Facility cited 907.2 and 907.3. 4/7/25-Facilty sent email that A/O 1
will not be retrained as she will be terminated from employment. 4/21/2025- Received an
email from the facility requesting the removal of the ICA for staff to return to work.
Retraining documentation was received for staff . and for another staff as they were
found to have not intervened when the resident was allowed to leave to the nurse's station
unattended. Staff was terminated due to this complaint on 4/8/2025 and staff was
terminated due to other issues on 3/27/2025. The ICA was lifted for staff to return to
normal job duties. 5/19/2025, documentation reviewed. Complaint founded by licensing.
Approved by Program Coordinator. Case complete.


summary: A resident reported that a staff member shoved her face into the floor during a restraint and another staff member kicked her in the side. This complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028267
Date of Incident: 3/14/2025
Date Received: 3/14/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: AV is . AO is an Unknown staff member. PRFC is
. reported that a staff member at Millcreek behavioral hospital
shoved her face into the floor during a physical hold. She also reported that a staff member
kicked her in the side. did not report the names of the staff.
Interim Action Narrative: were placed on
administrative leave pending licensing investigation.
Narrative:
Licensing Narrative: 3/14/25-Reviewed for licensing concerns. Phone call made to
of Millcreek. Client's and guardianship-AR Foster Care, ascertained.
Client discharged from Millcreek PRTF /25 at 12:15PM. Email sent to DCFS for further
information. Received email back from DCFS. 3/18/25-Facility visited with
It was determined that there are 2 A/O's in this complaint. Both these staff
have been placed on administrative leave. According to , resident alleged
that the incident happened in the school. There is no camera footage of the school. 2 other
residents interviewed. Complaint unfounded. 4/28/2025, Facility provided documentation
that was uploaded to the case. The case has been closed as unfounded by licensing.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Approved by Program Coordinator. Case complete. 5/7/25-ICA's lifted for staff involved in
case.


summary: A resident was injured after falling asleep and then falling out of her desk. The resident was transported to the emergency room for treatment before being released back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028257
Date of Incident: 3/13/2025
Date Received: 3/14/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient ) fell
asleep and fell out of her desk, hitting her head on the floor. The patient was assessed on
site and referred to , where she received and was
released to return without restrictions.
Interim Action Narrative: .
Narrative:
Licensing Narrative: 3/14/25-Reviewed for licensing concerns. 4/8/2025- Additional
information was received regarding this case and the case was reopened as a complaint
against the agency. Concerns have been raised that the resident may have fallen over in her
chair due to possible overmedication. The resident is currently on the following
medications: ?
Additionally, the resident received the following chemical restraints: -
-Facility
visited. Licensing requested MARs for the resident, all physician orders, and all restraint
packets to include the physician order for those restraints. All items provided to licensing.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported pain to his right hand after an altercation with a peer. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028213
Date of Incident: 3/11/2025
Date Received: 3/12/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description:
engaged in a physical confrontation with
on the basketball court during outside recreation time. The two patients were
immediately separated. did not initially report any injury. He reported pain in his
right hand on 3/10/25. Sent for x-rays on 3/11/25.
Interim Action Narrative: .
Narrative:
Licensing Narrative: 3/12/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that a staff member entered his bedroom and became physically aggressive, “slamming” him several times. This complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028130
Date of Incident: 3/8/2025
Date Received: 3/10/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description:
was displaying negative behaviors while on his living unit. When staff members
intervened, he went inside his bedroom. reported that staff member
entered his bedroom and was physically aggressive with him, "slamming" him several
times.
Interim Action Narrative: The involved staff member was placed on leave.
Narrative:
Licensing Narrative: 3/10/25-Phone call made to DCFS to consult on complaint. Phone
call made to Chris Butler of Millcreek. There is video of the incident but not once inside the
bedroom. Nursing notes and witness statements requested via email. The involved staff
member was placed on leave. 3/11/25-Nursing note and witness statements sent to
licensing and reviewed. One witness statement asserts that staff alleged in complaint
"pushed him back mildly". Visit scheduled for 3/12/25. 3/12/25-Facility visited. Licensing
complaint unfounded. 4/21/2025-The facility emailed the PRLU requesting that the ICA for
the staff be lifted. The PRLU reviewed the retraining documentation for the staff and lifted
the ICA for the staff so they may return to normal job duties. 4/28/2025, Facility provided
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

documentation that was uploaded to the case. The case has been closed as unfounded by
licensing. Approved by Program Coordinator. Case complete.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Mitzy Reynolds
Record Visit Date: 3/12/2025
Home Visit Date: 3/12/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Millcreek of Arkansas is a Psychiatric Residential Facility which is licensed to house 162 residents
ages 5-18. Current census: 158.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Facility visited on 3/12/25 in response to complaint 028130 that staff was physically aggressive
towards a client during an incident that occurred 3/8/25 at Rock Hill Cottage. Nursing note for dates
3/5/2025 through 3/9/2025 and witness statements from the resident, a peer, and two staff were
provided by the facility to licensing. A third-party staff witness statement describes that staff alleged
to have been physically aggressive “pushed him back mildly”, him referring to resident. Staff was
placed on administrative leave pending the completion of the investigation.
The staff named in this incident completed TCI training on 10/28/24. All background checks for this
staff were completed and approved. As a precautionary measure, the named staff will complete
retraining on TCI.
Licensing reviewed video of incident that took place on 3/8/2025. The staff/client ratio was reported
to be 2:10 at the time of the incident by Chris Butler as not all residents could be seen on the video
footage by the licensing specialist. Staff named in the complaint can be seen escorting the resident
to his room by grabbing one of resident’s arms, under the arm and gripping on the forearm. The
staff then sits in a chair outside of the resident’s room in a doorway that is visible on video. Behind
the doorway is the resident’s bedroom which is not visible in video. While the staff is sitting outside
the bedroom, the resident can be seen getting close to staff in an aggressive manner, putting his
face close to hers. The named staff is seen pushing in the resident’s direction as if to create space
between herself and resident. For a brief period, the staff is completely out of view in video, having
walked in the direction of resident’s room. The named staff then returns to her chair outside the
bedroom.
The licensing complaint isunfoundedfor violations related to standard 109.1.g which states “1.
Unprofessional conduct in the practice of child welfare activities shall include without limitation: (g)
Engaging in behavior that could be viewed as sexual, dangerous, exploitative, or physically harmful
to children.
***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of noncompliance is in error, you may
ask for reconsideration. The request for reconsideration must be in writing and delivered to the Department by certified mail
within twenty (20) business days of receipt of the notice of noncompliance. The request must specify the parts of the notice
that are alleged to be in error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty (20) days after
receipt of the request.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 3/12/2025
Provider Signature : Date: 3/12/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was sent to the emergency room for an assessment after receiving a laceration injury when another resident threw a dustpan.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028120
Date of Incident: 3/7/2025
Date Received: 3/10/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: ) was sent to
for assessment following an injury sustained when another
patient threw a dustpan. The nursing department assessed him and referred him out for
further treatment. The patient was
He was released to return to the facility without restrictions.
Interim Action Narrative: Client treated at hospital.
Narrative:
Licensing Narrative: 3/10/25-Reviewed for licensing concerns.
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summary: A resident reported that a staff member grabbed the hood of his hoodie while he was running, resulting in three petechiae marks on the front of his neck. The facility was cited 109.1.g for Unprofessional Conduct.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027607
Date of Incident: 2/16/2025
Date Received: 2/17/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type:
Report Description: ( , Parent Custody, ) reported
that staff member grabbed the hood of his hoodie while he was running
around in the living unit, which resulted in three petechiae marks on the front of his neck.
Nursing notes indicate that the three petechiae marks are approximately 2 inches long. Staff
was immediately placed on administrative leave pending the results of the
external investigation. . The
Interim Action Narrative: A/O placed on administrative leave pending
investigation.
Narrative: AV is AO/caretaker is (staff).
PRFC is . reported that staff member grabbed
the hood of his hoodie while he was running around in the living unit, which resulted in
three petechiae marks on the front of his neck. Nursing notes indicate that the three
petechiae marks are approximately 2 inches in length.
Licensing Narrative: 2/18/25-Reviewed for licensing concerns.
. Email sent to facility to ascertain if there is video of this
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humanservices.arkansas.gov

incident and to send licensing all witness statements and nursing notes. Visit scheduled as
soon as inclement weather clears up. Email received from Chris Butler of Millcreek that
there is video and witness statements and nursing notes would be sent to licensing.
2/18/25-Witness Statements and Nursing Notes received and reviewed by licensing.
2/20/25-Facility visited. Video reviewed of incident. Licensing complaint founded. Facility
cited 109.1g and 905.9. 2/25/2025, facility filed an appeal on 2/25/2025 regarding standard
905.9.

Office of Placement and Residential Licensing Unit
Division of Provider Services and Quality Assurance
P.O. Box 1437, Slot S530, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.682.8155
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DR
FORDYCE AR 71742-7110
Licensing Specialist: Clayton DeBoer
Person In Charge: Ben Beasley
Record Visit Date: 2/20/2025
Home Visit Date: 2/20/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Regulation Number: 100.109.1.g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Finding Description: Staff engaged in behavior that could be viewed as physically harmful to children.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Action Due Date: 2025-02-16
Action Due Description: Staff placed on administrative leave pending investigation. If staff employment is
retained, staff will re-complete a full TCI Training.
Comply Date:
Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
Regulation Number: 900.905.9
Regulation Description: Physical restraints shall be performed using minimal force and time necessary. Physical
restraint means the application of physical force without the use of any device, for the purposes of restraining the
free movement of a resident's body. Briefly holding a child without undue force in order to calm or comfort, or
holding a hand to safely escort a child from one area to another, is not considered a physical restraint.
Finding Description: Staff failed to use minimal force when they restricted the free movement of a resident as
they picked the client off the ground and moved them to a chair.
Action Due Date: 2025-02-16
Action Due Description: Staff placed on administrative leave pending investigation. If staff employment is
retained, staff will re-complete full TCI Training.
Comply Date:
Narrative:
Facility visited in response to complaint 027607 that staff caused physical harm to a client during an incident.
Video reviewed of incident that occurred in the Deerfield cottage on 2/16/2025. The client goes to the front
door of the cottage and bangs the back of his head on the door. Staff can be seen grabbing the client by the
arm and begins to escort him, grabbing only his arm away from the door. The client drops to the floor as if
dead weight. The client is seen hitting himself in the face. Staff then picks the client up off the floor and
carries him, feet barely off the ground, and sits him in a chair. When staff is seen on video picking the client
up, it does appear there may be tension on the client’s hoodie. Staff did not use proper TCI techniques during
the incident, per facility management.
The facility is being cited109.1gfor“Unprofessional conduct in the practice of child welfare activities shall
include without limitation: (g) Engaging in behavior that could be viewed as sexual, dangerous, exploitative,
or physically harmful to children”as evidenced by the staff grabbing the client by the arm and picking them
up off the ground resulting in three petechiae marks on the front of his neck and905.9“Physical restraints
shall be performed using minimal force and time necessary. Physical restraint means the application of
physical force without the use of any device, for the purpose of restraining the free movement of a resident's
body. Briefly holding a child without undue force in order to calm or comfort them or holding a hand to safely
escort a child from one area to another, is not considered a physical restraint”as evidenced by the staff
failing to use minimal force when they restricted the free movement of a resident as they picked the client off
the ground and moved them to a chair.
Licensing complaint has been founded.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20)days after receipt of the request.
Provider Comments: At Millcreek Behavioral Health, we remain steadfast in our commitment to the safety
and well-being of our residents and the integrity of our team. Our staff are trained to prioritize de-escalation
and safety interventions that align with best practices and regulatory standards.
In this instance, the staff member attempted to ensure the safety of a patient with an extensive history of self-
injury and aggression toward staff. This included responding with self-defense measures and utilizing a
physical escort to move the patient to a safer location—without wholly restricting the patient’s freedom of
movement. What is being labeled as a physical restraint refers to a brief hold lasting approximately four
seconds, during which the patient was moved about 10 feet to remove them from the potential for direct harm
from another escalated patient.
While another staff member was present on the unit, they were actively engaged in de-escalating another
patient at the time. Given the circumstances, the staff member involved made the decision she could with the
resources available to her in that moment. There was no intent to harm the patient. However, she did not use
an intervention method included in her initial training and acted independently, outside the scope of our
policies and expectations. This individual had successfully completed all pre-employment screenings, passed
extensive background checks, and underwent rigorous training to meet our high standards. However, her
actions deviated from those standards. As a result, the staff member must complete Therapeutic Crisis
Intervention recertification before returning to her assigned role.
Millcreek Behavioral Health remains committed to maintaining a safe, respectful, and nurturing environment
for all residents and ensuring our staff uphold the highest standards of care.
CCL Staff Signature : Date: 2/20/2025
Provider Signature : Date: 2/20/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident received a laceration to his elbow after being pushed by a peer. The resident was transported to the Emergency Room for treatment and returned to the facility afterward with no restrictions.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027538
Date of Incident: 2/11/2025
Date Received: 2/12/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , PRTF, , Parent Custody) was in
the hallway and another client pushed him. fell into the bathroom door. He was sent to
for the laceration on his elbow.
. He was sent back to Millcreek with no restrictions and to return
to normal activity.
Interim Action Narrative: Client taken to
Narrative:
Licensing Narrative: 2/12/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for a CT scan. The resident returned to the facility afterward.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027479
Date of Incident: 2/7/2025
Date Received: 2/10/2025
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: PRTF, state custody, ) went to
to check for . The CT came back normal and did not
find . then sent
back to Millcreek.
Interim Action Narrative: Client was taken to .
Narrative:
Licensing Narrative: 2/11/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov