report_id: M2022-552 Notice of Intent

summary: Enforcement

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
SECRETARY OF HEALTH
In the Matter of No. M2022-552
NOTICE OF INTENT TO
DAYBREAK YOUTH SERVICES " SPOKANE SUSPEND
License No. BHA.FS.60873305
Respondent
Pursuant to RCW 43.70.115, the Executive Director of the Department of Health
(Department), Behavioral Health Agencies Program (Program), on designation by the
Secretary, having authority to regulate Behavioral Health Agencies (BHAs) under chapters
71.05, 71.24, and 71.34 RCW, and chapter 246-341 WAG, hereby provides Notice of intent
to Suspend License No, BHA.FS,60873305 and a!! certifications associated with License
No. BHA.FS.60873305. This Notice will take effect and become a Final Order, without
further notice, twenty-eight (28) days after receipt, absent a timely request for an
adjudicative proceeding. This Notice is based on the following findings of fact and
conclusions of law.
1. FINDINGS OF FACT
1.1 The Program is a sub-unit of the Department with authority to license and
regulate BHAs, The Program's authority to license and regulate BHAs is found at
RCWs 71.05, 71.24, and 71.34, and WAC 246-341, and includes authority to examine any
part of the BHA at reasonable times and as needed; review and evaluate the BHA's records,
including clients' clinical records and staff personnel fifes; review the BHA's po!icies,
procedures, fiscal records, and other documents; and to interview staff members and
individuals receiving sen/ices. RCW 71 .24.037 (3) and (11 ), WAC 246-341-0605 (3) (a) - (c).
1.2 On June 28, 1984, the State of Washington issued Daybreak Youth
Semces - Spokane, located at 628 S Cowley St., Spokane, WA 99202
(Daybreak-Spokane), license no. BHA.FS.60873305 to operate as a BHA.
Daybreak-Spokane's BHA license is currently active.
1.3 Daybreak-Spokane is a non-profit BHA currently licensed and certified to
provide a number of inpatient and outpatient services. In addition to being required to
NOTICE OF iNTENT TO SUSPEND . ., ;. PAGE 1 OF 11
NO.M2022-552 nDir
comply with state licensing laws, Daybreak must also comply with 42 USC § 290dd-2 and
42 CFR Part 2 (Part 2).
1.4 Part 2 is a federal law that protects the confidentiality of substance use
disorder (SLID) records and information En the possession of Part 2 covered programs,
such as Daybreak-Spokane, and in the possession of other lawful holders, in general,
Part 2 prohibits Part 2 covered programs from disclosing Part 2 covered records and
information without patient consent. However, Part 2 permits Part 2 covered programs to
disclose Part 2 covered records and information to state agencies "authorized by law to
regulate the activities of the Part 2 program." 42 CFR § 2.53 (b)(2)(i). The Program is
authorized by law to regulate the activities of Daybreak-Spokane. Daybreak-Spokane is
therefore permitted to allow the Program to review, copy, remove, download, or forward
patient records so long as the Program agrees in writing to comply with the conditions
outlined in 42 CFR § 2.53(b)(1).
1.5 On or about February 10, 2022, the Program assigned an investigation of
Daybreak-Spokane to Program Investigator Deborah (Deb) Duke (investigator Duke).
The investigation (case no. 2022-1233) was based on a report from Department of
Children, Youth and Families Child Protective Services (DCYF/CPS) regarding
concerns of serious staff-to-client boundary violations by a staff person at
Daybreak-Spokane, Staff Member A. !n March 2022, the Program received a second
complaint from theSpokane Police Department regarding the same staff-to-patient
boundary violations, and a second investigation (case no. 2022-4048) was
subsequently assigned to Investigator Duke in response to it. As part of its
investigations, the Program informed Daybreak-Spokane in writing that the Program
would comply with the conditions in 42 CFR § 2.53(b)(1) to protect Part 2 covered
records and information obtained from Daybreak.
1.6 Staff Member A was hired by Daybreak-Spo.kane as a skEils coach in
November 2021. Staff Member A's duties included daily contact with minor female
patients at Daybreak-Spokane.,
1.7 During emp!oyment at Daybreak-Spokane, Staff Member A allegedly
engaged in inappropriate contact and boundary violations with minor female dients. The
conduct started on or around Staff Member A's start date with Daybreak-Spokane, and
included, but was not limited to:
NOTICE OF INTENT TO SUSPEND PAGE 2 OF 11
NO. M2022-552
A, A visit to Daybreak-Spokane on or about December 8, 2021 to "hang
with the girls," i.e., minor clients at Daybreak-Spokane, on Staff Member A's
day off. This visit resulted in counseling by Daybreak-Spokane.
B. A grievance filed by Client A on December 29, 2021 with
Daybreak-Spokane detailing Staff Member A hugging Client A and using
"prison sign language" to say he loved her.
C. A report on or about January 19, 2022 that Staff Member A
engaged with Client B via Staff Member A's personal social media
account.
D. Asking clients for hugs and talking to them about their bodies.
When rebuffed by a client who did not want to be hugged, Staff Member A
became confrontational.
E. Sharing lunch trays with ciients.
F. Telling clients that grievances had been filed against him by clients.
G. Telling a client that an implant in her arm was "disgusting."
H. "Siut-shaming" clients by commenting about their clothing choices.
1.8 In response to clients' grievances regarding Staff Member A's alleged
misconduct, Staff Member A aliegedly engaged in retaliation and bullying against minor
female clients.
1.9 Following reports of Staff Member A's alleged behavior and concerns with
the quality of care and/or management and oversight at Daybreak-Spokane, the idaho
Department of Health and Weifare suspended ali referrals to Daybreak.
1.10 On information and belief, on or about January 19, 2022, Daybreak-Spokane
initiated an internal investigation regarding Staff Member A)s alleged misconduct. Though
this internal investigation showed a concerning pattern of misconduct, the conclusion of
the investigation was that Staff Member A had not violated Daybreak-Spokane's code of
ethics. Staff Member A remained employed by Daybreak-Spokane and had continued
access to minor dients.
1,11 DaybreakdEd not report any of the above complaints or concerns, or
subsequent complaints and concerns, regarding Staff Member A to the Program.
1.12 The Program conducted its first on-site investigative visit to
Daybreak-Spokane on or about March 8-9, 2022. Daybreak-Spokane was cooperative
NOTICE OF INTENT TO SUSPEND PAGE 3 OF 11
NO. M2022-552
during this visit and provided the Program access to Staff Member A's training records
and improvement plan. The Program conducted a second on-site investigative visit to
Daybreak-Spokane on or about April 11-12, 2022, during which the Program
interviewed Staff Member A. Daybreak-Spokane was cooperative during this
investigative visit, as well.
1.13 On or about May 9, 2022, the Program met virtually with members of
Daybreak's management team to discuss the next steps in the Program's investigations.
During this meeting, the Program requested access to, or copies of, the complete client
records for specified clients; access to ail grievances filed against Staff Member A; ail
supervision notes related to Staff Member A; and assistance with scheduling additional
Daybreak-Spokane staff interviews. At this meeting, Investigator Duke probed
Daybreak-Spokane on why client and staff complaints about Staff Member A were not
reported to the Program.
1.14 Between May 9 and May 24, 2022, Daybreak-Spokane did not provide the
Program with the information the Program requested during the May 9, 2022 meeting.
Additionaiiy, Daybreak-Spokane did not facilitate staff interviews or client interviews. As
a result of Daybreak-Spokane's non-responsh/eness to the Program's investigative
requests, on or about May 24-25, 2022, Program investigators went on-site to
Daybreak-Spokane to continue to investigate Daybreak-Spokane's responses to the
alleged misconduct by Staff Member A and any related, alleged staff misconduct.
1.15 During prior investigations predating the Program's investigations arising
out of the allegations about Staff Member A, Daybreak-Spokane had provided Program
investigators with access to, or copies of, complete client records. During the
May 24-25, 2022 investigative visit, Daybreak-Spokane allowed the Program to review
parts of three dients' records, but Daybreak refused Program investigators access to
the complete client records. Program also requested copies of all grievances or
complaints regarding Staff Member A, and received only one En response to this
request. Program investigators left the facility due to a lack of cooperation by
Daybreak-Spokane, which prevented access to evidence requested in the investigation.
1.16 On or about May 26, May 27, June 2, and June 22, 2022,
Daybreak-Spokane, through counsel, stated that it intended to cooperate with the
Program's investigation. However, the stated intent to cooperate came with caveats.
NOTICE OF INTENT TO SUSPEND PAGE 4 OF 11
NO. M2022-552
The communications indicated that Daybreak-Spokane questioned the scope of the
Program's investigation and how the Program's request for access to records and
information was compatible with Part 2.
1.17 The Program directly addressed Daybreak-Spokane's questions regarding
the Program's investigations. On July 7, 2022, the Program sent Thomas (Tom) Russell,
Daybreak CEO, an investigative request letter, outlining the purpose of the Program's
investigation; the scope of the Program's investigation; the information to which the
Program required access in order to conduct its investigation; and the Program's legal
authority to conduct the investigation. In this letter, the Program, in writing, again
reiterated its commitment to abide by Part 2, specificaily listing the conditions identified
at 42 CFR § 2.53(b)(1 ). The letter informed Daybreak the Program would be re-initiating
its investigation on July 13, 2022.
1.18 On July 13,2022, investigator Duke emailed Daybreak CEO Mr. Russel!
and Daybreak employee Sandra Skok, notifying them the Program was continuing the
investigation of cases regarding aliegations of inappropriate staff behaviors at
Daybreak-Spokane. Investigator Duke requested the foliowing information, which was
needed to move the investigation forward:
» Copies of all complaints and grievances regarding any allegations of
inappropriate staff behaviors, including any behaviors that made dients
feel uncomfortable, from Juiy 1, 2021 to the present.
® A staff list with job titles and scheduling information, such as shifts and
days each person works, investigator Duke noted the Program intended to
be on-site for staff interviews.
* The entire client records for five, specifically identified clients.
1.19 On July 14, 2022, Daybreak, through counsel, responded to the Program's
July 13, 2022 email. Daybreak agreed to provide the Program's investigators access to
280 pages of documents and access to a "sma!! number of employees necessary for
DOH to conduct the review" described in the Department's July 7, 2022 letter. However,
Daybreak objected to parts of investigator Duke's investigative request, arguing it was
overly broad. Moreover, Daybreak declined to provide Investigator Duke all of the client
records requested, arguing the request was inconsistent with Part 2.
NOTICE OF INTENT TO SUSPEND PAGE 5 OF 11
NO. M2022-552
1.20 On July 18, 2022, Program investigators arrived at Daybreak-Spokane to
continue their investigation on-site. The Program's on-site investigation plan was to
obtain and/or review client records, interview staff, and interview clients receiving
services at Daybreak-Spokane on July 18 and 19. The Program's Investigative plan was
within the scope of its investigative authority and did not confiict with Part 2.
1.21 On July 18, 2022, the Program met with Daybreak-Spokane to attempt to
obtain the information and records it needed. The same day, Daybreak CEO Mr. Russe!!
emailed Investigator Duke to document a conversation they had regarding the
investigation. The email indicated the Program and Daybreak agreed about the scope of
the investigation, and Daybreak would provide the Program with the client records the
Program requested and would arrange staff interviews. However, Mr. Russell stated the
Department couid not interview clients without receiving their written consent, and
suggested the Program's and Daybreak's attorneys discuss the contents of a written
consent.
1.22 On July 18, 2022, the Program interviewed Director of Nursing Becky Pulito,
Mental Health Therapist Samantha Brown, and Admissions Manager Amanda Kerr.
Daybreak CFO Richard Reathaford and Daybreak Talent Acquisition Specialist Sachelle
McKenna attended the interviews. During the interviews, Mr. Reathaford interjected,
attempted to control the scope of the questioning, answered for an inten/iewee, and would
not allow interviewees to respond to questions he believed were, in his words, "he-said,
she-said" questions. Moreover, the Program did not receive any of the client records it
requested and were not allowed to interview clients, purportediy because of Part 2
restrictions.
1,23 On July 1 9, 2022, Program investigators arrived at Daybreak-Spokane at
6:15 AM. The Program's plan for the day was to conduct staff interviews, interview
clients, and review or obtain client records. The Program's July 19 investigation
unfolded as follows:
1.23.1 The Program first attempted to interview Team Leader
Nyneave Beach, with Mr. Reathaford and Ms, McKenna present. Shortly after the
Program began its interview, Mr. Reathaford interrupted, directing Nyneave Beach
to only answer questions related to policies, procedures, and processes.
Ms. Beach appeared confused, and stated that she couldn't answer the questions
NOTICE OF INTENT TO SUSPEND PAGE 6 OF 11
NO, M2022-552
without using "he-said, she said" information. Ms. Beach proceeded to answer
questions about select Daybreak processes and the interview concluded, but
Ms. Beach was unable to answer al! of the Program's questions due to
Mr. Reathaford's interference.
1.23.2 The next Daybreak staff member the Program interviewed
was Skills Coach Jessica Rose, Mr. Reathaford and Ms. McKenna were present.
Mr. Reathaforct again interrupted the Program's interview, arguing the scope of
the interview was limited to discussing policies and procedures oniy, which
truncated the interview.
1.23.3 The Program next attempted to interview Skiiis Coach
Joseph Aviia. Mr. Reathaford and Ms. McKenna were present. The Program
asked Mr. Avifa a question about staff-to-patient interactions that could make a
client fee! uncomfortable. At this question, Mr. Reathaford interrupted and
became confrontational with the Program. Mr. Reathaford argued that Mr. Avila
couid not answer the question because it called for specuiation, asking how
would Daybreak staff know what made a dEent uncomfortable. Mr, Reathaford
a!so argued the questions were outside the scope of the investigation.
Mr. Reathaford instructed Mr. Aviia to answer questions only about policies and
procedures, again making a thorough interview impossibie.
1.23.4 The next Daybreak staff member the Program attempted to
interview was Substance Use Disorder Professional Danica Skaiski.
Mr. Reathaford and Ms. McKenna were present. Mr. Reathaford interrupted the
interview, and directed Ms. Skalski to answer questions about poiicjes and
procedures only.
1.23.5 After the interview with Ms. Skaiski, investigator Duke spoke
to Mr. Reathaford about his conduct during the interviews. Investigator Duke
informed Mr. Reathaford that his ongoing interference with and interruption of
interviews was inappropriate, and that staff must be allowed to answer the
questions asked without his interference. Mr. Reathaford stated it was his role to
ensure the Program stayed within what Daybreak perceived to be the proper
parameters of the investigation. Mr. Reathaford told investigator Duke she was
being misleading to Daybreak staff, and she made them feel uncomfortable.
NOTICE OF INTENT TO SUSPEND PAGE 7 OF 11
NO. M2022-552
1.23.6 At about 1 1:00 AM, the Program's investigative manager
emailed Mr. Reathaford and instructed him to stop interfering with the Program's
interviews.
1.23.7 Investigator Duke and Mr. Reathaford spoke again about
Mr. Reathaford's conduct during the interviews. Investigator Duke asked him to
refrain from interrupting and interfering with interviews. Mr. Reathaford
responded that he was doing what he was there to do, which was to prevent the
Program from exceeding Daybreak's perceived scope of the investigation.
Mr. Reathaford stated he was directed to do this by Daybreak's attorney,
David Smith. Investigator Duke asked Mr. Reathaford, "...to be clear, you're
telling me that if you don't agree with the way things are said, you're going to say
something?" Mr. Reathaford responded he would interrupt and that it was his role
and obligation to do so. Mr. Reathaford stated, "I will not ailow questions to
deviate from policy and procedure," and for that reason he "politely re-directed
staff when they were attempting to answer questions" and would continue to do
so.
1.23.8 Mr. Reathaford's disruptive conduct and his promise to
continue to disrupt the interviews obstructed and would continue to obstruct the
flow of information. Such obstmctjve conduct compromised the reliability of the
staff inten/iews. For these reasons, the Program determined that continuing staff
interviews would not be fruitful.
1,23.9 The Program again requested to interview Daybreak-Spokane
clients. Daybreak denied this request, citing Part 2. Daybreak-Spokane's denia! of
access to interview clients prevents the Program from understanding how
Daybreak-Spokane staff behavior impacted client treatment and safety.
1.23.10 Daybreak-Spokane provided the Program 2450 pages of
hard-copy client records prior to the Program departing the facility on July 19.
However, instead of providing the complete client records as the Program had
requested, Daybreak provided only the records Daybreak deemed to be within
the scope of the Program's investigation.
//
NOTICE OF INTENT TO SUSPEND PAGE 8 OF 11
NO. M2022-552
1.24 Daybreak-Spokane's non-cooperation with the Program's investigations
and obstructive conduct during staff interviews has interfered with the Program's ability
to effectively continue its investigations of Daybreak-Spokane,
2. CONCLUSIONS OF LAW
Based on the foregoing Findings of Fact, the Department makes the following
Conclusions of Law:
2.1 The Secretary of Health, acting through his designee, has jurisdiction over
the licensee, Daybreak, and over the subject matter of this proceeding under
chapters 71.05, 71.24, and 71.34 RCW, and 246-341 WAC,
2.2 The Findings of Fact constitute violations of RCW 71.24.037,
WAG 246-341-0335(1 )(b) and (c), and WAC 246-341-0605(3).
2.3 The above violations demonstrate that Daybreak has failed to comply with
RCW 71.24 and 246-34.1 WAC.
2.4 Daybreak's failure to comply with ROW 71.24 and WAG 246-341 provides
grounds for the Department to deny, suspend, revoke, or place on probation Daybreak's
BHA license or specific program certifications underRCW43.70.115, chapters 71.05,
71.24, and 71.34 RCW, WAC 246-341-0335, and WAC 246-341-0605.
2.5 Daybreak's failure to comply with chapters 71.05, 71.24, 71.34 RCW, and
246-341 WAC provides grounds for the Department to assess a fee under ROW 43.70.250,
WAC 246-341-0335(5), and WAG 246-341-0605(5).
2.6 Daybreak has the right to contest a Department decision to deny, suspend,
revoke, or place on probation its BHA license by requesting an adjudicative proceeding
within twenty-eight (28) days of receipt of the Department's decision. RCW 43.70.115
chapter 34.05 ROW, chapter 246-10 WAG, and WAC 246-341-0335.
2.7 The Secretary may indicate when and under what circumstances an order
may become an effective Fina! Order. ROW 43.70.115(2) and RCW 34.05.461.
3. NOTICE OF SUSPENSION
Based on the above Findings of Fact and Conclusions of Law, the Secretary,
through his designee, enters the following:
3.1 Daybreak's License No. BHA.FS. 60873305 and associated certifications
are SUSPENDED INDEFINITELY. The SUSPENSION shall immediately be stayed for
14 days after this Notice becomes a Final Order.
NOTICE OF INTENT TO SUSPEND PAGE 9 OF 11
NO. M2022-552
3.2 Within 7-days after the Notice becomes a Final Order, Daybreak shaf!
submit a closure plan for its BHA, which includes: Information pertaining to the patient
census, case mix, and acuity of clients; explanation of plan to relocate patients to
appropriate care settings that offer similar services, including resources daybreak will use
to support client movement and identification of facilities who have agreed to receive
patients; plan to preserve and transfer client medical records; strategy for notifying clients
and their legal guardians of the license suspension and requirement to transfer patients;
and an explanation of the process for managing pharmacy records and controlied
substances. The closure plan shall be submitted by email to: lan Corbridge, Director,
Office of Community Health Systems, lan.Corbridae(5)doh.wa.gov.
3.3 This Notice will become a FINAL ORDER without further notice twenty-eight
(28) days from the date of receipt, absent a timely request for an adjudicative proceeding,
4. REQUEST FOR AN ADJUDICATIVE PROCEEDING
If you wish to contest the Department's decision in this matter, you or your
representative must file a written request with the Department's Adjudicative Service
Unit (ASU) in a manner that shows proof of the service on the ASU within TWENTY-
EIGHT (28) days of receipt of this decision. Please use the enclosed form labeled
"Application for AdjudEcative Proceeding." '
The mailing address is: The physical address is:
Department of Health Department of Health
Adjudicative Service Unit AdJudicatEve Service Unit
P.O. Box 47879 310 Israel Road SE
Oiympia,WA 98504-7879 . Tumwater, WA 98501
A copy of the Department's decision must be attached to the Application for an
Adjudicative Proceeding. FILING SHALL NOT BE DEEMED COMPLETE UNTIL THE
ASU ACTUALLY RECEIVES THE APPLICATION.
//
//
NOTICE OF.INTENTTO SUSPEND PAGE 10 OF 11
NO. M2022-552
You or your representative's FAILURE to submit an Application for an
AdjudEcative Proceeding within TWENTY-EIGHT (28) days of receipt of this decision will
constitute a waiver of. the right to a hearing; the Department may decide this matter
without you or your representative's participation and without further notice.
n. 8/1,
DATED: ,2022.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
BEHAVIORAL HEALTH AGENCY PROGRAM
lan Corbridge (Aug 1,2<rf2 10:00 PDT)
iAN CORBRIDGE
DIRECTOR
OFFICE OF COMMUNITY HEALTH
SYSTEMS
BEHAVIORAL HEALTH AGENCY PROGRAM
NOTfCE OF INTENT TO SUSPEND PAGE 11 OF 11
NO. M2022-552

inspection_number: M2022-552 Notice of Intent


state: AR

facility_name: Centers for Youth and Families - Little Rock

summary: Officers responded to the facility for a welfare check. Caller requested the officers check on his juvenile daughter who was admitted to the facility.

raw_content:
LITTLE ROCK POLICE DEPARTMENT ABBREVIATED INCIDENT REPORT

JUVENILE INFORMATION INCIDENT Report generated: 10/2/2025 9:41 PM

INCIDENT NUMBER UNIT ASSIGNED CALL DATE CALL TIME TYPE OF CALL

2025-123504 2X61 10/02/2025 16:50:00 CHKSUB

INCIDENT DATE LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

10/2/2025 4:50:23 PM

6501 W 12TH ST

OFFENSE

NON POLICE INCIDENT

OFFICERS RESPONDED TO THE LISTED ADDRESS FOR A CHECK SUBJECT. CALLER REQUESTED OFFICERS CHECK
THE WELFARE OF HER JUVENILE DAUGHTER WHO WAS CURRENTLY ADMITTED TO THE CENTERS FOR YOUTH AN
FAMILY. OFFICERS MADE CONTACT WITH THE JUVENILE WHO WAS IN GOOD HEALTH. NO ACTION WAS REQUIRED.
MVR AND BWC IN USE.

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
10/03/2025 02:39:01 | RAMSEY MITCHELL - Jy RAMSEY MITCHELL - gg MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23 Page 1 of 1

doc_type: Police Report


summary: Officers were dispatched to the facility to prevent a disturbance.

raw_content:
LITTLE ROCK POLICE DEPARTMENT INCIDENT REPORT

[_]JUVENILE INFORMATION

INCIDENT

Report generated: 9/23/2025 11:12 AM

INCIDENT NUMBER

2025-114860

UNIT ASSIGNED

2X72

CALL DATE

CALL TIME

09/13/2025

16:36:00

TYPE OF CALL

STNDBY

INCIDENT DATE

LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

9/13/2025 4:36:38 PM

6501 W 12TH ST

OFFENSE

INCIDENT OFFENSE TYPE
CRIMINAL TRESPASS

=
2.
x
4.

SUSPECTS USED:
[_](A) Alcohol
[_]© Computer Equip

[_]@) Drugs

VI Unknown

(N) Not Applicable /

TYPE OF CRIMINAL ACTIVITY:

(1®) Buying / Receiving
[]@ Exploiting Children

[_](©) Cultivate / Manufacture / Publish
[_]©) Operating / Promoting / Assisting

[_]CE) Transport / Transmit / Import [_]@©) Using / Consuming

[_]®) Distributing / Selling

[_]@) Possessing / Concealing

OFFENSE STATUS
HHH
5H 6H 7H 4
GANG RELATED INFO:
[10 Juvenile Gang

[1@ Otter Gang
[_]@) None / Unknown

LOCATION CODE:

[_](1) Air / Bus / Train Terminal
(02) Bank / Savings & Loan

(03) Bar / Night Club

(04) Church / Synagogue / Temple
[_](05) Commercial / Office Building
(06) Construction Site

(07) Convenience Store

(08) Department / Discount Store
(09) Drug Store / DR Office / Hospital
[_](10) Field / Woods

[_](11) Government / Public Building
(12) Grocery / Supermarket

(13) Highway / Road / Alley

(14) Hotel / Motel / Etc

[_](15) Jail / Penitentiary

[_](16) Lake / Waterway

[_]7 Liquor Store

[_](18) Parking Lot / Garage

[_](9) Rental / Storage Facility

(20) Residence / House

[_](21) Restaurant

[_](22) School / College

[_](23) Service / Gas Station

[_](24) Specialty Store (TV, Fur, Etc)
[V] (25) Other / Unknown

[_]@7) Abandoned/Condemned Structure
[_]G8) Amusement Park

(39) Arena / Stadium / Fairgrounds
[_](40) ATM Separate from Bank
(41) Auto Dealership New / Used
[_](42) Camp / Campground

[_](44) Daycare Facility

[_ (45) Dock / Wharf / Freight Terminal
[_](46) Farm Facility

[_](47) Gambling / Casino / Racetrack
[_]48) Industrial Site

[_](49) Military Installation

[_](60) Park / Playground

[_](1) Rest Area

[_] (52) School - College / University

[_] (53) School - Elementary / Secondary!
[_] 4) Shelter - Mission / Homeless
[_]©5) Shopping Mall

[_] ($6) Tribal Lands

[_](S7) Community Center

WEAPON FORCE:
(11) Firearm (Unknown)
(12) Handgun

(13) Rifle

(14) Shotgun

[_] C5) Other Firearm

[_] 20) Knife / Cutting Instr (Axe, etc)

_U
_U
_ Uo
_U

(FOR BURGLARY ONLY)

NUMBER OF PREMISES ENTERED

METHOD OF ENTRY:

C] @®) Forcible

[_]@) No Force

[_] G0) Btunt Object (Club, etc)
C] (35) Motor Vehicle (as weapon)
[_] 0) Personal Weapons (hands, etc)

(on 11-15, an "A" denotes Automatic or Semi-Automatic)

[_ ](50) Poison
L_|(60) Explosives

(65) Fire / Incendiary Device
(70) Narcotics / Drugs /
Sleeping Pills

[_](85) Asphyxiation

(90) Other

(95) Unknown

(99) None

NARCAN USED: | No

Yes

Other

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
09/14/2025 04:34:23 | KYLE DISHMAN - gj] ALEC TINER - MVR in use

LRPD Form 5501-01 Rev. RMS-2019-01-23

Page 1 of 6

INCIDENT NUMBER 2025-114860 JUVENILE INFORMATION Report generated: 9/23/2025 11:12 AM

NAME (Last, First, Middle) or BUSINESS

UNKNOWN AR

WORK PHONE: MOBILE PHONE:

SEX: [_]() Male ETHNICITY: [_](@)Hispanic RACE: [_](W) White [¥](B) Black [_](@ American Indian | DATE OF BIRTH
[V]® Female [_](U) Unk. | [V|(N) Non-Hispanic [_](U) Unk. [_]@) Asian / Pacific Islander [~](U) Unknown

(N) Nonresident (U) Unknown | [_](Y) Yes [V]()No [_]( Unk.

RES. STATUS: |W |(R) Resident MENTALLY AFFLICTED? | OCCUPATION / EMPLOYER:

Exact Age: 32 SUSPECT(S) VICTIM WAS: (by Suspect Number)
Range: __ > s @) 7-364 Days Old (SE) Spouse (AQ) Acquaintance
[JqNN) Under 24 Hrs. Old [[](99) Over 98 Years Old DL./ID No. (STATE) — (FR) Friend

(NB) 1-6 Days Old [_] @0) Unknown (PA) Parent (NE) Neighbor

(SB) Sibling (BE) Babysitter (baby)
THIS VICTIM RELATED TO WHICH OFFENSES? (BG) Boy/Girl Friend

AGE: | NIC: RELATIONSHIP OF THIS VICTIM TO SUSPECTS

6 {]7 [Js (CF) Child of BF / GF

[1@) Business [[]() Financial Inst. [7](U) Unknown SOR eneeexnal ae)

[1@® Religious [[](S) Society / Public [](O) Other = -———— —_—___ ©) Ev Spe
(EE) Employee
ER) Employer
(SS) Stepsibling (OR) Otherwise Known
(OF) Other Family (RU) Relationship Unknown]
(ST) Stranger ____ WO) Victim Was Suspect

[_]@) Apparent Minor Injury ({_]@) Apparent Broken Bones
[_]@ Possible Internal Injury — [__](T) Loss of Teeth [_]@) Severe Laceration
[_] ©) Other Major Injury [_]@) Unconsciousness

AGGRAVATED ASSAULT / HOMICIDE: [_](01) Argument [_] (02) Assault on Law Enf Officer (03) Drug Deal

[_]4) Gangland [_] 5) Juvenile Gang [_] (06) Lover's Quarrel [_]©7) Mercy Killings
[_](08) Other Felony Involved [_] (09) Other Circumstances [_](10) Unknown Circumstances [_] (20) Criminal Killed by Private Citizen
[](21) Criminal Killed by Police Officer [| (30) Child Playing w/ Weapon [_]G1) Gun-Cleaning Accident [](2) Hunting Accident

[_]@3) Other Negligent Weapon Handling [_] (34) Other Negligent Killings

CLOTHING DESCRIPTION

Page 2 of 6

INCIDENT NUMBER 2025-114860 JUVENILE INFORMATION Report generated: 9/23/2025 11:12 AM

SUSPECT #1

NAME (Last, First, Middle)

HOME PHONE: MOBILE PHONE:

SEX: [V](M) Male : ispani : @) Black [_]
() Female [_](U) Unk. [_](A) Asian / Pacific Islander [_ ]

RES. STATUS: [V]®) Resident MENTALLY AFFLICTED? OCCUPATION / EMPLOYER:
[_]@) Nonresident [_]

AGE: SUSPECTS ACTIONS RELATED TO: : WEAPONS AT ARREST:

Exact Age: 26 vi v2 v3 v4 im (01) Unarmed
. —_————_— v5 V6 v7 -
Range: = [_]Q1) Firearm (Unk)

(99) Over 98 Years Old DISPOSITION OF JUVENILE: DL. / ID No. (STATE) - oO (12) Handgun

[_]@4) Shotgun
[_]C5) Other Firearm

(o neugne --Vy)

THIS SUSPECT RELATES TO WHICH OFFENSES? [_](O) On View Arrest —

[_](6) Iegal Cutting Instrument
[_]7) Club/Blackjack/Brass

1 | C13 4 5 6 []7 [_](S) Summons /Cited  [_](T) Taken Into Custody

ARREST LOCATION: | ARREST DATE:

CHARGE:

ARRESTING OFFICERS
OFFICER 1:

OFFICER 2:
OFFICER 3:
OFFICER 4:

Suspect information continued on next page.

Page 3 of 6

INCIDENT NUMBER 2025-114860

[_]JUVENILE INFORMATION

SUSPECT #1

Report generated: 9/23/2025 11:12 AM

SUSPECT #

1

NAME (Last, First, Middle)

COMPLEXION:
[_]q) Light
[_](2) Medium
[¥] (3) Dark
[_]@) Acne
[_|(5) Freckled
[_]@ Ruddy
[_](7) Other

L | (8) Unknown

[_](1) Long

[V] (2) Medium
[_]@) Short
[_](4) Bald@ing)
[_](5) Other

[| (6) Unknown

HAIR LENGTH:

HAIR STYLE:

[_]@1) Afro

[_] (02) Wavy
[_](03) Straight
[_](04) Curly

[Vv] (05) Braided
[_](06) Ponytail
[_](07) Military
[_]@8) Processed
[_](09) Wig/Toupee
[_]@0) Other
[_](@11) Unknown

BUILD:

(_]q) Light
[V](2) Medium
[_]@G) Heavy
[_]4) Muscular
L] (5) Unknown

ADDED DESCRIPTION:

n/a

HAIR COLOR:
wv }(1) Black

[_](2) Blonde
(3) Brown
L_](4) Grey

(5) Red
|_]@© Sandy
(7) Other
|_|(8) Unknown

EYE COLOR:
(1) Blue
¥|(2) Brown
[_]@) Grey

(4) Green
(5) Hazel
(6) Other
L_|(7) Unknown

FACIAL HAIR:

[_] (02) Unshaven
(03) Full Beard
|_| (04) Must. (hvy)
(05) Must. (thin)
|_| (06) Brows (hvy)
(07) Brows (thin)
(08) Side Burns
(09) Goatee

(10) Other

[V] (11) Unknown

(01) Clean Shaven

DEMEANOR:

L]
L]
L]
L]
L]
L]
L]
L]
L]
L]
lv]
L]

(01) Angry

(02) Apologetic
(03) Calm

(04) Irrational
(05) Nervous
(06) Polite

(07) Professional
(08) Stupor

(09) Violent
(10) Drunk / High
(11) Other

(12) Unknown

SCAR / MARK:
(01) Head
[_](02) Neck
(03) Hand (rt)
|_](04) Hand (ift)
(05) Arm (rt)
[_](06) Arm (ift)
(07) Body
(08) Leg (xt)
(09) Leg (1ft)
(10) Other
[_](1) None
(12) Unknown

CLOTHING DESCRIPTION:

HAT

COAT

SHIRT

PANTS/DRESS
SHOES

(01) Arm (ift)
(02) Arm (rt)
(03) Leg (ft)

|_| (04) Leg (xt)

(05) Hand (ft)

[| (06) Hand (+t)
|_| (07) Face

(08) Neck

[|_| (09) Finger(s)

(10) Chest

[_](11) Back

Page 4 of 6

Report generated: 9/23/2025 11:12 AM

INCIDENT NUMBER 2025-114860 JUVENILE INFORMATION

NARRATIVE

OFFICERS RESPONDED TO A STANDBY TO PREVENT DISTURBANCE AT THE LISTED LOCATION. OFFICERS ARRIVED
ON SCENE AND MADE CONTACT WITH , WHO IDENTIFIED AS AN EMPLOYEE AT THE FACILITY.

WR fov'sep OFFICERS THAT AAUGHTER ATTENDS THE FACILITY. ADVIS

S THAT DA EEN TELLING cop rcrvns eye BEEN MEAN TO
HER. FFICERS THAT STA EIS OUTSIDE WAITING
FOR HE GETS OFF WORK. HE OFFICERS THAT THEY WANTED i |

BANNED DUE TO HER CONSTANTLY CA\ RBANCES EVERY TIME SHE'S THERE. OFFI ED

THAT SHE IS BANNED AND IF SHE COMES BACK, SHE WOULD BE ARRESTED FOR CRIMINAL
G. OFFICERS ISSUED AN INCIDENT CARD. BWC IN USE.

Page 5 of 6

INCIDENT NUMBER 2025-114860 im JUVENILE INFORMATION Report generated: 9/23/2025 11:12 AM

ADDITIONAL HOMICIDE CIRCUMSTANCES (Chinn Sih bcl's alien [J Criminal resisted arrest
[_](A) Criminal attacked police officer, that officer killed criminal [_]@) Criminal attempted flight from a crime [© Unable to determine /
[_]@) Criminal attacked police officer, criminal killed by other officer [_]) Criminal killed in commission of a crime not enough information

RELATED CASE NUMBER(S)

CAR JACKING? [_]YES [V]NO DRIVE-BY? [ ]YES [V¥|NO GANG RELATED? [_]YES [V|NO

HATE/BIAS RELATIONSHIP:  [V](88) None [_] YES, SEE BELOW
RACIAL (Anti-) RELIGIOUS (Anti-) ETHNICITY / NATIONAL ORIGIN (Anti-) SEXUAL (Anti-)

(11) White (21) Jewish [_] G2) Hispanic [_](41) Male Homosexual (Gay)

(12) Black (22) Catholic [_] (3) Other Ethnicity [_](42) Female Homosexual (Lesbian)
-— (13) American Indian / (23) Protestant . [_](43) Homosexual (Gay and Lesbian)
L_I Alaskan Native (24) Islamic (Muslim) SSE) [_](44) Heterosexual

(14) Asian / Pacific Islander (25) Other Religion [_] G1) Physical Disability [_](45) Bisexual

[_](15) Multi-Racial Group [_](26) Multi-Religious Group [_] (2) Mental Disability
[_](27) Atheist/A gnostic

Page 6 of 6


summary: Multiple deficiencies were cited in the Complaint Survey conducted on 9/4/2025.

raw_content:
PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
Complaint (AR00039573) was not in compliance,
all or in part, with deficiency cited at N127, N140,
N145, N149, N165, N178, N188.
The findings on this statement of deficiencies
demonstrate the facility is not in compliance with
the requirements of 42 CFR Part 483, Subpart B,
for Long Term Care Facilities.
N 127 PROTECTION OF RESIDENTS N 127
CFR(s): 483.356(a)(2)
An order for restraint or seclusion must not be
written as a standing order or on an as-needed
basis.
This ELEMENT is not met as evidenced by:
Based on record review and interviews the
facility failed to ensure that antipsychotic
medications were not ordered on an PRN
(as-needed) basis for 1 client (Client #1) of two
case mix clients reviewed for receiving
antipsychotic medications. The findings are:
Review of Client #1's facesheet dated 06/17/2025
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:PZOF11 Facility ID: 3000 If continuation sheet Page 1 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 127 Continued From page 1 N 127
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of a physician order dated 06/19/2025 by
APRN(Advanced Practice Registered Nurse) #3
revealed a PRN (as-needed) order for an
antipsychotic medication to be given every 12
hours as needed for anxiety/agitation.
Review of a report titled "Client Doctor Orders" for
Client #1 that included physician orders with a
date range between 06/02/25 and 09/032025,
included an order per APRN #3 dated 06/19/2025
for olanzapine (an antipsychotic medication) 5mg
(milligrams) tablet disintegrating oral, to be given
as needed every 12 hours for anxiety/agitation.
Review of Medical Progress notes for Client #1
revealed client #1 had received chemical
restraints after the provider had been notified of
aggressive behaviors and then provided the
authorization to administer the following
medication on the following dates:
- 06/18/25 at 3:45 AM; olanzapine (antipsychotic)
5 mg (milligrams) ODT(oral dissolving tablet) and
diphenhydramine (antihistamine with sedative
effect) 50 mg PO (by mouth) for physical
aggression;
-06/22/2025 at 2:24 PM; olanzapine 10 mg ODT
and diphenhydramine 50 mg PO for physical
aggression toward peers and yelling;
-06/28/2025 at 4:54 PM; olanzapine 5mg ODT for
aggression toward peers;
-07/15/2025 at 7:09 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for yelling at
staff and "provoking" peers;
-07/29/2025 at 7:14 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 2 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 127 Continued From page 2 N 127
toward peers;
-08/10/2025 at 10:07 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression
and attempting to fight with peers;
-08/14/2025 at 7:30 AM; olanzapine 5mg ODT for
fighting with peers;
-08/19/2025 at 7:21 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression
toward peers
-08/20/2025 at 7:35 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression,
attacking peers, yelling and cursing staff;
-08/24/2025 at 7:10 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for fighting with
peers, cursing and defiant with staff;
-08/27/2025 at 8:00 PM; olanzapine 5 Mg ODT
for yelling, falling on the floor, refusing to go to
bed and verbal aggression with staff;
-08/27/2025 at 9:35 PM; diphenhydramine 50 mg
PO for yelling purposely falling on the floor and
refusing to go to bed.
On 09/02/2025 during an interview that began at
2:50 PM with the NM/PM (Nurse
Manager/Program Manager) #1 verified that
olanzapine and diphenhydramine are written as
PRN orders the nurses are supposed to call the
physician before giving the medication for
aggressive behaviors and document the
circumstances and the administration of the
medication in the medical progress notes.
NM/PM #1 confirmed that the facility nurses do
not write a 1 time or stat order for the olanzapine,
but document it in the E-Mar (electronic
medication administration record) as given under
the PRN order.
On 09/04/2025 during a telephone interview that
began at 1:56 PM, APRN#3 verified he had
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 3 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 127 Continued From page 3 N 127
provided PRN orders for olanzapine for clients so
that clients can have the medication available
when they need it. He stated the only way to have
olanzapine in stock is to write the order as a PRN
for each client. APRN#3 reported that the
pharmacy will not give olanzapine as floor stock.
He stated the nurses are expected to call him or
the provider on call before giving olanzapine and
write a 1-time or now order each time a client is
given the olanzapine. APRN #3 reported that
often he also gives diphenhydramine with
olanzapine to help prevent EPS (extrapyramidal
symptoms) that can be associated with receiving
antipsychotic medications.
Review of a facility policy titled, "Medication
Management" with review date of "May 2025"
specified in part under the section for children
and adolescent medication management: that
physicians do not utilize PRN (as-needed) orders
except for over-the-counter medications for minor
medical conditions, and Stat orders are a one
time order prescribed for a specific condition
generally used in an acute, urgent or emergency
situation.
N 140 ORDERS FOR USE OF RESTRAINT OR N 140
SECLUSION
CFR(s): 483.358(a)
Orders for restraint or seclusion must be by a
physician, or other licensed practitioner permitted
by the State and the facility to order restraint or
seclusion and trained in the use of emergency
safety interventions. Federal regulations at 42
CFR 441.151 require that inpatient psychiatric
services for beneficiaries under age 21 are
provided under the direction of a physician.
This STANDARD is not met as evidenced by:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 4 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 140 Continued From page 4 N 140
Based on interviews and record review the
facility failed to ensure a physician's order for a
physical restraint was obtained for 1 Client (Client
#1) of two clients in the sample mix reviewed for
receiving physical restraints. The findings are:
Review of Client #1's facesheet dated 06/17/2025
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of an ESI (Emergency safety intervention)
dated 06/19/2025 for Client #1 indicated Client #1
had been placed in a physical restraint for
aggression toward staff, attempted property
destruction, and fighting with peers. Client #1 was
placed in a physical hold at 5:58 AM by QBHP
(Qualified Behavioral Health Professional) #8 and
released at 6:24 AM due to "no nurse present."
Under the section titled, "ESI Monitoring from
Onset of Restraint" documentation reflected "No
nurse was present for the hold" from the onset
though the release of the restraint.
Review of a report titled "Client Doctor Orders"
for Client #1 that included physician orders with a
date range between 06/02/25 and 09/032025,
revealed there was no physician order for a
physical restraint for 06/19/2025 for Client #1.
On 08/28/2025 during a phone interview that
began at 9:42 PM, QBHP# 8 verified that Client
#1 had a behavior on 06/19/2025 before 6:00 AM
which included yelling, agitation, and trying to
wake up the other clients on the dorm. QBHP #8
called a code over the walkie-talkie system and
QBHP#6 responded. When QBHP#6 arrived
Client #1 started hitting staff member QBHP #6
who instructed QBHP#8 to physically restrain the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 5 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 140 Continued From page 5 N 140
client and Client #1 was then restrained by
QBHP#8 for "30 to 45 minutes." QBHP#8
reported QBHP#6 called a code over the
walkie-talkie to request a nurse, but the nurse
was in another building, and it took "a long time"
before a nurse arrived. QBHP #8 reported he had
released the client from the restraint after 30 to
45 minutes because the nurse had not come yet
so QBHP#8 sat on the bed with the client who
had stopped screaming but was still crying.
QBHP #6 identified the nurse who responded
after the restraint was over as NM/PM (Nurse
Manager/Program Manager) #2.
On 09/02/2025 during an interview that began at
11:48 AM QBHP#6 verified she had worked on
06/19/2025 and had responded to a behavior with
Client #1 in the early morning. QBHP#6 reported
there was not a nurse in the building and Client
#1 had a behavior and was hitting staff and
yelling. QBHP#6 reported she called twice over
the walkie-talkie system and stated, "I have an
ESI, and I need a nurse present." QBHP #6
reported they released the client after 10 minutes
because the nurse never responded to the ESI.
QBHP #6 stated the building did not have a nurse
on 06/18/2025 after 11:00 PM for the rest of the
night shift. QBHP #6 reported she did not know
what time NM/PM #2 arrived.
On 08/28/2025 during an interview that began at
12:45 PM, NM/PM#1 reviewed the ESI
report/packet for Client #1 on 06/19/2025 and
stated that it was not completed because the
nurse did not respond to the ESI. NM/PM#1
confirmed there was no physician order received
because the nurse did not respond to the ESI.
NM/PM #1 identified the nurse present that night
was RN #7 who was covering both houses.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 6 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 140 Continued From page 6 N 140
On 09/03/2025 during a telephone interview that
began at 1:27 PM RN (Registered Nurse) #7 was
unable to recall which dates she had worked in
June of 2025 but did recall working on two
separate occasions that month when she was the
only nurse present for both houses. RN#7
reported she was not contacted during the night
for a restraint "at [name of house]" on either of
the dates she worked alone in [name of house].
Review of a facility policy titled, "Emergency
Safety Interventions" with a date of "May 2025"
specified in part under the section titled,
"Program Specific Procedures" for Psychiatric
Residential Treatment, that if the physician is not
available to order the ESI then the physicians
verbal order must be obtained by a nurse at the
time the ESI is initiated by staff.
N 145 ORDERS FOR USE OF RESTRAINT OR N 145
SECLUSION
CFR(s): 483.358(f)
Within 1 hour of the initiation of the emergency
safety intervention a physician, or other licensed
practitioner trained in the use of emergency
safety interventions and permitted by the state
and the facility to assess the physical and
psychological wellbeing of residents, must
conduct a face-to-face assessment of the
physical and psychological wellbeing of the
resident, including but not limited to-
(1) The resident's physical and psychological
status;
(2) The resident's behavior;
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 7 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 145 Continued From page 7 N 145
(3) The appropriateness of the intervention
measures; and
(4) Any complications resulting from the
intervention.
This ELEMENT is not met as evidenced by:
Based on interviews, record review and facility
policy review, the facility failed to ensure that a
face-to-face assessment was completed within
one hour of a restraint being initiated for one
client (Client #1) of four case mix clients reviewed
for emergency safety interventions. The findings
are:
Review of Client #1's facesheet dated 06/17/2025
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of an ESI (Emergency safety intervention)
dated 06/19/2025 for Client #1 indicated Client #1
had been placed in a physical restraint for
aggression toward staff, attempted property
destruction, and fighting with peers. Client #1 was
placed in a physical hold at 5:58 AM by QBHP
(Qualified Behavioral Health Professional) #8 and
released at 6:24 AM due to "no nurse present."
Under the section titled, "ESI Monitoring from
Onset of Restraint" documentation reflected "No
nurse was present for the hold" from the onset
though the release of the restraint. Under the
section titled, "ESI Face to Face Evaluation"
documentation indicated the evaluation which
included pulse, oxygen saturation, and blood
pressure was not completed due to no nurse
being present for the hold.
On 08/28/2025 during a phone interview that
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 8 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 145 Continued From page 8 N 145
began at 9:42 PM, QBHP# 8 verified that Client
#1 had a behavior on 06/19/2025 before 6:00 AM
which included yelling, agitation, and trying to
wake up the other clients on the dorm. QBHP #8
called a code over the walkie-talkie system and
QBHP#6 responded. When QBHP#6 arrived
Client #1 started hitting staff member QBHP #6
who instructed QBHP#8 to physically restrain the
client and Client #1 was then restrained by
QBHP#8 for "30 to 45 minutes." QBHP#8
reported QBHP#6 called a code over the
walkie-talkie to request a nurse, but the nurse
was in another building, and it took "a long time"
before a nurse arrived. QBHP #8 reported he had
released the client from the restraint after 30 to
45 minutes because the nurse had not come yet
so QBHP#8 sat on the bed with the client who
had stopped screaming but was still crying.
QBHP #6 identified the nurse who responded
after the restraint was over as NM/PM (Nurse
Manager/Program Manager) #2.
On 09/02/2025 during an interview that began at
11:48 AM QBHP#6 verified she had worked on
06/19/2025 and had responded to a behavior with
Client #1 in the early morning. QBHP#6 reported
there was not a nurse in the building and Client
#1 had a behavior and was hitting staff and
yelling. QBHP#6 reported she called twice over
the walkie-talkie system and stated, "I have an
ESI, and I need a nurse present." QBHP #6
reported they released the client after 10 minutes
because the nurse never responded to the ESI.
QBHP #6 stated the building did not have a nurse
on 06/18/2025 after 11:00 PM for the rest of the
night shift. QBHP #6 reported she did not know
what time NM/PM #2 arrived.
On 08/28/2025 during an interview that began at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 9 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 145 Continued From page 9 N 145
12:45 PM, NM/PM#1 reviewed the ESI
report/packet for Client #1 and stated that it was
not completed because the nurse did not respond
to the ESI. NM/PM#1 reported the face-to-face
assessment, the client debriefing session, and
the guardian was not notified because the nurse
was not present and that is the responsibility of
the nurse who responds to the ESI. NM/PM#1
also verified there was no physician order
received because the nurse did not respond to
the ESI.
On 09/02/2025 during an interview that began at
2:50 PM, NM/PM #1 verified she had worked on
06/18/2025 from 7:00 PM to 11:00 PM and when
she left, there was only one nurse on campus to
cover both houses until 7:00 AM on 06/19/2025.
NM/PM#1 stated that the walkie-talkie system
has reception and reaches from house to house
for communication between the staff and the
nurses.
On 09/02/2025 during an interview that began at
4:22 PM NM/PM #2 verified she had arrived at
the facility on 06/19/2025 in the AM "before 8
maybe around 7." NM/PM #2 she was informed
of the ESI by QBHP# 6 however, NM/PM#2 did
not do an assessment on Client #1 but conducted
a general check on the clients. NM/PM #2
reported she did not "think" she had done a body
audit or post evaluation on Client #1 after arriving
at the facility. NM/PM#2 reported that the
assessments should be done by the nurse
responding to the ESI. The Surveyor asked, "If no
one responds when should the assessment be
done?" NM/PM #2 stated, "As soon as possible."
On 09/03/2025 during a telephone interview that
began at 1:27 PM RN (Registered Nurse) #7 was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 10 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 145 Continued From page 10 N 145
unable to recall which dates she had worked in
June of 2025 but did recall working on two
separate occasions that month when she was the
only nurse present for both houses. RN#7 stated
on those nights she was responsible for "over 60"
clients between the two houses after 11:00 PM on
the 7 PM to 7 AM shift. RN#7 stated she had
reported to NM/PM#2 that she felt that was an
unsafe ratio especially since the "houses are not
connected." RN#7 reported she was not
contacted during the night for a restraint "at
[name of house]" on either of the dates she
worked alone in [name of house].
Review of a facility policy titled, "Emergency
Safety Interventions" with a date of "May 2025"
specified in part under the section titled,
"Program Specific Procedures" for Psychiatric
Residential Treatment, that within one hour of the
initiation of an ESI a physician, an RN, or a
trained licensed practitioner must conduct a
face-to-face assessment of the physical and
psychological well-being of the client.
N 149 ORDERS FOR USE OF RESTRAINT OR N 149
SECLUSION
CFR(s): 483.358(h)
Staff must document the intervention in the
resident's record. That documentation must be
completed by the end of the shift in which the
intervention occurs. If the intervention does not
end during the shift in which it began,
documentation must be completed during the
shift in which it ends. Documentation must
include all of the following:
This ELEMENT is not met as evidenced by:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 11 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 149 Continued From page 11 N 149
Based on interviews and record review the
facility failed to ensure that an Emergency safety
intervention assessment with required information
regarding chemical restraints were documented
in clients' charts for 1 client (Clients #1) of 2
clients reviewed for receiving chemical restraints:
The findings are:
Review of Client #1's facesheet dated 06/17/2025
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of a physician order dated 06/19/2025 by
APRN #3 revealed a PRN (as-needed) order for
an antipsychotic medication to be given every 12
hours as needed for anxiety/agitation,
Review of a report titled "Client Doctor Orders" for
Client #1 that included physician orders with a
date range between 06/02/25 and 09/032025,
that included diphenhydramine 50 mg to be given
orally on the following dates. 06/18/2025,
07/15/2025, 07/29/2025, 08/20/2025, and
08/24/2025.
Review of Medical Progress notes for Client #1
revealed client #1 had received chemical
restraints after the provider had been notified of
aggressive behaviors and then provided the
authorization to administer the following
medication on the following dates:
- 06/18/25 at 3:45 AM; olanzapine (antipsychotic)
5 mg (milligrams) ODT(oral dissolving tablet) and
diphenhydramine (antihistamine with sedative
effect) 50 mg PO (by mouth) for physical
aggression;
-06/22/2025 at 2:24 PM; olanzapine 10 mg ODT
and diphenhydramine 50 mg PO for physical
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 12 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 149 Continued From page 12 N 149
aggression toward peers and yelling;
-06/28/2025 at 4:54 PM; olanzapine 5mg ODT for
aggression toward peers;
-07/15/2025 at 7:09 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for yelling at
staff and "provoking" peers;
-07/29/2025 at 7:14 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression
toward peers;
-08/10/2025 at 10:07 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression
and attempting to fight with peers;
-08/14/2025 at 7:30 AM; olanzapine 5mg ODT for
fighting with peers;
-08/19/2025 at 7:21 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression
toward peers
-08/20/2025 at 7:35 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for aggression,
attacking peers, yelling and cursing staff;
-08/24/2025 at 7:10 PM; olanzapine 5mg ODT
and diphenhydramine 50 mg PO for fighting with
peers, cursing and defiant with staff;
-08/27/2025 at 8:00 PM; olanzapine 5 Mg ODT
for yelling, falling on the floor, refusing to go to
bed and verbal aggression with staff;
-08/27/2025 at 9:35 PM; diphenhydramine 50 mg
PO for yelling purposely falling on the floor and
refusing to go to bed.
On 09/02/2025 during an interview that began at
2:50 PM NM/PM (Nurse Manager/Program
Manager) #1 verified that olanzapine and
diphenhydramine are written as PRN orders the
nurses are supposed to call the physician before
giving the medication for aggressive behaviors
and document the circumstances and the
administration of the medication in the medical
progress notes. NM/PM #1 confirmed that the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 13 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 149 Continued From page 13 N 149
facility nurses do not write a 1 time or stat order
for the olanzapine, but document it in the E-Mar
(electronic medication administration record) as
given under the PRN order. NM/PM #1 reported
that the nurses complete an ESI packet if the
client is put into a physical restraint but not if they
only received the olanzapine and
diphenhydramine for aggressive behaviors.
NM/PM #1 verified that Client #1 had only 1 ESI
packet completed since admission due to a
physical restraint and did not have an ESI packet
completed for the dates the olanzapine and
diphenhydramine was given for aggressive
behaviors. NM/PM#1 stated that ESI
documentation is not completed for any chemical
restraint unless it is combined with a physical
restraint.
On 09/02/2025 during an interview that began at
4:22 PM, NM/PM #2 verbally confirmed that
olanzapine and diphenhydramine given to clients
for behaviors is a chemical restraint.
On 09/04/2025 during a telephone interview that
began at 1:56 PM, APRN#3 verified he had
provided PRN orders for olanzapine for clients so
that clients can have the medication available
when they need it. He stated the only way to have
olanzapine on stock is to write the order as a
PRN for each client. APRN#3 reported that the
pharmacy will not give olanzapine as floor stock.
He stated the nurses are expected to call him or
the provider on call before giving olanzapine and
write a 1-time or now order each time a client is
given the olanzapine. APRN #3 reported that
often he also gives diphenhydramine with
olanzapine to help prevent EPS (extrapyramidal
symptoms) that can be associated with receiving
antipsychotic medications. APRN#3 verbally
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 14 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 149 Continued From page 14 N 149
confirmed that if a client receives olanzapine
alone or with diphenhydramine for aggressive
behavior it would be considered a chemical
restraint and an would be considered an ESI
(emergency safety intervention) and should be
completed and documented as such including
assessments, notification of guardians, debriefing
follow ups. APRN #3 stated he was not aware
the ESI packets were not being completed for the
chemical restraint episodes and this concern
would be addressed immediately.
Review of a facility policy titled, "Emergency
Safety Interventions" with a date of "May 2025"
specified in part under the definitions section that
an "Emergency Safety Situation" is an
unanticipated client behavior that places the client
or others at serious threat of violence or injury if
no intervention occurs. Under the section titled,
"Psychiatric Residential Treatment" an
emergency medication may be used in the form
of oral medication only upon the order of the
physician in response to an emergency safety
situation as an emergency safety intervention.
N 165 MONITORING DURING AND AFTER N 165
RESTRAINT
CFR(s): 483.362(a)
Clinical staff trained in the use of emergency
safety interventions must be physically present,
continually assessing, and monitoring the physical
and psychological well-being of the resident and
the safe use of restraint throughout the duration
of the emergency safety intervention.
This STANDARD is not met as evidenced by:
Based on record review and interviews, the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 15 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 165 Continued From page 15 N 165
facility failed to ensure that a nurse was present
during a physical restraint to assess and monitor
the physical and psychological safety and
well-being of one client (Client #1) out of two
clients in the case mix reviewed for receiving
physical restraints. The findings are:
Review of Client #1's facesheet dated 06/17/2025
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of an ESI (Emergency safety intervention)
dated 06/19/2025 for Client #1 indicated Client #1
had been placed in a physical restraint for
aggression toward staff, attempted property
destruction, and fighting with peers. Client #1 was
placed in a physical hold at 5:58 AM by QBHP
(Qualified Behavioral Health Professional) #8 and
released at 6:24 AM due to "no nurse present."
Under the section titled, "ESI Monitoring from
Onset of Restraint" documentation reflected "No
nurse was present for the hold" from the onset
though the release of the restraint. Under the
section titled, "ESI Face to Face Evaluation"
documentation indicated the evaluation which
included pulse, oxygen saturation, and blood
pressure was not completed due to no nurse
being present for the hold.
On 08/28/2025 during a phone interview that
began at 9:42 PM, QBHP# 8 verified that Client
#1 had a behavior on 06/19/2025 before 6:00 AM
which included yelling, agitation, and trying to
wake up the other clients on the dorm. QBHP #8
called a code over the walkie-talkie system and
QBHP#6 responded. When QBHP#6 arrived
Client #1 started hitting staff member QBHP #6
who instructed QBHP#8 to physically restrain the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 16 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 165 Continued From page 16 N 165
client and Client #1 was then restrained by
QBHP#8 for "30 to 45 minutes." QBHP#8
reported QBHP#6 called a code over the
walkie-talkie to request a nurse, but the nurse
was in another building, and it took "a long time"
before a nurse arrived. QBHP #8 reported he had
released the client from the restraint after 30 to
45 minutes because the nurse had not come yet
so QBHP#8 sat on the bed with the client who
had stopped screaming but was still crying.
QBHP #6 identified the nurse who responded
after the restraint was over as NM/PM (Nurse
Manager/Program Manager) #2.
On 09/02/2025 during an interview that began at
11:48 AM QBHP#6 verified she had worked on
06/19/2025 and had responded to a behavior with
Client #1 in the early morning. QBHP#6 reported
there was not a nurse in the building and Client
#1 had a behavior and was hitting staff and
yelling. QBHP#6 reported she called twice over
the walkie-talkie system and stated, "I have an
ESI, and I need a nurse present." QBHP #6
reported they released the client after 10 minutes
because the nurse never responded to the ESI.
QBHP #6 stated the building did not have a nurse
on 06/18/2025 after 11:00 PM for the rest of the
night shift. QBHP #6 reported she did not know
what time NM/PM #2 arrived.
On 08/28/2025 during an interview that began at
12:45 PM, NM/PM#1 reviewed the ESI
report/packet for Client #1 and stated that it was
not completed because the nurse did not respond
to the ESI. NM/PM#1 reported the face-to-face
assessment, the client debriefing session, and
the guardian was not notified because the nurse
was not present and that is the responsibility of
the nurse who responds to the ESI. NM/PM#1
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 17 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 165 Continued From page 17 N 165
also verified there was no physician order
received because the nurse did not respond to
the ESI.
On 09/02/2025 during an interview that began at
2:50 PM, NM/PM #1 verified she had worked on
06/18/2025 from 7:00 PM to 11:00 PM and when
she left, there was only one nurse on campus to
cover both houses until 7:00 AM on 06/19/2025.
NM/PM#1 stated that the walkie-talkie system
has reception and reaches from house to house
for communication between the staff and the
nurses.
On 09/02/2025 during an interview that began at
4:22 PM NM/PM #2 verified she had arrived at
the facility on 06/19/2025 in the AM "before 8
maybe around 7." NM/PM #2 she was informed
of the ESI by QBHP# 6 however, NM/PM#2 did
not do an assessment on Client #1 but conducted
a general check on the clients. NM/PM #2
reported she did not "think" she had done a body
audit or post evaluation on Client #1 after arriving
at the facility. NM/PM#2 reported that the
assessments should be done by the nurse
responding to the ESI. The Surveyor asked, "If no
one responds when should the assessment be
done?" NM/PM #2 stated, "As soon as possible."
On 09/03/2025 during a telephone interview that
began at 1:27 PM RN (Registered Nurse) #7 was
unable to recall which dates she had worked in
June of 2025 but did recall working on two
separate occasions that month when she was the
only nurse present for both houses. RN#7 stated
on those nights she was responsible for "over 60"
clients between the two houses after 11:00 PM on
the 7 PM to 7 AM shift. RN#7 stated she had
reported to NM/PM#2 that she felt that was an
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 18 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 165 Continued From page 18 N 165
unsafe ratio especially since the "houses are not
connected." RN#7 reported she was not
contacted during the night for a restraint "at
[name of house]" on either of the dates she
worked alone in [name of house].
Review of a facility policy titled, "Emergency
Safety Interventions" with a date of "May 2025"
specified in part under the section titled,
"Program Specific Procedures" for Psychiatric
Residential Treatment, that clinical staff such as a
nurse must be physically present to continually
assess and monitor the physical and
psychological well-being of the client and the safe
use of a restraint throughout the duration of the
intervention.
N 178 NOTIFICATION OF PARENT(S) OR LEGAL N 178
GUARDIAN
CFR(s): 483.366
If the resident is a minor as defined in this
subpart:
483.366(a) The facility must notify the parent(s) or
legal guardian(s) of the resident who has been
restrained or placed in seclusion as soon as
possible after the initiation of each emergency
safety intervention.
This STANDARD is not met as evidenced by:
Based on record review, interview, and facility
policy reviews, the facility failed to ensure
documentation for guardian notification was in the
client's clinical record after the implementation of
an emergency safety intervention for one (Client
#1) of two case mix clients who had restraints
documented in their record. The findings are:
Review of Client #1's facesheet dated 06/17/2025
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 19 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 178 Continued From page 19 N 178
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of an ESI (Emergency safety intervention)
dated 06/19/2025 for Client #1 indicated Client #1
had been placed in a physical restraint for
aggression toward staff, attempted property
destruction, and fighting with peers. Client #1 was
placed in a physical hold at 5:58 AM by QBHP
(Qualified Behavioral Health Professional) #8 and
released at 6:24 AM due to "no nurse present."
Under the section titled, "ESI Monitoring from
Onset of Restraint" documentation reflected "No
nurse was present for the hold" from the onset
though the release of the restraint. In response to
the printed question of who notified the guardian
the documentation reflected, "No nurse was
present for the hold." In response to the question
"Was a letter mailed to parent" in this section the
response was "N/A. (not applicable)"
On 08/28/2025 during a phone interview that
began at 9:42 PM, QBHP# 8 verified that Client
#1 had a behavior on 06/19/2025 before 6:00 AM
which included yelling, agitation, and trying to
wake up the other clients on the dorm. QBHP #8
called a code over the walkie-talkie system and
QBHP#6 responded. When QBHP#6 arrived
Client #1 started hitting staff member QBHP #6
who instructed QBHP#8 to physically restrain the
client and Client #1 was then restrained by
QBHP#8 for "30 to 45 minutes." QBHP#8
reported QBHP#6 called a code over the
walkie-talkie to request a nurse, but the nurse
was in another building, and it took "a long time"
before a nurse arrived. QBHP #8 reported he had
released the client from the restraint after 30 to
45 minutes because the nurse had not come yet
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 20 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 178 Continued From page 20 N 178
so QBHP#8 sat on the bed with the client who
had stopped screaming but was still crying.
QBHP #6 identified the nurse who responded
after the restraint was over as NM/PM (Nurse
Manager/Program Manager) #2.
On 09/02/2025 during an interview that began at
11:48 AM QBHP#6 verified she had worked on
06/19/2025 and had responded to a behavior with
Client #1 in the early morning. QBHP#6 reported
there was not a nurse in the building and Client
#1 had a behavior and was hitting staff and
yelling. QBHP#6 reported she called twice over
the walkie-talkie system and stated, "I have an
ESI, and I need a nurse present." QBHP #6
reported they released the client after 10 minutes
because the nurse never responded to the ESI.
QBHP #6 stated the building did not have a nurse
on 06/18/2025 after 11:00 PM for the rest of the
night shift.
On 08/28/2025 during an interview that began at
12:45 PM, NM/PM#1 reviewed the ESI
report/packet for Client #1 and stated that it was
not completed because the nurse did not respond
to the ESI. NM/PM#1 reported the face-to-face
assessment, the client debriefing session, and
the guardian was not notified because the nurse
was not present and that is the responsibility of
the nurse who responds to the ESI. NM/PM #1
identified the nurse that was on duty during the
ESI as RN (Registered Nurse) #7.
On 09/02/2025 during an interview that began at
4:22 PM NM/PM #2 verified she had arrived at
the facility on 06/19/2025 in the AM "before 8
maybe around 7." NM/PM #2 she was informed
of the ESI by QBHP# 6 and identified the nurse
on duty at that time was RN#7.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 21 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 178 Continued From page 21 N 178
On 09/03/2025 during a telephone interview that
began at 1:27 PM RN (Registered Nurse) #7 was
unable to recall which dates she had worked in
June of 2025 but did recall working on two
separate occasions that month when she was the
only nurse present for both houses." RN#7
reported she was not contacted during the night
for a restraint "at [name of house]" on either of
the dates she worked alone in [name of house].
Review of a facility policy titled, "Emergency
Safety Interventions" with a date of "May 2025"
specified in part under the section titled, "General
Principles" that the guardian of the client must be
notified as soon as possible but no later than 24
hours after the ESI. The staff must make at least
two attempts and document the attempts in the
electronic medical record.
N 188 POST INTERVENTION DEBRIEFINGS N 188
CFR(s): 483.370(a)
Within 24 hours after the use of the restraint or
seclusion, staff involved in an emergency safety
intervention and the resident must have a
face-to-face discussion. This discussion must
include all staff involved in the intervention except
when the presence of a particular staff person
may jeopardize the wellbeing of the resident.
Other staff and the resident's parent(s) or legal
guardian(s) may participate in the discussion
when it is deemed appropriate by the facility. The
facility must conduct such discussion in a
language that is understood by the resident and
by the resident's parent(s) or legal guardian(s).
The discussion must provide both the resident
and staff the opportunity to discuss the
circumstances resulting in the use of restraint or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 22 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 188 Continued From page 22 N 188
seclusion and strategies to be used by the staff,
the resident, or others that could prevent the
future use of restraint or seclusion.
This STANDARD is not met as evidenced by:
Based on record review and interviews the
facility failed to ensure that a post intervention
debriefing was completed with 24 hours of 1
client (Client #1) of 2 casemix clients who were
reviewed for being placed in a physical restraint.
The findings are:
Review of Client #1's facesheet dated 06/17/2025
included diagnoses of disruptive mood
dysregulation disorder, impulse control disorder
and attention deficit disorder with hyperactivity.
Review of an ESI (Emergency safety intervention)
dated 06/19/2025 for Client #1 indicated Client #1
had been placed in a physical restraint for
aggression toward staff, attempted property
destruction, and fighting with peers. Client #1 was
placed in a physical hold at 5:58 AM by QBHP
(Qualified Behavioral Health Professional) #8 and
released at 6:24 AM due to "no nurse present."
Under the section titled, "Client Debriefing"
documentation reflected client debrief was
incomplete and last attempt to debrief with client
was on 06/19/2025 at 7:02 AM. The section
containing questions to ask the client were left
unanswered.
On 08/28/2025 during a phone interview that
began at 9:42 PM, QBHP# 8 verified that Client
#1 had a behavior on 06/19/2025 before 6:00 AM
which included yelling, agitation, and trying to
wake up the other clients on the dorm. QBHP #8
called a code over the walkie-talkie system and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 23 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 188 Continued From page 23 N 188
QBHP#6 responded. When QBHP#6 arrived
Client #1 started hitting staff member QBHP #6
who instructed QBHP#8 to physically restrain the
client and Client #1 was then restrained by
QBHP#8 for "30 to 45 minutes." QBHP#8
reported QBHP#6 called a code over the
walkie-talkie to request a nurse, but the nurse
was in another building, and it took "a long time"
before a nurse arrived. QBHP #8 reported he had
released the client from the restraint after 30 to
45 minutes because the nurse had not come yet
so QBHP#8 sat on the bed with the client who
had stopped screaming but was still crying.
QBHP #6 identified the nurse who responded
after the restraint was over as NM/PM (Nurse
Manager/Program Manager) #2.
On 09/02/2025 during an interview that began at
11:48 AM QBHP#6 verified she had worked on
06/19/2025 and had responded to a behavior with
Client #1 in the early morning. QBHP#6 reported
there was not a nurse in the building and Client
#1 had a behavior and was hitting staff and
yelling. QBHP#6 reported she called twice over
the walkie-talkie system and stated, "I have an
ESI, and I need a nurse present." QBHP #6
reported they released the client after 10 minutes
because the nurse never responded to the ESI.
QBHP #6 stated the building did not have a nurse
on 06/18/2025 after 11:00 PM for the rest of the
night shift.
On 08/28/2025 during an interview that began at
12:45 PM, NM/PM#1 reviewed the ESI
report/packet for Client #1 and stated that it was
not completed because the nurse did not respond
to the ESI. NM/PM#1 reported the face-to-face
assessment, the client debriefing session, and
the guardian was not notified because the nurse
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 24 of 25

PRINTED: 09/16/2025
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
04L101 B. WING _____________________________ 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6501 W 12TH STREET
CENTERS FOR YOUTH AND FAMILIES INC
LITTLE ROCK, AR 72225
(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 188 Continued From page 24 N 188
was not present and that is the responsibility of
the nurse who responds to the ESI. NM/PM #1
identified the nurse that was on duty during the
ESI as RN #7.
On 09/02/2025 during an interview that began at
4:22 PM NM/PM #2 verified she had arrived at
the facility on 06/19/2025 in the AM "before 8
maybe around 7." NM/PM #2 she was informed
of the ESI by QBHP# 6 and identified the nurse
on duty at that time was RN#7.
On 09/03/2025 during a telephone interview that
began at 1:27 PM RN (Registered Nurse) #7 was
unable to recall which dates she had worked in
June of 2025 but did recall working on two
separate occasions that month when she was the
only nurse present for both houses." RN#7
reported she was not contacted during the night
for a restraint "at [name of house]" on either of
the dates she worked alone in [name of house].
Review of a facility policy titled, "Emergency
Safety Interventions" with a date of "May 2025"
specified in part under the section titled, "General
Principles" that a post intervention client
debriefing must occur within 24 hours after the
use of any form of ESI (Emergency Safety
Intervention) and that all staff must be present
with the exception of a particular staff person if
that person might jeopardize the well-being of the
client.
9.26.2025
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:PZOF11 Facility ID: 3000 If continuation sheet Page 25 of 25

doc_type: Complaint Survey


summary: A resident was transported to the ER to remove an object stuck in her ear.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 032394
Date of Incident: 08/24/2025
Date Received: 08/25/2025
Facility Name: Elizabeth Mitchell Centers
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Under Review
DPSQA - Incident & Accident - OLTC
Report Description: went to staff on duty and stated that her ear was itching and
she had used a small toy crab in an attempt to scratch it. The toy crab broke off in her ear.
The nurse on duty was notified and assessed , but was unable to remove the object.
was sent to for removal of the object and prescribed ear drops for 7
days.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident