summary: A resident was sent to Forrest City Medical Center due to suicidal gestures and verbalizing a suicide plan.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023502
Date of Incident: 8/23/2024
Date Received: 8/26/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest
City Medical Center ER by order of Psychiatrist due to suicidal gestures and verbalizing a
suicide plan. Resident admitted to Perimeter Acuter, West Memphis AR 08/26/2024.
Interim Action Narrative: Resident was evaluated at FCMC and admitted into acute care.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documenation for this incident will has been uploaded. Facility reported
the plan is for the resident to return from acute care. A safety plan will be implemented
starting with a CSSR along with additional precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


state: AR

facility_name: Perimeter Behavioral of Forrest City

summary: A resident was sent to Forrest City Medical Center for an x-ray of his right hand due to complaint of pain resulting from an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023426
Date of Incident: 8/23/2024
Date Received: 8/23/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out to Forrest City
Medical Center for x-ray to his right hand due to complaint of pain. Resident states hand
pain is a result of a fight last week. Resident returned to the milieu, same day, 1459 (2:59
pm) with no issue.
Interim Action Narrative: Resident was evaluated at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was sent to Forrest City Medical Center for an x-ray of his left hand due to complaints of pain following a fight with another resident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023427
Date of Incident: 8/22/2024
Date Received: 8/23/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out to Forrest City
Medical Center for x-ray to his left hand due to complaint of pain. Resident states hand pain
started last week during a fight with another Resident. Resident returned to the milieu,
same day, 1459 (2:59 pm) with no issue.
Interim Action Narrative: Resident was evaluated at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provdier reported incident for licensing concerns.
Facility provided documentation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray of his right hand after he was injured in an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023424
Date of Incident: 8/22/2024
Date Received: 8/23/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest
City Medical Center for x-ray to his right hand due to complaint of pain. Pain started after a
brief fight with a Resident. Bullying behaviors have since been addressed. Resident returned
to the milieu, same day, 1330 (1:30 pm) with no issue and bandage wrap.
Interim Action Narrative: Resident was evaluated at FCMC and placed on activity
restriction.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this incident. Resident was placed on activity
restriction.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his inner thigh due to redness, swelling, and irritation.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023314
Date of Incident: 8/18/2024
Date Received: 8/19/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City Medical Center
for further evaluation to his inner thigh due to redness, swelling, and irritation per order of
APRN. Resident returned to the milieu, same day, 1750 (5:50 pm) with no issue.
Interim Action Narrative: Resident was ordered to be evaluated at FCMC by APRN.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this incident that will be reviewed. 8/20/2024, Program
Coordinator reviewed documentation provided by the facility and uploaded document.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to perform a Buildings and Grounds walkthrough. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 8/16/2024
Home Visit Date: 8/16/2024
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Licensing completed a buildings and grounds walkthrough of the PRTF 100 unit, the SRP 200 unit, the 100
A/B dayrooms, and the gymnasium.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

The buildings have obvious signs of wear and tear to include paint missing beside a resident's bed from the
resident picking at it, doors with damage around the bottom, and tiles that are chipped in the showers.
Licensing spoke to the facility Program Director who stated that they have two full time maintenance crew
and one part time that are continuously trying to keep up with the building as it is aging. All areas viewed
today were clean and sanitary
Licensing encouraged the facility to make updates to the buildings to improve its appearance. Licensing will
return within the next three months to complete another walkthrough to view any improvements that have
been made.
MARS Reviewed at Nurses station 1- All initialed and up to date.
Provider Comments:
CCL Staff Signature : Date: 8/16/2024
Provider Signature : Date: 8/16/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: A resident was sent to Forrest City Medical Center after continued complaints of pain and discomfort in his right foot.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023366
Date of Incident: 8/10/2024
Date Received: 8/12/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident continued to complain of pain and appear to have further
discomfort in his right foot. After assessment from Nurse and Consultation with the Staff
APRN, resident was taken to Forrest City Medical Center for further physical care and
examination and foot was stabilized. Resident returned to facility for continued care and
monitoring of right foot.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing informed of provider reported incident via telephone.
8/14/2024, Licensing reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after complaining of pain to his right foot and difficulty walking from tripping while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023365
Date of Incident: 8/9/2024
Date Received: 8/13/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident was playing basketball and tripped and hurt his right foot and
complained of pain and difficulty walking. After assessment from Nurse and Consultation
with the Staff APRN, resident was taken to Forrest City Medical Center for an Xray and
further physical assessment and care. .
. Resident was set back to facility for continued care and observation of
Nurses. Given pain medications as needed and placed on activity restrictions for two days to
allow his ankle to rest and heal.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing informed of incident via telephone. 8/14/2024, Licensing
revewied provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that a staff member choked him in his room. The complaint was UNFOUNDED by Licensing.

raw_content:
ARK ANS A §S
DEPARTMENT OF

»-¢ Services

Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 023232
Date of Incident: 8/9/2024

Date Received: 8/13/2024

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

Report Description: fs made after allegation from resident that
staff choked him in his room on 300 8-8-2024. P| was accepted. Name of contact is

Interim Action Narrative: Staff suspended pending investigation.

Maltreatment Narrative: AV is approximately 13yo a. AO is age unknown

AV is currently at Perimeter Behavioral Health in Forrest City, Arkansas.
AO is an employee at the facility. AV reported that he and AO were in a heated argument
and AO choked him in his room at 2230 on 08AUG2024. AV stated he could breathe with no
problem.

Licensing Narrative: 8/13/2024, Program Coordinator was informed via telephone by CEO.
8/14/2024, Licensing looked in I: assinged
to contact the facility. 8/16/2024, Licensing followed up with
contact the facility. Permission granted. Program Manager visisted the facility and reviewed
camera footage. 8/20/2024, faciity provided documentation from the Staff
member will be retrained on de-escalation techniques. Program Coordinator request4ed
documentation of training once completed. 8/22/2024, facility provided documentation.
Case completed.

and requested permission
for permission to

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

ARKANSAS
) DEPARTMENT OF

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Chelsea Vardell
Person In Charge:

Record Visit Date: 8/16/2024

Home Visit Date: 8/16/2024

Purpose of Visit: Complaint Visit

Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Licensing visited the facility to discuss complaint case 023232.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Licensing reviewed camera footage dated for 8/11/2024 starting at 21:26. There are three staff on the unit and
residents can be seen standing in their doorways. At 21:28 the A/O can be seen entering the bedroom of
resident [M. and the A/V. The staff exits shortly and returns back into the room at 21:29. The facility
reports that the staff had entered the room because the A/V was starting to become upset with his roommate
and the A/O entered to keep distance between the two residents. The A/O can then be seen calmly exiting the
room at 21:30 along with the A/V as they appear to be calmly talking with one another. One staff, | hada
clear view of the bedroom as she was sitting in a chair outside the room and witnessed the A/V and A/O's
interactions. The video recording ends at 21:32.

Licensing obtained witness statements from the two roommates present in the room during the incident, the
A/O and staff on the unit.

The A/O began work at the facility on 6/10/24 and has had no other complaints made against him. The A/O
was trained in Handle with Care on 6/12/24.

The staff is currently placed on suspension pending the results of the investigation. Licensing is not prepared
to leave a finding at this time.

Provider Comments:

CCL Staff Signature : Date: 8/16/2024
Posy
Provider Signature : Date: 8/16/2024
) ne |
He WINE

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

ARKANSAS
) DEPARTMENT OF

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/21/2024

Home Visit Date: 8/21/2024

Purpose of Visit: Revisit Complaint

Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

No in-person licensing visit was completed on 8/21/2024.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Licensing received a complaint on 8/9/2024 for ELS Case #023232.

This complaint has been UNFOUNDED by Licensing.

Provider Comments:

CCL Staff Signature : Date: 8/21/2024
Mh A\\ Ih

’ V
Provider Signature : Date: 8/21/2024

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


summary: A resident alleged that a staff member hit him. The facility was cited 110.12 for late reporting.

raw_content:
Resident submitted a communication form on 8/28/2024 about a missing folder and
8/7/2024 about a snack. 9/4/2024, Program Coordinator discussed complaint and reviewed
camera footage with , Director of Quality Risk Management. Facility was cited
for 110.12. Case closed.


summary: A resident was sent to Forrest City Medical Center due to complaints of pain after falling while playing basketball in the gym.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022988
Date of Incident: 8/2/2024
Date Received: 8/5/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out to Forrest City
Medical Center for further evaluation to his left ankle per order of APRN. Resident fell while
playing basketball in the gym. Resident returned to the milieu, same day, 1030 (10:30 am)
with no issue.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 8/5/2024-Licensing emailed the facility for the resident's hospital
discharge paperwork. Facility states that the child did not go to the ER, but did go for an x-
ray appointment. The documentation of that x-ray has been uploaded to this case.
8/6/2024, Program Coordinator visited the facility to follow up on provider reported
incident. Resident was placed on activity restriction and reassessed on 8/5/2024.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after complaints of mouth pain resulting from an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022931
Date of Incident: 7/31/2024
Date Received: 8/1/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to Nurse
with complaint of pain in his mouth. He was sent out to Forrest City Medical Center for
further evaluation per order of APRN. Resident returned to the milieu, same day, 1407 (2:07
pm) with no issue.
Interim Action Narrative: Resident was assessed by the nurse and sent to FCMC for an
evaluation.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns and inquired about camera footage. Facility provided documentation for
this incident. Facility reported no camera footage being available. 8/6/2024, Program
Coordinator inquired about witness statements. Facility reported they are still working on
obtaining documentation. Facility also reported that resident had an altercation with a peer
over a remote. 8/12/2024, Program Coordinator followed up with facility regarding witness
statements. 8/13/2024, facility provided witness statements. 8/14/2024, Program
Coordinator reviewed witness statements.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after he was hit in the nose by a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022856
Date of Incident: 7/28/2024
Date Received: 7/29/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was in a physical altercation
with a peer and hit in the nose. He was sent out to Forrest City Medical Center for further
evaluation. Residents were separated and interviewed by Safety Team. Resident returned to
the milieu, same day, 2235 (10:35 pm) Resident placed on activity restriction until reassessed
by APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/29/2024- Requested nursing notes and hospital discharge
paperwork. 7/30/24- Received documents from the facility. 8/2/2024, Program Coordinator
inquired about camera footage and precautions 8/6/2024, Program Coordinator visited the
facility to follow up on provider reported incident. Facility reported residents were placed on
peer restriction.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A report alleged that a staff member allowed a resident to be punched on by another resident, resulting in bruises. The facility was cited 110.12 and 907.2 and received technical assistance for 110.9.a 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: 023712
Date of Incident: 7/27/2024
Date Received: 9/4/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: July 27th a
. Call was around a Staff member who allowed a Resident to be punched
on by another Resident intermittently resulting in bruises. Resident's referred to this as a
"punching game." Staff member did verbally address the Resident's and documented issue
but did not physically step in to further intervene.
Interim Action Narrative: Staff member was suspended pending investigation.
Maltreatment Narrative:
The AV is currently at Perimeter Behavioral of
Forrest City. The AV has bruises on his left arm and stated it was from playing football. It
was found that the AV was being punched by another resident. The AO witnessed the AV
being punched and did not intervene. The facility has this incident on camera.
Licensing Narrative: Program Coordinator was informed of complaint during another visit.
Facility was encouraged to enter complaint into ELS and provide documentation. Program
Coordinator followed up with facility for more information. 9/5/2024, facility reported there
is camera footage of this incident. Program Coordinator will schedule and day and time to
review camera footage. 9/6/2024, Program Coordinator reviewed camera footage. Facility
provided an email regarding findings. Facility will be cited for standards 110.9.a T/A, 110.12,
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

and 907.2. 9/9/2024, Program Coordinator checked case unsubstantiated. Facility
provided training documentation. 9/20/2024, Case completed.


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

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022814
Date of Incident: 7/25/2024
Date Received: 7/26/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was in a physical
altercation with a peer while playing dodge ball in the gym. This resulted in swelling to his
face and head. He was sent out to Forrest City Medical Center for further evaluation.
Resident returned to the milieu, same day, 1815 (6:15 pm).
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 7/26/20524- Licensing emailed the facility for the discharge
information from the hospital. 8/2/2024, Program Coordinator inquired about camera
footage and precautions. 8/6/2024, Program Coordinator visited the facility to follow up on
provider reported incident. Residents were placed on peer restriction.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022631
Date of Incident: 7/16/2024
Date Received: 7/17/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was involved in physical
altercation with peers and after compliant of pain. After consultation between Nurse and
APRN resident was sent to Forrest City Medical Center for X-RAY and further medical
evaluation after he was evaluated by the Nurse. Resident and
given medical screening exam no further from
FCMC. Sent back to facility for continuance of care by Nurses.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing received the serious occurrence form via email. 7/17/2024,
Program Coordinator reviewed provider reported incident for licensing concerns. Program
Coordinator inquired about camera footage, location of abrasion, and documentation.
7/18/2024, facility reported there is camera footage and the abrasion is located on the
resident's face.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022398
Date of Incident: 7/2/2024
Date Received: 7/3/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was in a physical altercation
with a peer. This resulted in an injury and he was sent out to Forrest City Medical Center for
further evaluation. Resident returned to the milieu, same day
. He was also
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 07/08/24 inquiry sent. 07/09/24 video footage has been saved. Body
check uploaded. 07/18/24 inquired again about direct care staff as that information was not
provided with the body check/nurse's notes. Agency responded: Staff were on site and
utilizing Handle With Care PRT. No citations.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to review children’s records. Technical assistance was provided for 903.5.d for treatment plans that did not contain a plan to meet the educational needs of the residents.

raw_content:
DB ARKANSAS
\ DEPARTMENT OF

MAN
y b¢ cemveces

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Chelsea Vardell
Person In Charge: Antoine Jackson
Record Visit Date: 7/2/2024

Home Visit Date: 7/2/2024

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Number: 900.903.5.d
Regulation Description: The child's treatment plan shall contain, at the minimum:

Finding Description: All treatment plans reviewed did not contain a plan to meet the educational needs of the
resident on the treatment plan.

Action Due Date:
Action Due Description:
Comply Date:

Sub-Regulation Level 1 Description: A plan to ensure that the child's educational needs are met according to
applicable state law;

Action Due Description:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Licensing specialist and program manager visited the facility and reviewed 6 children's records to include:

04. (g)- No treatment plan or treatment plan reviews in the chart. The

facility was able to produce signed copies of the treatment plan and reviews which were then added to the
chart.

All required information was reviewed within in the children's records to include restraint packets and
physician's orders.

It was noted during the review that all master treatment plans do not contain a plan to ensure the educational
needs of the child are met as required in standard 903.5.d. Program manager and licensing specialist discussed
this with management at the facility. The facility management reports they will request to add educational
goals to the treatment plan from corporate. The facility reports they were following guidance separating
educational reports from the treatment plan from other entities.

T/A provided for standard 903.5.d

Provider Comments:

CCL Staff Signature : Chelera Ve anrXtele Date: 7/15/2024
Provider Signature : Dr ai (etter of Buuliiey ash Mar Date: 7/15/2024

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


summary: A resident engaged in self-injurious behaviors by collecting a small piece of broken glass from a clock and asking three of his peers to cut him after attempting to cut himself.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022344
Date of Incident: 6/29/2024
Date Received:7/1/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident, , engaged in self-injurious
behaviors by collecting a small piece of broken glass. Resident asked three other Residents
to cut him after attempting to cut himself. Two rejected his request and one decided to after
trading the request for a snack. The cut resulted in bleeding, and the Resident was
transported to Forrest City Medical Center. All clocks have been reviewed to ensure no
residual glass is present. Existing glass will be removed from the clocks. Resident is
currently on line of sight supervision. Resident and peer who performed the cut have been
separated and Hall?s changed. Resident and peer were interviewed separately by the Safety
Team. Residents were asked how likely they were to self-harm again and/or ask any
Resident for assistance to which they both replied, ?they do not know.? Psychoeducation
around self-harming/self-harm ideations, as well as bodily injuries was completed by the
Clinical Director and Director of Nursing. Both Residents also were also assessed by their
Therapist 07/01/2024. Both Residents will undergo daily body checks by the Nursing team
to assess for any self-harm injuries until further notice.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: LS conducted follow up on 07/03/24 since there was not time during
on site visit of 07/02/24 as other matters took precedence. 07/03/24 agency declared the
clocks have been replaced. No citations.


summary: A resident was transported to Forrest City Medical Center after engaging in self-injurious behavior by banging his head against a door.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022346
Date of Incident: 6/28/2024
Date Received:7/1/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident, , engaged in self-injurious
behavior by hanging his head against a door. This resulted in an injury and he was sent out
to Forrest City Medical Center for further evaluation. Resident returned to the milieu, same
day, at 1034 (10:3 am cst).
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A staff member was suspended due to an allegation from a former Resident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022695
Date of Incident: 6/24/2024
Date Received: 7/19/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: Staff member, , was suspended due to an allegation from a
former Resident.
Interim Action Narrative: Staff member was placed on suspension pending investigation.
Licensing Narrative: On 6/21/2024, Program Coordinator received notification via email
that inquired about a former resident and current staff member
Per email, the Quality Risk Director was to submit the serious
occurrence in ELS. 7/11/2024, Program Coordinator received a phone call from the facility
regarding this complaint and if staff member could return to work. At that time, Program
Coordinator was unaware that the provided was the wrong .
7/15/2024, Program Coordinator inquired for more information and was made aware of the
correct . 7/18/2024, facility reported resident's name and that he was
admitted on and discharged on . Facility was informed that
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

information previously provided by the on staff member was in reference to an
older pending out of and provided the name of the
and 7/19/2024, facility emailed Program Corodinator an email from the
stating the the case and inquired if staff member
could return to work. Facility was advised to enter the into ELS to be reviewed
by Licensing. 7/22/2024, Program Coordinator followed up with facility regarding training
documentation. 7/25/2024, training documentation received. 7/29/2024, Program
Coordinator discussed ICA with Program Manager. ICA was lifted and facility informed
that staff member could return to work. Complaint approved by Program Coordinator. Case
complete.


summary: A resident eloped from the facility before being returned by the Forrest City Police Department.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 022207
Date of Incident: 6/22/2024
Date Received:6/24/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident,
, eloped from Perimeter Behavioral
Forrest City for approximately one hour and forty-three minutes before being returned by
Forrest City Police Department, same day. A portion of the fencing was lifted up by another
Resident, and the Residents eloped. Camera review was conducted by the Safety Team.
Bars for fence re-baring have been ordered and the Safety team is evaluating all fencing to
ensure no other parts need to be re-bared. No outdoor recreation will commence until
fencing is completed (all recreation and physical activity will be in the gym. For Staff
involved, supervision expectations will be retrained on this week. A refresher on supervision
will be completed this week for all Staff.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 06/24/24 agency notified LS via email of this incident providing
additional documentation. 06/25/24 LS sent inquiry re missing youth. 06/25/24 agency
responded: After conferring with the Staff involved, Lead Staff, and reviewing the camera
again it was approximately six minutes. There was a headcount before the transition from
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

outside to the gym which is when Staff realized Residents missing and called Lead Staff.
6/28/2024, Program Coordinator called FCPD and was informed there was no report.


summary: Licensing visited the facility to review personnel records. No deficiencies cited.

raw_content:
Arkansas Department of Human Services
Placement & Residential Licensing Unit
Licensing Compliance Record
Agency Name: Perimeter Behavioral of Forrest City Person In Charge: Charlotte Lockhart
Address: 603 Kittle Rd., Forrest City, AR 72335 Phone: (870) 633-3200
Licensing Specialist: Eleanor White
Date of Visit: 06/18/24 Purpose of Visit: Personnel Records Review
STANDARD COMPLIANCE DATE
DISCUSSION/OBSERVATION
REVIEWED DATE CORRECTED
Time: 1:00 PM to 3:30 PM
Census: 58
Licensing Specialist reviewed the following 10 personnel records:
• -no discrepancies.
•
-no discrepancies.
• -no discrepancies.
• -background check
paperwork completed and present but was not properly submitted.
• -no
discrepancies.
• no discrepancies.
• no discrepancies.
• background check
paperwork completed and present but was not properly submitted.
• no discrepancies.
• no discrepancies.
Reviewed the following termed staff’s personnel records:
• -no discrepancies.
Records contained the required verifications, certifications, and documentation
per the MLS. Staff training is up to date to include 10 hrs. of SRU training.
T/A was given on the 2 new staff members whose background check paperwork
is present, completed, and notarized but was not submitted correctly to the
central registry per consulting with Cynthia Smith, PRLU Administrative
Analyst. The agency will be following up with Cynthia Smith to get these ran
and completed within 10 days. The agency will notify licensing once these
checks are completed. This agency has had a challenge with retaining an HR
Personnel Staff Member.
COMMENTS of Person receiving form
. Charlotte Lockhart, CEO 6/18/24 Eleanor White 06/18/24
PERSON SIGNING AS RECEIVING DATE LICENSING SPECIALIST DATE


summary: A resident was sent to Forrest City Medical Center for evaluation of his nose after he was hit while horseplaying with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021943
Date of Incident: 6/10/2024
Date Received:6/13/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident, 8 , was sent to Forrest City
Medical Center by order of APRN for further evaluation to his nose. Resident reported pain
after reporting stating he was ?hit in the nose while horseplaying? with a peer. Resident
returned to the milieu same day at 1332 (1:32 pm cst) with no other issues presented. D/C
paperwork from Forrest City Medical Center is forthcoming.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing made aware of incident via email. 06/18/24 reviewed
incident with agency while on site. No licensing concerns or violations to the MLS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A 5-year Validation survey was conducted from 06/03/2024 through 06/07/2024. Complaint #AR00033421, was not in compliance, all or in part, with deficiencies cited at N0142 and N0156.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
June 18, 2024
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, LLC
1521 Albert St.
Forrest City, AR 72335
Dear Ms. Lockhart:
On June 7, 2024, a Recertification, and Complaint Investigation survey was conducted at your facility
by the Office of Long Term Care to determine if your facility was in compliance with Federal
requirements for Psychiatric Residential Treatment Facilities participating in the Medicaid (Title XIX)
Program. This survey found that your facility had deficiencies requiring correction/substantial
correction prior to a revisit as specified in the attached CMS-2567.
Plan of Correction
A POC must be submitted within 10 calendar days of you receipt of the Statement of
Deficiencies. Failure to submit a POC may result in termination. Include a completion date for each
deficiency cited.
Theresa Forrest, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 320-6235
email to Theresa.Forrest@dhs.arkansas.gov.
Your Plan of Correction must also include the following:
a. Address how the corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
b. Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
c. Address what measures will be put into place or systemic changes will be made to ensure that the
deficient practice will not recur;
d. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must
be implemented, and the corrective action evaluated for its effectiveness.
Charlotte Lockhart - Woodridge Of Forrest City, Llc - - (AOLTC - PRTF OTC) Page 1]

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

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
A 5 year Validation survey was conducted from
06/03/2024 through 06/07/2024.
Complaint #AR00033421, was not in compliance,
all or in part, with deficiencies cited at N0142 and
N0156.
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
N 142 ORDERS FOR USE OF RESTRAINT OR N 142
SECLUSION
CFR(s): 483.358(c)
A physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must order the least
restrictive emergency safety intervention that is
most likely to be effective in resolving the
emergency safety situation based on consultation
with staff.
This ELEMENT is not met as evidenced by:
Based on record review and interview, the facility
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 1 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 1 N 142
failed to ensure an order for a physical and
chemical restraint were not received at the same
time for 5 (Clients #1, #4, #5, #8 and #9) case
mix clients.
The findings are:
1. Client #1 had diagnoses of disruptive mood
dysregulation disorder and attention deficit
hyperactivity disorder.
a. The "Physician Order Physical Restraint" form
dated 10/01/2023 was reviewed and read in part,
"Order date: 10/01/2023, Time of order: 1950
[7:50 PM]..., From: [Physician's Name]".
b. The "Physician Order Emergency Medication"
order form dated 10/01/2023 was reviewed and
read in part, "Today's date: 10/01/2023..., Time:
1950..., Benadryl 100 mg [milligram]..., Thorazine
50 mg..., From: [Physician's Name]".
c. The "Physician Order Physical Restraint" form
dated 11/05/2023 was reviewed and read in part,
"Order date: 11/05/2023, Time of order: 1445
[2:45 PM]..., From: [Physician's Name]".
d. The "Physician Order Emergency Medication"
order form dated 11/05/2023 was reviewed and
read in part, "Today's date: 11/05/2023..., Time:
1445..., Benadryl 50 mg..., Zyprexa 10 mg...,
From: [Physician's Name]".
2. Client #4 had diagnoses of generalized anxiety
disorder, attention deficit hyperactivity disorder
and post traumatic stress disorder.
a. The "Physician Order Physical Restraint" form
dated 05/04/2024 was reviewed and read in part
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 2 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 2 N 142
"Order date: 05/04/2024, Time of order: 0325
[3:25 AM]..., From: [Physician's Name]".
b. The "Physician Order Emergency Medication"
order form dated 05/04/2024 was reviewed and
read in part "Today's date: 05/04/2024..., Time:
0325..., Thorazine 25 mg..., Benadryl 25 mg...,
From: [Physician's Name]".
3. Client #5 had diagnosis of major depressive
disorder, severe with psychotic features, and
generalized anxiety disorder.
a. The "Physician Order Physical Restraint" form
dated 12/09/2023 was reviewed and read in part
"Order date: 12/09/2023, Time of order: 1949
[7:49 PM]..., From: [Physician's Name]".
b. The "Physician Order Emergency Medication"
order form dated 12/09/2023 was reviewed and
read in part "Today's date: 12/09/2023..., Time:
1949..., Benadryl 25 mg..., Thorazine 25 mg...,
From: [Physician's Name]".
4. Client #8 had diagnosis of major depressive
disorder, severe with psychotic features, and
generalized anxiety disorder.
a. The "Physician Order Physical Restraint" form
dated 04/01/2024 was reviewed and read in part
"Order date: 04/01/2024, Time of order: 2022
[10:22 PM]..., From: [Physician's Name]".
b. The "Physician Order Emergency Medication"
order form dated 04/01/2024 was reviewed and
read in part "Today's date: 04/01/2024..., Time:
2022..., Benadryl 25 mg..., Thorazine 25 mg...,
From: [Physician's Name]".
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 3 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 3 N 142
c. The "Physician Order Physical Restraint" form
dated 04/12/2024 was reviewed and read in part
"Order date: 04/12/2024, Time of order: 0927
[09:27 AM]..., From: [Physician's Name]".
d. The "Physician Order Emergency Medication"
order form dated 04/12/2024 was reviewed and
read in part "Today's date: 04/12/2024..., Time:
0927..., Benadryl 50 mg..., Thorazine 25 mg...,
From: [Physician's Name]".
e. The "Physician Order Physical Restraint" form
dated 04/26/2024 was reviewed and read in part
"Order date: 04/26/2024, Time of order: 1545
[3:45 PM]..., From: [Physician's Name]".
f. The "Physician Order Emergency Medication"
order form dated 04/26/2024 was reviewed and
read in part "Today's date: 04/26/2024..., Time:
1545..., Thorazine 25 mg..., Benadryl 50 mg...,
From: [Physician's Name]".
g. The "Physician Order Physical Restraint" form
dated 05/08/2024 was reviewed and read in part
"Order date: 05/08/2024, Time of order: 1805
[6:05 PM]..., From: [Physician's Name]".
h. The "Physician Order Emergency Medication"
order form dated 05/082024 was reviewed and
read in part "Today's date: 05/08/2024..., Time:
1805..., Zyprexa 10 mg..., Benadryl 50 mg
[milligram]..., From: [Physician's Name]".
i. The "Physician Order Physical Restraint" form
dated 05/17/2024 was reviewed and read in part
"Order date: 05/17/2024, Time of order: 1521
[3:21 PM]..., From: [Physician's Name]".
j. The "Physician Order Emergency Medication"
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 4 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 4 N 142
order form dated 05/17/2024 was reviewed and
read in part "Today's date: 05/17/2024..., Time:
1521..., Thorazine 50 mg..., Benadryl 50 mg...,
From: [Physician's Name]".
5. Client #9 had diagnosis of
a. The "Physician Order Physical Restraint" form
dated 10/08/2023 was reviewed and read in part
"Order date: 10/08/2023, Time of order: 1500
[3:00 PM]..., From: [Physician's Name]".
b. The "Physician Order Emergency Medication"
order form dated 10/08/2023 was reviewed and
read in part "Today's date: 10/08/2023..., Time:
1500..., Benadryl 50 mg..., Thorazine 50 mg...,
From: [Physician's Name]".
c. An "Emergency Safety Interventions" policy
was received on 06/04/2024 at 8:56 AM, it was
reviewed and read in part, "...The use of physical
restraint shall always be implemented, utilizing
the least restrictive measure to prevent a resident
from injuring self or others in an emergency
safety situation..., Medication is a crisis
intervention used to resolve an emergency safety
situation to contain severe, out of control
behavior, exacerbation of psychosis which is
likely to cause harm to the resident other
residents, or staff..., A written order from the
physician is required or the use of a physical
restraint, or emergency medication..., The
physician must order the least restrictive
emergency safety intervention that is most likely
to be effective in resolving the emergency safety
intervention based on the consultation with staff.
The ordering physician must sign the verbal order
within forty-eight (48) hours..."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 5 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 5 N 142
d. On 06/04/2024 at 3:00 PM, the Director of
Nursing (DON) stated the facility had "been
written for that before" when asked about getting
physical and chemical restraint orders at the
same time.
e. On 06/06/2024 at 2:24 PM, the DON was
asked when should a chemical restraint be
considered with a behavior incident. She stated
when a behavior continues to escalate in a
physical restraint. The Surveyor asked should a
physical restraint and chemical restraint be
ordered at the same time. She stated, "No."
N 156 ORDERS FOR USE OF RESTRAINT OR N 156
SECLUSION
CFR(s): 483.358(j)
The physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must sign the restraint or
seclusion order in the resident's record as soon
as possible.
This ELEMENT is not met as evidenced by:
Based on interview and record review the facility
failed to ensure physician's orders were signed
and, in the clients, record for 4 (Clients #4, #5, #8
and #10) case mix clients.
The findings are:
1. Client #4 had diagnoses of generalized anxiety
disorder, attention deficit hyperactivity disorder
and post-traumatic stress disorder.
a. Client #4's record of Emergency Safety
Interventions were reviewed, and the following
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 6 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 156 Continued From page 6 N 156
deficient practice was identified.
b. The "Physician Order Physical Restraint" forms
dated 04/01/2024 for the following times 1:40 PM,
2:23 PM, 3:52 PM, and 4:04 PM; 04/24/2024 for
7:25 AM; 05/02/2024 for 7:12 AM; 05/02/2024 for
7:15 AM; 05/04/2024 for 3:25 AM; 05/04/2024 for
3:25 AM; 05/08/2024 for 3:28 PM; 05/13/2024 for
9:27 AM were reviewed, the physician's signature
was absent and the order was not in the clients
record.
c. The "Physician Order Emergency Medication"
order forms dated 04/01/2024 for 4:05 PM;
05/02/2024 for 7:15 AM; 05/04/2024 for 3:25 AM;
and 05/13/2024 for 9:35 AM were reviewed, the
physician's signature was absent, and the order
was not in the clients record.
2. Client #5 had diagnoses of major depressive
disorder severe with psychotic features, and
generalized anxiety disorder.
a. The "Physician Order Physical Restraint" form
dated 05/11/2024 for 7:25 PM was reviewed, the
physician's signature was absent, and the order
was not in the clients record.
b. The "Physician Order Emergency Medication"
order form dated 05/11/2024 for 7:30 PM was
reviewed, the physician's signature was absent,
and the order was not in the client's record.
3. Client #8 had diagnoses of major depressive
disorder severe with psychotic features and
generalized anxiety disorder.
a. The "Physician Order Physical Restraint" forms
dated 04/01/2024 for 3:05 PM and 10:22 PM;
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 7 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 156 Continued From page 7 N 156
04/04/2024 at 12:30 PM; 04/05/2024 at 9:05 AM;
04/09/2024 for 8:52 AM and 12:40 PM;
04/10/2024 for 12:49 PM, 1:22 PM, and 5:54 PM;
04/14/2024 for 5:04 PM; 4/15/2024 for 8:06 AM
and 2:16 PM; 04/16/2024 for 8:50 AM;
04/18/2024 for 5:07 PM; 04/19/2024 for 12:26
PM; 04/23/2024 for 12:52 PM; 04/24/2024 for
4:32 PM; 04/27/2024 for 9:40 AM and 1:02 PM;
05/16/2024 for 2:14 PM; and 05/17/2024 for 3:21
PM were reviewed, the physician's signature was
absent, and the order was not in the clients
record.
b. The "Physician Order Emergency Medication"
order forms dated 04/05/2024 for 9:07 AM;
04/09/2024 for 9:05 AM and 12:41 PM;
04/10/2024 for 1:06 PM; 04/15/2024 for 8:12 AM;
04/16/2024 for 9:00 AM; 04/18/2024 for 5:13 PM;
04/19/2024 for 12:36 PM; 04/23/2024 for 12:53
PM; 05/16/2024 for 2:15 PM; and 5/17/2024 for
3:21 PM were reviewed, the physician's signature
was absent, and the order was not in the clients
record.
4. Client #10 had diagnoses of disruptive mood
dysregulation disorder and psychosis.
a. The "Physician Order Physical Restraint" forms
dated 04/21/2024 for 7:40 PM, and 05/17/2024 at
7:48 AM were reviewed, the physician's signature
was absent, and the order was not in the client's
record.
b. An "Emergency Safety Interventions" policy
was received on 06/04/2024 at 8:56 AM, it was
reviewed and read in part, "...A written order from
the physician is required or the use of a physical
restraint, or emergency medication...The ordering
physician must sign the verbal order within
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 8 of 9

PRINTED: 06/18/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
04L115 B. WING _____________________________ 06/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 156 Continued From page 8 N 156
forty-eight (48) hours..."
c. On 06/06/2024 at 2:24 PM, the Director of
Nursing (DON) was asked when the physician's
orders should be signed and put in the client's
record. She said, within 24 hours. The Surveyor
asked what was hindering the physician in signing
the orders. She said that when the nurses get the
orders, they are then scanned to the physician
where she signs them every morning. The DON
said she doesn't know what the reason is that the
orders haven't been signed, stating she has a
"whole stack" that needs to be signed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV711 Facility ID: 3012 If continuation sheet Page 9 of 9

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
June 26, 2024
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
Dear Ms. Lockhart:
On June 7, 2024, we conducted a Recertification and Complaint Investigation survey at your facility.
You have alleged that the deficiencies cited on that survey have been corrected. We are accepting your
allegation of compliance and have approved your plan of correction and presume that you will achieve
substantial correction by June 26, 2024.
We will be conducting a revisit of your facility to verify that substantial correction has been achieved
and maintained.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email
to: Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
Theresa Forrest, Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
tf
Charlotte Lockhart - Woodridge Of Forrest City, Llc -- -- (AOLTC-14) Page 1

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
July 10, 2024
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
Dear Ms. Lockhart:
During the Revisit Survey conducted on July 8, 2024, your facility was found to be in compliance with
program requirements. Please email the signed CMS 2567 Theresa.Forrest@dhs.arkansas.gov.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email to
Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
DPSQA/Office of Long Term Care
Survey and Certification Section
tf

PRINTED: 07/10/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
R
04L115 B. WING _____________________________ 07/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{N 000} Initial Comments {N 000}
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
A revisit was conducted on July 8, 2024, for all
deficiencies cited on June 7, 2024. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PYV712 Facility ID: 3012 If continuation sheet Page 1 of 1

doc_type: Complaint Survey


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

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021850
Date of Incident: 6/7/2024
Date Received:6/10/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City Medical Center by
order of APRN for further evaluation to his right hand due to pain and swelling. Pain and
swelling originated from Resident punching a wall. Resident returned to the milieu same
day at 1440 (2:40 pm cst) with no other issues presented.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 06/10/24 incident is being reviewed for licensing concerns. 06/18/24
reviewed this incident while on site with agency. Youth is doing well. No violations to the
MLS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center due to complaint of back and leg pain from a car accident while on pass.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021762
Date of Incident: 6/5/2024
Date Received:6/6/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City Medical Center by
order of APRN due to complaint of back and keg pain. The Safety team learned while
speaking with Resident and his Mother that while on pass, he and his mother were involved
in a car accident. Resident returned to the milieu same day at 1700 (5:00 pm cst) with
bandages and RICE instructions. No other issues presented.
Interim Action Narrative: Resident was sent to FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns. Facility provided documentation that has been uploaded. Facility
reported that resident is not on any restrictons due to resident having full range of motion
and no injuries.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after injuring his right hand while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021623
Date of Incident: 5/29/2024
Date Received: 5/31/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City
Medical Center by order of APRN for further evaluation and X-Ray of his right hand.
Resident accidentally injured his right hand while playing basketball. Resident returned to
the milieu same day at 1545 (3:45 pm cst) with no issues. Please see attached D/C
paperwork from Forrest City Medical Center. Resident is currently on activity until further
evaluation by APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/30/24 Agency sent LS White an email re this incident and the
following attachments: serious occurrence report and imagining report. 05/31/24 LS White
sent inquiry as to how this youth's hand is doing? 05/31/24 4:55 PM Agency responded: I
spoke with him today. He is fine. No licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after labs run at admission showed some low levels.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021690
Date of Incident: 5/29/2024
Date Received:6/4/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number:142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City Medical Center by
order of APRN for further assessment after his lab results reported some low levels.
Resident returned to the milieu same day at 1717 (5:17 pm cst) with no issues.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 06/04/24 LS White received notification of this incident via email
from the agency before it was entered into ELS and initiated inquiry. 06/04/24 Agency's
response: Apologies it is now entered into ELS. Perhaps the Nursing note, attached, could
further explain the occurrence. All Residents receive lab work upon admission, minimum,
and some of his levels were out of range (low). For further evaluation and abundance of
cation, he was sent out. None of the indicators were life threatening. I am also tagging our
DON who could further explain it as well. No licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for a psych evaluation due to self-harm behaviors, including wrapping a cable cord around his throat and stating “I want to die” for approximately one minute.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021589
Date of Incident: 5/29/2024
Date Received: 5/30/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City
Medical Center by order Physician for psych evaluation due to self-harm behaviors
including wrapping a cable cord around his throat and stating ?I want to die? for
approximately one minute. Red discoloration and one scratch noted with no other injuries.
Breathes even. Columbia Suicide Screening completed with a score of four. The
maintenance team has since put the cord backed further into the ceiling and blocked off
access to the cord from the ceiling. The cord?s necessity is being evaluated to determine if it
can be removed. Resident refused transportation to Forrest City Medical Center but was
transported via ambulance. Resident?s caseworker was at Forrest City Medical Center with
Resident. Resident was accepted into Acute (Perimeter Behavioral West Memphis) and
transport is expected today at 0800 (8:00 am cst) from Forrest City Medical Center.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/30/24 LS White sent inquiry re youth. 05/30/24 agency's response:
He most likely will return but this is not definite. A final decision will be made before
discharge from acute care. 05/30/24 LS White: Please keep us updated on his return to or
discharge from your program after acute treatment is completed. Thank you. No licensing
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

concerns at this time as agency acted within the MLS taking prompt action to ensure the
safety of this resident.


summary: A resident was sent to Forrest City Medical Center after rolling his right ankle while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021571
Date of Incident: 5/28/2024
Date Received: 5/29/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent to Forrest City
Medical Center by order APRN for further evaluation of his right ankle. Resident
accidentally rolled his ankle while playing basketball in the gym, swelling and pain noted.
Resident returned from Forrest City Medical Center at approximately 1600 (4:00 pm) with no
new issues. Resident is on activity restriction for a until 06/01 pending further evaluation by
APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/30/24 LS White initiated follow up with agency re youth's status.
05/30/24 Agency responded: Resident is doing well. I spoke with him yesterday evening
and reports no issues. The Resident was wearing proper footwear. There is a check
completed in the morning and before gym time. Our Residents just tend to treat their gym
time like a NBA Championship game and rolling ankles is not uncommon for frequent
basketball players. No licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after hurting his ankle by falling while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021535
Date of Incident: 5/24/2024
Date Received: 5/28/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City
Medical Center by order APRN for further evaluation of his right ankle. Resident
accidentally tripped and fell hurting his ankle while playing basketball in the gym, swelling
and pain noted. Resident returned from Forrest City Medical Center at approximately 1600
(4:00 pm) with no new issues. Resident is on activity restriction until further evaluation by
APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/28/24 Follow up for licensing concerns initiated. 05/28/24 Agency
reports: activity restriction lifted yesterday. He is doing fine. No concerns or violations to
the MLS found.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after injuring himself with a pencil.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021432
Date of Incident: 5/21/2024
Date Received: 5/22/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City
Medical Center by order APRN for further evaluation to his left arm. Resident injured
himself with a pencil from his pocket after being upset with a peer and began to tantrum,
escalating to self-harm behavior. The pencil was confiscated, and sweeps were conducted.
is on self-harm precautions until further evaluation. The second Resident is on assault
precautions. Both Residents are currently on line of sight supervision, as well as, peer
restriction until further evaluation. Camera footage reviewed and both Residents were
interviewed by the Safety Team. They both verbalized understanding the expectations
around peer restriction. Resident returned from Forrest City Medical Center at
approximately 1950 (7:50 pm) with no new issues, and wound cleansed. The Nursing
department bandaged wound upon return. PWound care ongoing by Nursing department.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/22/24 Follow up will be initiated when time permits as this is not
reportable. 05/23/24 it was verified that this youth was seen at the ER component of the
Forrest City Medical Center. Youth is doing better. No concerns as agency staff acted
within the MLS and implemented safety plan regarding this occurrence.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after injuring his right ring finger while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021363
Date of Incident: 5/17/2024
Date Received: 5/20/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent to Forrest City
Medical Center for further evaluation to his right ring finger after complaint of pain, slight
swelling noted. Resident describes playing basketball and the basketball hit his right ring
finger. Resident returned from Forrest City Medical Center at approximately 1746 (5:46 pm)
with no new issues. Resident on activity restriction until further assessment by
Nursing/APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: While on site this occurrence was verbally reviewed with agency. It is
reported that the injury is sport related and client is doing well and is on activity restriction
to prevent further injury. No licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident alleged a staff member slapped him after attempting an Emergency Safety Intervention (ESI).

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021325
Date of Incident: 5/15/2024
Date Received: 5/17/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: Resident, ,
? after attempting an ESI. Staff suspended .
. Resident, witness, and Staff
written statements collected and camera and Nursing note review conducted.
came out today and interviewed Resident and
witness (Resident?s roommate). was provided copies of all aforementioned
statements and documents. Outcome pending. Resident verbalizes feeling safe at this time
(05/17/2024).
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 05/20/24 LS White sent email to requesting
permission to begin the licensing investigation. 05/20/24 granted
permission therefore LS White conducted a camera review. 05/22/24 LS White will
complete the licensing investigation ASAP. Waiting for agency to provide additional
statements from staff who witnessed the restraint hold. Please note the actual restraint hold
was not captured on camera as it was facilitated in the youth's bedroom. At the time of
camera review on site the agency had only collected statements from residents witnesses,
the and the which are conflicting. The additional staff statements will help to
determine if there was any violations to the MLS. 6/172024,


summary: A resident reported that a staff member choked him. The facility was cited 109.1.g, and the staff member was terminated as a result of this incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021133
Date of Incident: 5/8/2024
Date Received: 5/9/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: Resident, , stated to Nurses that
The was immediately placed on suspension and is currently still on
suspension. The Resident?s and witnesses were interviewed by a member of the Safety
Team and their written statements were collected. Additionally, camera footage was
reviewed by the Safety Team. Based on our internal findings, the will be
terminated 05/09/2024. Resident verbalizes feeling safe at this time (05/09/2024).
Interim Action Narrative: Staff was terminated.
Maltreatment Narrative:
Licensing Narrative: Licensing follow up is in process. 05/13/24 LS White and LS Norton
completed camera footage review. See attached inspection. Licensing determines that this
complaint is founded based on the MLS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further assessment of his right foot after complaint of pain from playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021055
Date of Incident: 5/6/2024
Date Received: 5/6/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent by order of APRN to
Forrest City Medical Center for further assessment to his right foot after complaint of pain
after playing basketball. Resident returned to the milieu at 1415 (2:15 pm cst) with no issues
and no new complaints of pain. Resident is on activity restriction until released by APRN.
Orthopedic appointment pending.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/07/24 LS White will follow up with agency during in person visit.
No licensing concerns at this time. 05/13/24 during in person visit regarding another
incident LS White addressed this occurrence also. Agency reported that resident is doing
fine, no more complaints of pain, and has been released from activity restrictions. No
citations as agency acted within the MLS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after hurting his right hand while playing in the gym.

raw_content:
AR KAN S A S&S
DEPARTMENT OF

+4 HUMAN
<a¥ SERVICES

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

Notice of Serious Incident
Case Number: 020999
Date of Incident: 4/29/2024

Date Received: 4/30/2024

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

Report Description: PO hurt right hand while
playing in the gym, pain and swelling was noted. After consultation with APRN from Nurse
resident was sent to Forrest City Medical Center for assessment and X-Ray. Resident was
diagnosed with unspecified sprain of right wrist, initial encounter, contusion of right hand,
initial encounter. For treatment elastic bandage and RICE therapy recommend and sent
back to the facility for further care and treatment from the Nurse. In addition Ibuprofen
600mg oral tablet take every six hours as needed.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Facility reported having computer problems since 4/29/2024. Serious
Occurrence Reporting Form emailed to Licensing. 5/2/2024, Program Coordinator entered
incident into ELS.

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


summary: A resident alleged that a staff member squeezed him hard from behind like a bear hug until his face turned red, leaving marks across his chest. The facility was cited 907.2, 905.10, and 109.1.g, and the staff member was terminated 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: 021001
Date of Incident: 4/27/2024
Date Received: 4/30/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description:
Please see information
below: On Saturday, April 27, 2024, 6:30 PM,
wrote:
The call was made
because resident alleged that during lunch a staff member squeezed him from behind
resulting in marks across his chest. Internal investigation of the incident has taken place
. The staff involved has been suspended pending
investigation.
Interim Action Narrative: Staff member was placed on suspension pending investigation.
Maltreatment Narrative: AV is 13 yo . PRFC is Mother . AO
is staff member at Perimeter Behavioral in Forrest City. stated that on 4/27 he was
in the dining room and came up to him and squeezed him hard from behind like a
bear hug until his face turned red. did not mention if his breathing was affected.
said did this because wouldn?t sit down. has several
areas of petechiae on his chest due to this and starting to form bruises. It is unknown how
long ?s stay at Perimeter is, but he does not have a discharge date as of now.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Facility reported computer issues on 4/29/2024. Serious Occurrence
Reporting Form emailed to Licensing. 5/2/2024, Program Coordinator entered incident
into ELS. Program Coordinator checked CHRIS for name of investigator. 5/3/2024,
Program Coordinator contacted investigator for permission to contact the facility. Program
Coordinator requested for camera footage to be saved of the incident. 5/6/2024, Program
Coordinator followed up with investigator for permission ton contact the facility. Licensing
received permission to contact the facility. 5/7/2024- Program Manager and Licensing
Specialist visited the facility reviewed camera footage, nursing notes, and witness
statements. The facility was cited for 907.2, 905.10, 905.4.g, and 109.1.g. Staff was terminated
from the facility and the witnessing staff will be retrained.


summary: A resident was sent to Forrest City Medical Center after reporting swelling and pain of the right index finger.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 021000
Date of Incident: 4/26/2024
Date Received: 4/30/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Private Placement Resident reported
swelling and pain of the right index finger ad reports that it has been swollen for a week and
he does not know the origin of the pain and swelling. When asked why he waited so long to
report his injury, the resident was not able to give an explanation. No bruising was noted. It
is observed that resident may have PTSD from past ER visit that resulted in hospitalization
as to why he did not disclose injury earlier. After consultation with the APRN from Nurse
resident was sent to the Forrest City Medical Center. Findings from X-Ray was normal, soft
tissues are normal, no acute findings from the Medical Center.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Facility reported computer issues since 4/29/2024. Serious
Occurrence Reporting Form emailed to Licensing. 5/2/2024, Program Coordinator entered
incident into ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported an allegation of abuse that took place during an Emergency Safety Intervention (ESI). A staff member was terminated.

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: 020933
Date of Incident: 4/25/2024
Date Received: 4/26/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description:
due to allegation of abuse by resident that
resident reported took place during an ESI.
Corrective Actions Taken: Staff have been suspended pending investigation. Internal
investigation of the incident has taken place .
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/15/24 LS White sent an inquiry re the status of this youth and any
additional information regarding this incident. 05/20/24 during in person visit agency
reported this staff was terminated on 04/29/24 as she violated the agency's restraint hold
policy. Agency stated that staff-initiated restraint hold due to resident's repeated attempts to
break into the nurses station and attempting to damage property. No citations as agency's
staff acted within MLS 905.10. Physical restraint shall be initiated only by staff trained by a
certified instructor in a nationally recognized curriculum, and only to prevent injury to the
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

child, other people or property, and shall not be initiated solely as a form of discipline. The
agency shall maintain documentation that staff is deemed competent in physical restraint.
The facility reports that no witness statements were gathered regarding the incident.


summary: A resident was left unsupervised after he hid from staff behind his bedroom door as they were transitioning the hall residents to the cafeteria for breakfast. The facility was cited 907.2 as a result of this incident.

raw_content:
There is no camera footage as resident hid behind his bedroom door from staff and was left
unsupervised while the rest of the hall transitioned to cafeteria. 05/20/24 LS White
completed an in person follow up on this incident. The incident was not reportable per MLS
109.17: The agency shall notify the Licensing Unit by the next business day of serious
injuries requiring emergency medical treatment, agency vehicle accidents, arrests,
elopements, suicide attempts, or deaths and maintain documentation of the incident and
notification. However, since the facility acknowledged the incident as ?an incident of safety
and supervision oversight? and called the hotline ?due to safety and supervision issue of the
resident where resident was left unsupervised" they are in violation of MLS 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.

Arkansas Department of Human Services
Placement & Residential Licensing Unit
Licensing Compliance Record
Agency Name: Perimeter Behavioral of Forrest City Person In Charge: Charlotte Lockhart
Address: 603 Kittle Rd., Forrest City, AR 72335 Phone: (870) 633-3200
Licensing Specialist: Eleanor White
Date of Visit: 05/20/24 Purpose of Visit: complaint and PRI follow ups.
ELS Case 020934
STANDARD COMPLIANCE DATE
DISCUSSION/OBSERVATION
REVIEWED DATE CORRECTED
Time 1:00 PM to 3:00 PM
Census: 54
Licensing Specialist Eleanor White reviewed the following incident with Immanuel
Morris, Director of Quality and Risk Management.
On 04/25/24 Resident hid from staff behind his bedroom door as they were
transitioning the hall residents to the cafeteria for breakfast. Resident was left
unattended for approximately 19 minutes in his room There are no cameras in
the bedrooms therefore no camera footage to review. An incident of safety and
supervision oversight
Agency initiated and verified with licensing the following corrective actions: 1) an
internal investigation of the incident to include
2) all staff involved were given a corrective action write up 3) all
staff involved were trained/retrained in safety and supervision of residents and
signed training competency form in understanding of the supervision oversight.
MLS 109.17 states "The agency shall notify the Licensing Unit by the next
business day of serious injuries requiring emergency medical treatment, agency
vehicle accidents, arrests, elopements, suicide attempts, or deaths and maintain
documentation of the incident and notification." This occurrence does not
categorically meet any of the reportable occurrences as outline in MLS 109. 17.
However, since the facility acknowledges the incident as “an incident of safety
and supervision oversight” “due to the safety and
supervision issue of the resident where resident was left unsupervised" they
violated MLS 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. N/C
COMMENTS of Person receiving form
Eleanor White 05/20/24
PERSON SIGNING AS RECEIVING DATE LICENSING SPECIALIST DATE


summary: A resident was sent to Forrest City Emergency Room due to psychosis with suicidal/homicidal ideations with intent. The resident was assessed and was transported for acute care.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 020859
Date of Incident: 4/24/2024
Date Received: 4/25/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Private Placement Date/Time of incident:
04/24/24 @ 1519 PM Client was sent to Forrest City ER with transportation due to
psychosis with suicidal/homicidal ideations with intent. Client was assessed and was
transported to Rivendell Acute for further evaluation and treatment.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 05/15/24 LS White sent inquiry re this occurrence and agency
responded as follows: Resident was admitted to Rivendell for acute treatment. Resident
returned back to PBFC 05/02/24 and has not presented these symptoms since. No licensing
concerns or citations to the MLS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 020796
Date of Incident: 4/22/2024
Date Received: 4/23/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent by order of APRN
to Forrest City Medical Center for further assessment to his face. Resident and peers were in
a physical altercation that resulted in a nose injury. The Resident and peers are peer
restricted. Room changes have been implemented as well as assault precautions. Resident
returned to the milieu at 2058 (8:58 am cst) with no issues and no new complaints of pain.
Resident is on activity restriction until released by ENT. ENT appointment is 04/29/2024
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 04/23/24 LS White received notification of this incident from the
agency. Inquiry was sent as to what caused the altercation between the residents and what
action had been taken to prevent any further occurrences. Agency responded as follows: it is
not known what caused the fight but they have been on peer restriction. 05/15/24 LS White
conducted a final follow up and agency reported resident is recovered and is doing fine.
No licensing concerns or violations to the MLS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov