summary: A resident complained that a staff member scratched his right arm and said inappropriate things about the resident’s mother. The facility was cited 907.2 and 905.16 as a result of this incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027164
Date of Incident: 1/21/2025
Date Received: 1/29/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type:
Report Description: Director of Quality and Risk Management received communication
(phone call) that Resident, , accused Staff member,
or scratching his right arm and saying ?I will f*ck your mom.? AR DHS visited
and interviewed and 01/29/2025. Status of is pending, referral
number . Statements from Resident, Staff, and witness have been collected. Camera
review has been conducted. An ICA request has been submitted.
Interim Action Narrative: Staff placed on administrative leave pending the results of the
investigation.
Narrative: av is his PRFCs name is unknown and the AO
is a staff member at Perimeter Behavioral Group Home for Children. on Jan 23, A staff
member at the Arkansas group home , told the AV , " i fucked your mother". Av then went
after the staff member . Av was restrained he has scratches on his right forearm avs arms
were held behind his back and causing his arms to go numb
Licensing Narrative: Program Coordinator looked in .
1/30/2025, licensing requested and
for the facility to save camera footage. Witness statements were also requested. Facility
reported incident was not accepted by . Facility inquired about the
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

status of the ICA and was informed that the request was sent to management. Facility
reported that camera footage has been saved. ICA request denied by licensing due to staff
member being named in multiple previous incidents. 3.20.25- Email received from Director
of Quality and Risk Management stating the following: has been on
suspension since January 30th. We will offer conditional return to under the
following requirements: mandated retraining around therapeutic engagement with
Residents, thirty-day performance improvement plan (PIP), and a temporary shift change
(second shift to first shift )to work side by side with precepting supervisor to ensure quality
of care. A conversation with his Director explaining this was held today. Employee will sign
an attestation of policies. will return to work tomorrow, 1st shift.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Andrea Adamson
Person In Charge: Immanuel Morris
Record Visit Date: 2/4/2025
Home Visit Date: 2/4/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulation Number: 900.905.16
Regulation Description: Staff shall continually monitor each child in seclusion or restraints and shall document.
Finding Description: A female staff left a one-person restraint between the AV and AO three times resulting in
the restraint being left unmonitored by any other staff.
Action Due Date: 2025-02-19
Action Due Description: The facility shall retrain staff on appropriate supervision and how to aid staff during the
course of a restraint hold.
Comply Date:
Regulation Number: 900.907.2
Regulation Description: Child caring staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s
age, individual differences and abilities, surrounding circumstances, hazards and risks.
Finding Description: Staff failed to provide adequate supervision to the resident during a restraint hold when
leaving the AV and AO alone three times during the course of the restraint hold.
Action Due Date: 2025-02-19
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 4

Action Due Description: The facility shall retrain both staff in appropriate supervision of the residents to ensure
their safety and well-being.
Comply Date:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
The Licensing Specialist visited the agency in regard to complaint case # 027164.
AMENDED AFTER APPEAL
Camera footage was reviewed of the alleged incident, and the following was noted:
Footage beginning at approximately1842 the AV is seen standing outside of his room with the AO and a
female staff member.
AV is seen going back into his room and shortly after AO is seen moving quickly into the bedroom after the
AV. Nothing can be seen happening inside the bedroom, however, there is another female staff member that is
seen leaning on the doorframe of the bedroom during the initiation of the restraint. The female staff member
does not move from the doorway to assist the staff with the restraint hold. At 18:53 the female staff member
can be seen walking away from the doorway of the bedroom where restraint is occurring on the AV by the
AO. The female staff member is seen talking to another staff member on the hallway then goes to other
bedrooms to look in on other residents but does not have a view of the physical restraint occurring in the AV
bedroom. The female staff member does return to the doorway of the AV’s room briefly before leaving again
at 18:55 as she walks to other staff on the hallway, returning to the doorway of the AV’s room at 18:56. The
female staff leaves the doorway of the AVs room again and leaves the hallway to the nurse’s station at 18:58
returning at 18:59. The nurse enters the unit at 19:00 and looks in on the physical restraint occurring in the
bedroom. Both the AV and the AO are then seen walking out of the bedroom at 19:02.
Licensing interviewed the AV with the OLTC and reviewed the witness statements. The AV presented with a
fresh red mark that he reported was from earlier in the morning when he was involved in a restraint, but it was
not causing him any pain or discomfort.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 4

A review of the AO personnel file showed previous corrective actions have been taken on the staff by the
facility for issues concerning the following:
•Code of Conduct; Unprofessionalism by "allowing outside relationships to spill into workplace, impacting
residents and caused several altercations amongst residents"-2.9.23
•Left Resident unattended-10.23.23
•Improper Containment-1.7.24
•Conduct pertaining to "refraining from any verbal abusive language in front of residents; will not engage in
any verbal or physical altercations in front of residents; adhere to all program rules and guidelines."-10.30.24
This also resulted in a suspension from 10.30.24 to 11.6.24
Licensing is unable to determine what occurred during the restraint hold of the resident in the bedroom as it is
off camera, and the witness statements are contradictory. However, camera footage did reveal concerns
related to the supervision of the resident while in a restraint hold. One staff member who was in the doorway
while the one-person restraint was taking place in the resident’s room between the AV and AO was not
assisting the AO. Additionally, the female staff in the doorway does not consistently monitor the physical
restraint occurring in the bedroom off camera between the AV and AO as she steps away several times before
returning to the doorway.
The facility will be cited for:
907.2failing to ensure adequate supervision to ensure the safety and well-being of a resident.
905.16failing to continually monitor each child in a restraint.
The AO is currently suspended pending the results of the investigation. Please ensure that the two other staff
present during the restraint on the hall are retrained on appropriate supervision and aiding staff during a
restraint by 2/19/2025.
Licensing is unable to determine if there were any violations to standards 905.4.g using lewd or obscene
language as a form of disciplinary actions or 905.9 using the minimal force necessary during the course of a
restraint hold at this time.
Complaint case is founded for violations of standards 907.2 and 905.16.
***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 4

CCL Staff Signature : Date: 2/4/2025
Provider Signature : Date: 2/4/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 4 of 4


state: AR

facility_name: Perimeter Behavioral of Forrest City

summary: Residents eloped from the premises by climbing a gate then climbing a fence. Forrest City Police Department was notified, and the residents were located and returned safely to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026966
Date of Incident: 1/19/2025
Date Received: 1/21/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents, ,
eloped from the property at approximately 17:48:19 after transitioning from the gym.
Residents swiftly jumped out of line at 17:46:35 and hid behind the maintenance shed while
the remaining Residents transitioned from the gym into the main building. They then
climbed the gate that exits the gym into the courtyard at 17:47:20 and ran to the fence,
climbing it to elope at 17:48:19. Staff noticed Residents were missing at 17:46:38 and began
seeking them. Forrest City Police Department notified. Residents were safely returned at
17:59:00 resulting in a time 10 mins and 41 seconds from elopement to return. The Safety
team conducted camera review (source of timestamps) and surveyed the fencing where the
Residents eloped. A tree limb will be cut to reduce likelihood of it being used to climb as it
is near the fencing were the Residents eloped. Residents placed on elopement precautions.
Interim Action Narrative:
Narrative:
Licensing Narrative: 1.23.25- Specialist emailed facility inquiring about ratio and procedure
1.23.25- Facility replied with the following: 4 Staff and 18 Residents. Procedurally, a
headcount and pocket check are completed before transitioning and the Residents walk in a
straight line to the next destination
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: Licensing visited the facility to conduct a Buildings and Grounds walkthrough. The following areas were reviewed: 100-400 Halls, Cafeteria, Gym, Courtyard. No issues were identified in any of the areas reviewed.

raw_content:
521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Andrea Adamson
Person In Charge: Immanuel Morris
Record Visit Date: 1/16/2025

Home Visit Date: 1/17/2025

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Licensing Specialist reviewed the following areas:

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

MH ARK ANBA S
) DEPARTMENT OF

> HUMAN
a\ SERVICES

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

y
y

Page 1 of 2

100 Hall:No issues, all rooms clean and hallway free of clutter. (105, 107)
200 Hall:No issues, all rooms clean and hallway free of clutter. (202, 206)
300 Hall:No issues, all rooms clean and hallway free of clutter. (302, 305, 306)

400 Hall:No issues, all rooms clean and hallway free of clutter. (403, 407, 408)

Cafeteria:Kitchen has received new cooking equipment; everything was clean, and staff was wearing correct
equipment.

Gym:Clean and bathroom was tidy.

Courtyard: Well maintained and workers were installing water tank. if
Cosmetic:New darker blue paint seen accenting lighter colors, looked very nice | 00 Lt ql Swed
Facility was receiving and installing a new water tank during the walkthrough

Facility has received approval for new showe 2

***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of

the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.

Provider Comments:

CCL Staff Signature : Date: 1/17/2025

Date: 1/17/2025

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

doc_type: Compliance Report


summary: A resident was sent to the emergency room after complaints of pain to his left pinky finger. The pain originated from a prior physical altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026581
Date of Incident: 1/2/2025
Date Received: 1/3/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
by order of Physician after complaint of pain to his left pinky. Resident
states origin of pain was from a prior physical altercation. Resident returned to the facility,
same day, at 1855 (6:55 pm cst) with no further issue. Resident is activity restriction until
further evaluation.
Interim Action Narrative:
Narrative:
Licensing Narrative: 1.6.25- Facility sent over SOF paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the emergency room for further evaluation after getting hit in the nose by a peer. The residents were peer restricted, and the peer is on assault precautions.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026583
Date of Incident: 1/2/2025
Date Received: 1/3/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
for further evaluation after getting unexpectedly hit by
a peer in the nose. Residents were peer restricted and Resident who hit is on assault
precautions. Resident returned to the facility, same day, at 1320 (1:20 pm cst) with no further
issue. Resident is activity restriction until further evaluation.
Interim Action Narrative:
Narrative:
Licensing Narrative: 1.6.25- Facility sent over SOF regarding incident
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for further evaluation after informing Nursing he did not feel well due to allegedly taking a non-prescribed medication.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026507
Date of Incident: 12/30/2024
Date Received: 12/31/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out by order of
Physician for further evaluation after informing Nursing he did not feel well after allegedly
taking a non-prescribed medication. An internal investigation has commenced. All labs
returned back normal. Resident returned to the facility, same day, at 1855 (6:55 pm cst) with
no further issue.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/31/2024-Licensing emailed the facility to determine if the resident
stated what the medication was and how he obtained it. Licensing also requested
information regarding any witnesses that may have seen him with the medication or seen
him take the medication. The facility responded stating "Resident is unaware of what the
alleged medication was. A full investigation is underway, but I will say this would not be a
first if he did not take a medication at all and faked the symptoms to take a field trip."
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers responded to the facility in reference to an employee being assaulted by one of the residents.

raw_content:
FORREST CITY rae 1 Incident

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FORREST CITY, AR. 72335
Crime / Incident (Primary, Secondary, Tertiary) = ee
5-13-206 ASSAULT 2ND [On orFron] 12/22/2024 | 14:56 | Sun _|
eS) ee et
L_]_[Repored [12/22/2024 | 14:56 | Sun _|
Cross Street 1521 ALBERT STREET

Latitude / Longitude County
ST FRA
Dispo = Victim ‘RP" = Reporting Party “W" = Witness “S" = Suspect “O" = Other

Last, First, Middle (Firm if Business) Sex Age Hair Eyes | Home Phone
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Address DOB DL Number State Work Phone
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DL Number State
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Address DOB DL Number

Location of Incident 1521 Albert St, Forrest City, AR

First, Middle (Firm if Busines:

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City, State, Zip Code =f State # FBI || a Phone

Synopsis

Continuation PropertyList
Attached L_] | attached _ L_]| ProveryOamages $0.00
Press Domestic Violence
R
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Gang Related N Victim Senior Citizen LJ
Solvability County

Report Complete/Ready for Review C] CADICFS Event # 2412220013

Assigned To Date

Officer ID OFFICER NATHAN HAWKINS 550 Lt Hampton [Sono

Z222z222222222

Printed By/On; 412 / 01/21/2025 09:55:21
CrimeStar® Law Enforcament Records Management System
Licensed to; FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page 2 Incident conta
POLICE DEPARTMENT- -__ Narrative

on 12/22/24 I, Ptl Hawkins responded to a call Perimeter Behavioral facility at
1521 Albert Street in reference to an employee needing to file a report after
being assaulted by one of the juveniles at that facility. Upon my arrival I

made contact with the victim (Trey Smith). Mr. Smith stated that i
knocked the headliner of the ceiling down and found a brick inside of it. Mr.
Smith also advised that hen took that brick, ran down the other end

of the hallway, busted out a window and began to cut himself with a piece of the

broken glass from the window. Mr. Smith stated that he tried to intervene by
stopping from harming himself, but eee bail began striking him
his rig

with the broken glass causing laceration to Shoulder and arm. Mr.
Smith advised that he was able to take the glass away a Mr. Smith
advised that he didn't medical attention but he wanted a report on file as his
job requires.

Officer ID OFFICER NATHAN HAWKINS Le Youur y Hampton ag: Tenanes sf

UM

Printed By/On; 412 / 01/21/2025 09:55:30

CrimeStar® Law Enforcement Records Management System ‘“
Licensed to: FORREST CITY AR POLICE DEPARTMENT

doc_type: Police Report


summary: A resident was sent for further evaluation after self-harming his left arm following an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026385
Date of Incident: 12/21/2024
Date Received: 12/23/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out by order of
Physician for further evaluation to his after Staff presented Resident to Nurses for self-
harming to his left arm. Prior to, Resident had a physical confrontation with a Resident who
wears a cast. Resident who fought has been placed on assault precautions and
Residents have been peer restricted. Resident returned to the facility, same day, at 1649 (4:49
pm cst) with no further issue. Resident will have intermittent neuro checks for 48 hours.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.26.24- Specialist received discharge paperwork from facility and
uploaded it
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for further evaluation after presenting to the nurse with an egg-sized knot on his forehead that he received while horseplaying with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026199
Date of Incident: 12/15/2024
Date Received: 12/16/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out by order of
Physician for further evaluation to his after presenting to the nurses with egg sized knot on
his forehead. Swelling noted. Resident was horseplaying with a peer resulting in him
accidentally hitting his forehead. Resident returned to the facility, same day, at 1910 (7:10
pm cst) with no further issue. Resident will have intermittent neuro checks.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.16.24- Facility emailed SOF AND FCMC DISCHARGE documents
to specialist.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for further evaluation of his right ankle due to complaints of pain after rolling his ankle while playing basketball in the gym.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025938
Date of Incident: 12/5/2024
Date Received: 12/6/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out by order of
Physician for further evaluation to his right ankle after complaint of pain. Swelling noted.
Resident accidentally rolled his ankle while playing basketball in the gym. Resident
returned to the facility, same day, at 2210 (10:10 pm cst) with no further issue. Resident is
wearing a boot and on activity restriction until further evaluation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.9.24 Licensing specialist uploaded SOF documents provided by
facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his mouth after falling and busting his lip.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025844
Date of Incident: 11/29/2024
Date Received: 12/2/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City Medical Center by
order of Physician for further evaluation to his mouth after accidentally falling on the unit
and busting his lip. Resident returned from the ER same day at 1417 (2:17 pm cst) and is on
activity restriction until further evaluation by APRN. He has two stitches to his left lower
lip. Ordered Ibuprofen 800 mg q12 prn and Augmentin TID x 7days, with suture removal to
be arranged in 7 days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.3.24- Facility emailed SOF paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after being slammed to the gym floor during a physical altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025840
Date of Incident: 11/29/2024
Date Received: 12/2/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City Medical Center
by order of Physician after a physical altercation where he was slammed to the gym floor.
Peer placed on assault precautions and peers are restricted. Resident returned from the ER
11/30/2024 at 1417 (2:17 pm). and is on activity restriction until further evaluation by APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.3.24 Facility sent SOF via email
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand due to complaints of pain after punching a door window.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025842
Date of Incident: 11/28/2024
Date Received: 12/2/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City Medical Center
by order of Physician for further evaluation to his right hand after complaints of pain after
punching a door window. Resident returned from the ER same day at 1632 (4:32 pm cst)
and is on activity restriction until further evaluation by APRN. Window is not broken.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12.3.24- facility emailed SOF paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center due to his tooth falling out after a basketball accident in the gym.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025785
Date of Incident: 11/26/2024
Date Received: 11/27/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City Medical
Center by order of Physician due to his tooth falling out after a basketball accident in the
gym. Resident returned from the ER 11/26/2024 at 1938 (7:38 pm). and is on activity
restriction until further evaluation by APRN. Resident is on antibiotics, special mouthwash,
and a liquid diet. He was made an emergency Dentistry appointment today, 11/27/2024.
Resident returned to facility at 1115 (11:15 pm cst) with tooth reinserted/attached no further
issues. Resident currently has a splint in his mouth and will have a root canal in two weeks.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.27- Facility sent SORF and discharge paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to review the Corrective Action Agreement with the facility CEO, Risk Manager, and Program Director.

raw_content:
&@ RK AN & A SE
DEPARTMENT GF

) \-7 HUMAN
= .{ SERVICES

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Kendra Slade
Person In Charge: Charlotte Lockhart
Record Visit Date: 11/26/2024

Home Visit Date: 11/26/2024

Purpose of Visit: Consultation Visit

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

Regulations Not Correctable:

Narrative:

Time of Visit: 12:15 pm to 1:45 pm

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 1 of 2

Census: 56

Program Coordinator reviewed the Corrective Action Agreement with Mrs. Charlotte Lockhart, CEO, Mr.
Immanuel Morris, Risk Management, and Mr. Cliff Williams, Program Director.

Mr. Morris informed Program Coordinator per the 521 issued on 10/28/2024, Licensing gave the facility two
(2) weeks to repair the flooring in the bathroom located in the gym. The flooring has been repaired and
caulking has been applied around the toilet. Per Mr. Williams, maintenance pulled and reset the flooring
around the toilet.

Mr. Williams informed Program Coordinator the mats in the showers are pulled and cleaned daily. The roof is
currently being replaced with more renovations to come now. The facility is currently waiting for approval
from the corporate office for some new paint that will not be easy for the residents to peel.

Mr. Williams followed up with maintenance regarding the letter from the fire marshal. The Maintenance
Supervisor informed Mr. Williams that he would follow up with the fire department to obtain a letter. The
Maintenance Supervisor will go to the office to see if the letter has been completed.

Reviewing the Corrective Action Agreement, an error was found. Program Coordinator informed Mrs.
Lockhart that the document would be revised. Mrs. Lockhart inquired about the Corrective Action Agreement
since repairs have been completed.

Provider Comments:

CCL Staff Signature : Date: 11/26/2024

Provider Signature : Date: 11/26/2024

CREEK, Dirt ng baal ¢ Bele Mant.

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


summary: Licensing completed a Buildings and Grounds walkthrough of the facility. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Kendra Slade
Person In Charge: Charlotte Lockhart
Record Visit Date: 11/26/2024

Home Visit Date: 11/26/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time of visit: 12:15 pm to 1:45 pm

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

ARKANSAS
) DEPARTMENT OF

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

Page 1 of 2

Census: 56
Program Coordinator Slade was escorted throughout the facility by Mr. Morris and Mr. Williams.

The following areas were observed: grounds, administration, gym, cafeteria, residents’ hall including the
bedrooms and bathrooms.

Program Coordinator observed lawn care contractors on the grounds mowing grass and blowing leaves. No
residents were present on the grounds. The Maintenance Supervisor was observed sitting outside on the
courtyard while the contractors were maintaining the grounds inside the fence.

Mr. Williams informed Program Coordinator that a roofing company was replacing the roof. Per Mr.
Williams, the roofing company are about 95% complete. Program Coordinator observed roofing materials on
the opposite side of the fence out of reach from the residents.

Entering the gym, Program Coordinator observed residents playing basketball, sitting on the benches, walking
around the gym, and a resident was observed laying on a bench. The ratio for the gym was 3:15.

Program Coordinator could smell the aroma of cleaning products throughout the residents’ halls. On the 400
Hall the ration was 1:6. The residents were participating in downtime. Residents were observed in their rooms
resting (laying on their beds awake), reading a book, or talking to staff/peers.

Walking to the cafeteria, Program Coordinator could hear music. The residents were eating desserts provided
by the facility. Ratio 4:18, staff were observed throughout the cafeteria. Residents were observed sitting down
at the table eating or communicating with peers. Other residents were observed dancing and singing songs
with staff.

Mr. Williams informed Program Coordinator that a fire drill was completed on 11/25/2024 and documentation
was provided.

Provider Comments:
CCL Staff Signature : Date: 11/26/2024
Provider Signature : Date: 11/26/2024

fA]
Te Director oF guratity + Rik Mayet

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

 &@ RK AN & A SE
DEPARTMENT GF

) \-7 HUMAN
= .{ SERVICES

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Kendra Slade
Person In Charge: Charlotte Lockhart
Record Visit Date: 11/26/2024

Home Visit Date: 11/26/2024

Purpose of Visit: Consultation Visit

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

Regulations Not Correctable:

Narrative:

Time of Visit: 12:15 pm to 1:45 pm

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 1 of 2

Census: 56

Program Coordinator reviewed the Corrective Action Agreement with Mrs. Charlotte Lockhart, CEO, Mr.
Immanuel Morris, Risk Management, and Mr. Cliff Williams, Program Director.

Mr. Morris informed Program Coordinator per the 521 issued on 10/28/2024, Licensing gave the facility two
(2) weeks to repair the flooring in the bathroom located in the gym. The flooring has been repaired and
caulking has been applied around the toilet. Per Mr. Williams, maintenance pulled and reset the flooring
around the toilet.

Mr. Williams informed Program Coordinator the mats in the showers are pulled and cleaned daily. The roof is
currently being replaced with more renovations to come now. The facility is currently waiting for approval
from the corporate office for some new paint that will not be easy for the residents to peel.

Mr. Williams followed up with maintenance regarding the letter from the fire marshal. The Maintenance
Supervisor informed Mr. Williams that he would follow up with the fire department to obtain a letter. The
Maintenance Supervisor will go to the office to see if the letter has been completed.

Reviewing the Corrective Action Agreement, an error was found. Program Coordinator informed Mrs.
Lockhart that the document would be revised. Mrs. Lockhart inquired about the Corrective Action Agreement
since repairs have been completed.

Provider Comments:

CCL Staff Signature : Date: 11/26/2024

Provider Signature : Date: 11/26/2024

CREEK, Dirt ng baal ¢ Bele Mant.

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


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand following a fight with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025660
Date of Incident: 11/21/2024
Date Received: 11/21/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City Medical Center by
order of Physician for further evaluation to his right hand due to complaint of pain. Resident
was in a fight with a peer. Swelling noted. Resident returned same day at 1331 (1:31 pm cst)
with no issues and is on activity restriction until further evaluation by APRN. Resident is
also on assault precautions and peer restricted from peer he fought.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.25.24- emailed facility with questions 12.2.24- Visited Facility and
reviewed footage Footage starts on 11.19.24 @ 2037- Video shows a different resident
standing in hallway appearing to be talking towards a staff member. Other residents were
off screen standing in hallway waiting for hygiene, when comes around the corner to
land a blow on resident due to disrespectful phrases being said about female staff. Staff
immediately separated the two residents and de-escalated the situation all within a matter of
80 seconds. Ratio seen on video 3:2 (staff: resident.)
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A complaint received states that a resident’s head was slammed into a wall by a staff member during a restraint. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025787
Date of Incident: 11/20/2024
Date Received: 11/26/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: Licensing received notification of report
Per notification: Verbal confrontation escalated into
physical confrontation with allegations that ended up slamming head
into the wall because he would not drop the cooler. Youth was in pain and his air supply
was impacted.
Interim Action Narrative: The staff was working under the supervision of the floor
supervisor with no contact with the A/V in this case pending investigation results.
Licensing Narrative: Program Coordinator received notification. 11/27/2024, Program
Coordinator inquired about date of incident. It was reported that the incident happened on
11/20/2024 in the evening. The incident information info was entered
Program Coordinator spoke with
who requested a copy of the notification. 12/2/2024, permission
granted to contact the facility. informed Licensing he has spoken with
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

the AV and AO. 12/2/2024- Licensing Specialist went to facility to review video footage, as
below: Licensing Specialist arrived at facility @1115 and was greeted by the Director of
Quality and Risk Management. The Director and Specialist reviewed footage of incident.
Footage begins on 11.20.24 @ 1808 Ratio is 4:3 -1808 AV is seen engaging in aggravating
behavior, punching in direction of other residents, arguing with staff, flipping the chairs and
taking things out of people's hands repeatedly. -1809 AV is seen picking up Gatorade
container of water and begin swinging it into hallway, presumably this occurs after AV
began threatening AO. -1810 AO plus other staff attempt to removed Gatorade container
from AV hands and AO is attempting a physical restraint to aid in removal of the object. -
1811 AO radio is seen kicked across room as attempt to call nurse was made and other staff
call nurse before full physical restraint is made. Resident is then seen stiffening legs straight
and hooking feet into arms of the chair while staff attempt not to slip over water and
removed the chairs. -1812 resident is seen attempting to get himself out of the hold and is
placed against the wall -1813 Nurse arrives and chemical restraint is given. -1816 Resident
still has not de-escalated and continues to threaten AO during hold, so the physical hold
was transferred to different staff. -1820 AV is taken to room Licensing is not prepared to
leave a finding at this time. 12/27/2024, Program Coordinator spoke with
regarding this complaint. inquired if licensing had any concerns.
was provided with licensing's 521. 1/3/2025,
and specialist informed.


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand following an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025592
Date of Incident: 11/18/2024
Date Received: 11/19/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest
City Medical Center by order of Physician for further evaluation to his right hand. Resident
states he punched a peer two weeks ago and pain in his right hand persisted. Swelling
noted. Resident returned same day at 1305 (1:05 pm cst) with no issues and is on activity
restriction until further evaluation by APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.19.24- Facility emailed Specialist the incident report and FCMC
discharge paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand due to continued pain after punching a box.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025597
Date of Incident: 11/17/2024
Date Received: 11/19/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
Forrest City Medical Center by order of Physician for further evaluation to his right hand.
Resident states he punched a box in the gym several weeks ago when upset at a peer and
pain in his right hand persisted since. Swelling noted. Resident returned same day at 2250
(10:50 pm cst) with no issues and is on activity restriction until further evaluation by APRN.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.19.24- Facility emailed specialist with copy of SOR and FCMF
discharge paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand due to continued pain after an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025349
Date of Incident: 11/7/2024
Date Received: 11/8/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out to
Forrest City Medical Center by order of Physician for further evaluation to his right hand.
Resident states he punched a peer two weeks ago but just presented complaint as pain
persisted. Swelling noted. Resident returned same day at 2040 (8:40 pm cst) with no issues
and is on activity restriction until further evaluation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.12.24- Licensing Specialist received nursing notes
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand after punching a door window.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025348
Date of Incident: 11/7/2024
Date Received: 11/8/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out to Forrest City Medical Center
by order of Physician for further evaluation to his right hand. Resident was upset, walked
out of assigned area in unit hallway and punched a door window. Resident returned same
day at 2040 (8:40 pm cst) with no issues and is on activity restriction until further evaluation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.12.24- Licensing Specialist inquired about location of staff as well as
damages done to door 11.14.25 Facility responded with: Staff where present in the hallway
when he went to the other end of the hallway. No damage was done door.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right hand after punching a window.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025320
Date of Incident: 11/6/2024
Date Received: 11/7/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City
Medical Center by order of Physician for further evaluation to his right hand. Resident was
upset, walked out of assigned area in cafeteria and punched a window. Resident returned
same day at 1530 (3:30 pm cst) with no issues and is on activity restriction until further
evaluation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.8.24- Licensing Specialist inquired if window was broken. 11.8.24-
Facility stated window was not broken
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation after rolling his ankle when getting out of bed.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025259
Date of Incident: 11/5/2024
Date Received: 11/6/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was sent out to Forrest City Medical Center by
order of Physician for further evaluation to his left ankle. Resident complained of pain after
reporting rolling his ankle when getting out of bed the same morning. No bruising or
swelling noted. Resident returned same day at 1556 (3:56 pm cst) with no issues and is on
activity restriction until further evaluation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.6.24- Specialist received discharge paperwork for resident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for further evaluation of his right eyebrow after a physical confrontation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025258
Date of Incident: 11/5/2024
Date Received: 11/6/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City
Medical Center by order of Physician for further evaluation to his right eyebrow after a
physical confrontation with a peer. Resident returned same day at 1556 (3:56 pm cst) with no
issues and is on activity restriction until further evaluation. Resident and peer are peer
restricted.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11.6.24- Specialist uploaded SOF as well as discharge paperwork.
Inquired on where altercation took place. 11.7.24- Incident took place in the gym.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing conducted follow up on a buildings and grounds walkthrough for issues previously cited. The facility received technical assistance for 914.9.

raw_content:
ARKANSAS
DEPARTMENT GF

4 HUMAN
“a\ SERVICES
Division of Child Care & Early Childhood Education

P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Andrea Adamson
Person In Charge: Immanuel! Morris
Record Visit Date: 10/28/2024

Home Visit Date: 10/28/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Number: 900.914.9

Regulation Description: A record of drills shall be maintained, showing date and time of day of the drill, number
of participants, and length of time required to reach safety.

Finding Description: Licensing reviewed documentation and noted that they were missing the number of
participants (to include residents) as well as time to reach safety. TA was provided to include these going forward.

Action Due Date:

Action Due Description: Facility will include the census of participants to include residents as well as time it took
to reach safety from here on out.

Comply Date:

Action Due Description: Facility will include the census of participants to include residents as well as time it took
to reach safety from here on out.

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

Regulation Not Applicable:
Regulations Not Correctable:

Narrative:

Licensing Specialist and Program Manager were escorted by DOC and DQRM to complete a follow up on the
buildings and grounds walkthrough.

The areas observed were as follows:
Outside courtyard:Culvert drain was cut and smoothed where it had previously been broken.

4100 Hall Bathroom:Facility has removed the damaged door, as it was not necessary to replace. Mats are still
in place over a a oe to et ae, to residents while folly continues to seek on for

100 Hall Dayroom: Wall was repainted and the caulking removed.

Cafeteria:Residents were viewed eating lunch, ratio was 4:13 and in regulation.
300 Hall room 302:door was repainted from the chipping.
Gym:Residents were viewed having recreation time and the ratio was 3:14 in regulation.

Gym Bathroom:Lineoleum was still broken around the ring of the toilet, DOC informed Licensing that they
are still needing to find the correct linoleum type for that specific floor.Licensing gave them a 2-week

Fire and Severe Weather Logs:Licensing reviewed documentation and noted that they were missing the
number of participants (to include residents) as well as time to reach safety.

:A record of drills shall be maintained, showing date and time of day of
the drill number of participants, and length of time required to reach safety.

Child Record Review

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

eviewed record and noted 2 reported Physical restraints, however it was noticed in a
nursing assessment for 9.28.24 that both a chemical and physical restraint were used. Facility restraint logs do
have these notated, but no physician order or restraint documentation was located in the resident file for the
chemical or physical restraint on 9.28.24. The facility was able to locate the documentation outside of the
resident's file and provided it to licensing.

Treatment plans were reviewed for resident Bh eatment
plan was individualized and highly detailed, where master treatment plan appeared to be missing
information and was not specific to the child's needs. The Clinical Director explained that resident as
resistant upon developing his treatment plan so they developed one goal and will continue to add to his goals
as he is in treatment.

Provider Comments:

CCL Staff Signature : Date: 10/29/2024
ry | |
We | | M4
Provider Signature : Date: 10/29/2024

, Director of Bunality + Bash mgt

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


summary: A resident was sent to Forrest City Medical Center for evaluation of his head/face after colliding with another resident while playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025053
Date of Incident: 10/28/2024
Date Received: 10/29/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , accidentally collided
with another Resident while playing basketball in the gym and hit his head. Resident denied
pain but was sent out to Forrest City Medical Center by order of Physician for additional
evaluation to his head/face. Resident is on activity restriction until further evaluation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10.31.24- Facility emailed a copy of the xray and discharge paperwork
to Licensing Specialist.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation of his nose after an altercation with a peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025052
Date of Incident: 10/28/2024
Date Received: 10/29/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents, and peer
were in a physical altercation. was sent out to Forrest City Medical
Center by order of Physician for additional evaluation to his nose. was sent out to Forrest
City Medical Center by order of Physician for additional evaluation to his hand. Both
Residents were individually interviewed by the Safety team. Residents are currently peer
restricted. is on assault precautions and unit restriction. is on activity
restriction until ENT appointment, November 4th.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10.31.24- Licensing Specialist emailed facility to ask if there was any
footage, witness statements and for nursing notes. 10.31.24- Facility responded with
discharge paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after falling while playing in the gym.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024849
Date of Incident: 10/18/2024
Date Received: 10/21/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident reported pain
in hand after falling in the gym while playing. APRN after consulting with the Nurse
ordered resident to go to Forrest City Medical Center for a Xray of his left hand; After
assessment Medical Center . Referred to
Jonesboro Sports Medicine for further assessment and care. Appt. wil be set up after answer
from the clinic.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Program Coordinator received an email regarding this incident.
10.24.24- Licensing Specialist emailed facility requesting discharge paperwork and if an
appointment had been made with 10.24.24- Facility responded " appointment
is scheduled for 10/28 @ 2:40." and provided requested paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after reporting chest pain.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024851
Date of Incident: 10/18/2024
Date Received: 10/21/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident reported
chest pain APRN after consulting with the Nurse ordered resident to go to Forrest City
Medical Center for Chest Xray; After assessment Medical Center
. Flonase Nasal Spray 50mg 1 spray n each nostril prescribed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Program Coordinator was informed of the incident via email. 10.24.24-
Licensing Specialist emailed facility requesting discharge paperwork. 10.24.24- Facility
responded with requested paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation due to chest pain and issues with urinating regularly.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024852
Date of Incident: 10/18/2024
Date Received: 10/21/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident was assessed by APRN due
to issue with chest pain and urinating regularly. APRN after consulting with the Nurse
ordered resident to go to Forrest City Medical Center for EKG ad XRAY and Urinalysis
After assessment Medical Center
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Program Coordinator was informed of this incident via email.
10.24.2024- Licensing Specialist emailed facility requesting discharge paperwork. 10.24.2024-
Facility responded with requested paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after presenting with psychotic behaviors and symptoms.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024805
Date of Incident: 10/17/2024
Date Received: 10/18/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident presented with
psychotic behaviors and symptoms that were unsafe and unstable to merit placement in an
acute setting. Clinical Director made the recommendation after clinical observation to
Psychiatrist and Psychiatrist ordered be sent to Forrest City Medical Center to be
assed and placed in acute care. Due to clinical, mental health, and behavioral symptoms
temporarily going beyond to scope of RTC care. Resident was discharged back to the care
of Perimeter Behavioral of Forrest City on 10-17-24 after Medical Center was not able to find
acute care.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10.21.24- Licensing Specialist emailed facility to inquire if they will
continue to seek acute placement or if the behavior was resolved. 10.24.24- Facility
responded with: " From my understanding, did not get placed in acute care but
returned here to PBFC."
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Two residents eloped from the facility and were returned by the Forrest City Police Department the same day.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024709
Date of Incident: 10/12/2024
Date Received: 10/14/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents,
eloped from the premise at 1307 (1:07 pm cst) 10/12/2024. Residents were
returned by Forrest City Police Department same day at 1341 (1:41 pm cst) totaling
approximately 34 minutes. Witness statements collected and Residents are currently on
elopement precautions. The Safety Team reviewed camera footage. Staff received written
corrective actions 10/14/2024, and while ratio was 4:12, a mandatory retraining on
positioning and supervision will happen this week. The fence company is out today
repairing the fence. All recreation/leisure activity will only occur in the gym until repairs are
fully completed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reached out to the Facility and requested copies
of the witness statements, written corrective actions, retraining roster and before/after
pictures of the fence. 10.16.24- Facility responded with: "There are only 3 forms even though
four Staff were involved. The fourth Staff opted to quit. The training will occur post their
Suspension which is complete 10/16/2024. Lastly, please see the attached are the photos of
the fence. Repairs were completed today."
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to two juveniles jumping the fence.

raw_content:
‘FORREST CITY Call For Service
POLICE DEPARTMENT Event Detail Page
225 N. ROSSER ST.

FORREST CITY, AR. 72335 Event # 2410120005 rant 95/2024
Date 40/12/2024|"* Saturday |"™° 14:06:32 Agency FCPD
a

we | Address
5 Location 7529 ALBERT
> City FORREST CITY County §T FRA State AR
uu | - ___.. REPORTING PARTY INFORMATION ey
@ |_Nime_523,522,521,520,605
a
>
© ie . RESPONSE INFORMATION : |
A Minutes of ail
fo) asvodiated Units
re 0
=
é) DispatchD 464
ee _ CALL DETAILS .
Call Type  24R RUNAWAY Priority

Description :

JENNIFER 2 JUVENILES JUMPED THE FENCE

Disposition €¢ CALL CLEARED

Comments

EMD Code

Printed By/On: 412 / 10/25/2024 10:39:43
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT


summary: Multiple deficiencies were noted during the Inspection of Care (IOC) conducted on 10/10/24. A Corrective Action Plan (CAP) was submitted and approved.

raw_content:
SR018282 The provider requested the Child
Maltreatment on 07/12/24; however, no
outcomes were provided.
241.100B State Criminal SR018275 The provider utilized Global Human
Background SR018284 Resource Research for the background
Check - IP SR018287 check; however, these results are not
Acute Para- SR018289 complete to include the Arkansas State
professional Police database.
SR018282 The provider utilized Verified First for the
SR018286 background check; however, these results
SR018291 are not complete to include the Arkansas
SR018293 State Police database.
SR018295
SR018280 The provider utilized DISA Global
Solutions Inc for the background check;
however, these results are not complete to
include the Arkansas State Police database.
Medicaid IP Sec. 2: CPR training - SR018280 No file received.
221.804; IP Acute
42 CFR 482.130,
483.376
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed in the educational classroom setting. Staff were calmly interacting with clients
and providing a therapeutic environment that was conducive for learning and treatment therapies. Clients were
noted to be engaged in the classroom setting. Staff to client ratio was adequate and followed the facility’s staffing
ratio requirements policy.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being complaint with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, count, reconciliation, and
handling of controlled substances, and medication discrepancies.
The facility nurse was able to verbalize the step-by-step process of medication delivery including the
demonstration of the five rights of medication administration, documentation of medication delivery,
verification of client taking medication including mouth/cheek checks, and how clients are educated about each
medication. The facility nurse also verbalized the process utilized when a client refuses medication. The tour of
medication room completed no discrepancies with medication storage, cleanliness of medication room, and
knowledge of medication dispensing found.
Woodridge of Forrest City, LLC – Forrest City, AR – IOC Report 3 | P ag e

Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge of Forrest City, LLC – Forrest City, AR – IOC Report 4 | P ag e

doc_type: IOC Report


summary: Resident went to Forrest City Medical Center for an x-ray of his left foot after complaining of pain from playing basketball.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024639
Date of Incident: 10/9/2024
Date Received: 10/10/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , went to Forrest City
Medical Center for x-ray of left foot after complaint of pain after playing basketball.
Resident is on activity restriction until reassessment by Physician.
Interim Action Narrative: 10.9.24 Resident went to FCMC for x-ray
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed for concerns 10.11.24 Facility provided
FCMC discharge paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident went to Forrest City Medical Center ER to recheck/reclose a healing wound (see incident report from 09/23/2024).

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024571
Date of Incident: 10/5/2024
Date Received: 10/7/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, went to Forrest City Medical
Center ER to recheck/reclose healing wound (see serious occurrence from 09/23/2024).
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10.7.24-Licensing Specialist emailed Facility for discharge paperwork
and how the wound reopened? 10.8.24- Licensing Specialist and Program Manager went to
facility regarding this case and others. When discussing this incident, we were made aware
that the camera in the 300-hall small dayroom does not work. The Facility has already input
a service request for this, and only upper management is aware as to keep everyone safe.
The incident was described as another resident coming up to this child and punching him
specifically in the wound. It happened quickly and the boys were separated immediately,
and both put on assault precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Andrea Adamson
Person In Charge: Immanuel Morris
Record Visit Date: 10/8/2024
Home Visit Date: 10/8/2024
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Licensing Specialist and Program Manager went to facility regarding case #024571 and others. When
discussing this incident, we were made aware that the camera in the 300-hall small dayroom does not work. The
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Facility has already input a service request for this, and only upper management is aware as to keep everyone
safe.
The incident was described as another resident coming up to this child and punching him specifically in the
wound. It happened quickly and the boys were separated immediately and put on assault precautions.
Provider Comments:
CCL Staff Signature : Date: 10/8/2024
Provider Signature : Date: 10/8/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident went to Forrest City Medical Center ER due to complaints of shortness of breath and feeling like his throat was closing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 024511
Date of Incident: 10/3/2024
Date Received: 10/4/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , went to Forrest City
Medical Center ER due to complaint of shortness of breath feeling like his throat was
closing. Vitals were normal and EpiPen administered at 0945 (9:45 am) with improved
results. EMS arrived at 0950 (9:50 am). No evidence of peanuts on premises or peanut
consumption based on camera review, food inspection, Resident interview and peer
interview. Resident returned to milieu same day at 1430 (2:30 pm) without further issue.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed for concerns. Also, emailed Facility with
questions regarding how child came into contact with peanuts as well as asking for safety
plan. 10.8.24- Program Manager and Licensing Specialist visited Facility and discussed how
the child came into contact with the Peanuts. Facility states the did a thorough investigation
and noted there was no explanation for how the allergy was triggered. They did update all of
his information as the intake paperwork did not say he had a peanut allergy. His photo with
his allergy was added to the nursing board.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Andrea Adamson
Person In Charge: Immanuel Morris
Record Visit Date: 10/8/2024
Home Visit Date: 10/8/2024
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Program Manager and Licensing Specialist visited Facility and discussed case 024511. Licensing asked how the child
came into contact with the peanuts. Facility states they did a thorough investigation and noted there was no explanation
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

for how the allergy was triggered as no food on the menu for the day reportedly contained peanuts. The child also did
not know where he would have come into contact with the peanuts. The facility did inform us that at intake the Resident
informed them of the allergy and at that time the photo with allergy information was added to the Dietary board.
Provider Comments:
CCL Staff Signature : Date: 10/8/2024
Provider Signature : Date: 10/8/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


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

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024315
Date of Incident: 9/26/2024
Date Received: 9/27/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest
City Medical Center by order of Physician for further assessment after complaint of pain to
his eye after physical altercation with a peer. Residents were separated and assault
precautions initiated. Resident returned to milieu same day at 1400 (2:00 pm) without issue.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 10.3.24-Licensing Specialist emailed Facility with questions regarding
incident, also inquired about possible footage. 10.3.24-Facility responded letting Licensing
Specialist know that they did have footage and would retain it. 10.8.24- Licensing Specialist
and Program manager watched video and determined no further action was needed as
Facility was in ratio and placed both children on appropriate assault precautions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing completed a walkthrough of the 300 hall, 400 hall, dayrooms, and gym. The facility was cited 910.1, 911.15.f, and 911.6 for deficiencies identified during the review.

raw_content:
ARKANSAS
_ DEPARTMENT OF

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Chelsea Vardell
Person In Charge: Immanuel Morris
Record Visit Date: 9/25/2024

Home Visit Date: 9/25/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulation Number: 900.910.1
Regulation Description: The grounds of the facility shall be kept clean and free of safety hazards.

Finding Description: Broken culvert drain, exposing sharp jagged edges was viewed near the walkway to the
school/administration building.

Action Due Date: 2024-10-25

Action Due Description: Please replace the pipe or cover it to ensure that children cannot trip or catch their foot
on the edges.

Comply Date:

Action Due Description: Please replace the pipe or cover it to ensure that children cannot trip or catch their foot
on the edges.

Regulation Number: 900.911.15.f

Regulation Description: Areas used by children shall be designed, constructed, and furnished to reduce risk of
suicide and assault including, but not limited to:

Finding Description: Strings were found in a hoodie located in room 302.

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

Action Due Date: 2024-09-25
Action Due Description: The hoodie was removed from the room on site.
Comply Date:

Sub-Regulation Level 1 Description: Children’s personal items that contain cords, pull-ties, strings, or other
parts that could be used to inflict self-injury shall not be left in the child’s room unless the dangerous component
has been removed.

Action Due Description: The hoodie was removed from the room on site.
Regulation Number: 900.911.6
Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.

Finding Description: Facility walls throughout the building appeared dirty with smudges on them and peeling
paint. Dayroom 1B had silicon caulking that had drained down the wall for another repair and was left, peeling
back the paint. The baseboard trim was hanging off with debris built up around it in Dayroom 1B. Room 306 had
broken concrete along the bottom wall and was missing trim. Room 407 exposed wire behind the sprinkler head
that is protruding from the wall and the tile was broken by the resident bed. Bathroom in gym had torn linen oleum
around the toilet and a makeshift wooden toilet back cover anchored to the wall. The shower and bathroom door
on the 100 hall was seen to be in disrepair and needs replaced. The sprinklers in rooms 302 and 303 were
protruding from the wall and could not be pushed back into place during the visit.

Action Due Date: 2024-10-25
Action Due Description: Please have all the areas mentioned in the report repaired within 30 days.

Comply Date:

Action Due Description: Please have all the areas mentioned in the report repaired within 30 days.

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Program manager and licensing specialist completed a buildings and grounds walkthrough of the 300 hall, 400
hall, dayrooms, and gym. Licensing also asked to view areas of the 100 hall that were mentioned during the visit
on 8/16/2024 needing repairs. Those areas were viewed and had not yet been repaired.

Outside courtyard staff/child ratio- 4:14- All other residents were in active group sessions.

100 Hall

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

¢The hallway for the resident's bedroom was recently repainted.

*No bedrooms were viewed during this visit.
*The bathroom door and shower tiles had not been repaired since they were discussed during the last visit on

8/16/2024.
*Dayroom 1B: What appeared to be silicon caulking was seen on the walls dripping down and dried to the wall.

The walls of the room appeared dirty, and the baseboard trim was peeling away from the wall.

300 Hall
*Room 302: String discovered in a hoodie, loose sprinkler fixture, paint was being chipped away on the door.
*Room 303: Loose sprinkler fixture came out of the wall enough to potentially allow something to be hung on the

piping or pulled down/out.
«Room 306: Broken concrete along bottom wall, missing trim.
400 Hall

*Room 403: Empty.
*Room 407: Description: missing sprinkler head, exposed wire. Tile was broken.
«Room 408: No issue.
Gym
*Gym bathroom seen with ripped linoleum around the toilet. The back of the toilet had also been removed and
replaced with a wooden top that is mounted to the wall.

Outside Courtyard

Broken culvert drain, exposing sharp jagged edges. The facility states that children should be walking on the
concrete path. Licensing discussed that since this is located next to the path, it could potentially harm someone if

they did decide to walk on or near it.
Nurses station 2 MARs was reviewed for the following resident with no concerns noted.

Provider Comments:

CCL Staff Signature : Date: 9/26/2024

Provider Signature : Date: 9/26/2024

www.arkansas.gov/dhs

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


summary: A resident was sent to Forrest City Medical Center after bumping heads with a peer while horseplaying. The facility was cited 907.3 for being out of ratio during this incident.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024196
Date of Incident: 9/22/2024
Date Received: 9/23/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City
Medical Center by order of Physician for further assessment to his head after accidentally
bumping heads with a peer while horseplaying. Please see attached d/c paperwork from
FCMC. Resident returned to milieu same day at 2025 (8:25 pm) without issue. By order of
Physician: Neuro checks every 48 hours and Resident is on activity restriction for seven
days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/25/2024- Licensing visited the facility to discuss the case and
review camera footage. The facility was unable to locate exactly when and where the
resident was injured in the video review. Camera footage was reviewed of the gym and
courtyard on 9/22/2024 from 16:40-16:52. Video showed the gym was non-compliant with
ratio regulations 2:17. The facility reports they will speak with the staff to determine the
correct time frame of when the resident was injured so that licensing can review the correct
video at a later date. 10/8/24- Licensing Specialist and Program Manager went to facility
and determined that no further action was needed.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Chelsea Vardell
Person In Charge: Immanuel Morris
Record Visit Date: 9/25/2024
Home Visit Date: 9/25/2024
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulation Number: 900.907.3
Regulation Description: Staff/child ratio shall be at least 1:6 during waking hours and 1:8 during sleeping hours.
Finding Description: Video review of the gym on 9/22/2024 showed the staff/child ratio at 2:17.
Action Due Date:
Action Due Description:
Comply Date:
Action Due Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Program Manager and licensing specialist visited the facility to discuss the case and review camera footage.
The facility was unable to locate exactly when and where the resident was injured in the video review.
Camera footage was reviewed of the gym and courtyard on 9/22/2024 from 16:40-16:52. Video showed the
gym was non-compliant with ratio regulations 2:17. The facility reports they will speak with the staff to
determine the correct time frame of when the resident was injured so that licensing can review the correct
video at a later date.
The facility is being cited for 907.3 for failing to maintain a ratio of 1:6 in the gym on 9/22/2024.
Provider Comments:
CCL Staff Signature : Date: 9/26/2024
Provider Signature : Date: 9/26/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

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www.arkansas.gov/dhs
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summary: A resident was sent to Cross Ridge Community Hospital for assessment of his nose after a physical altercation with his peer.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024055
Date of Incident: 9/18/2024
Date Received: 9/18/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Cross
Ridge Community Hospital by order of Physician for further assessment to his nose. Please
see attached d/c paperwork from FCMC. Residents were separated and was
moved to another Hall. Both Residents were interviewed by the Safety team morning of
09/18/2024. Both Residents verbalized no intention to pursue physical altercation. Resident
returned to milieu same day at 2054 (8:54 pm) without issue. Resident is on activity
restriction until assessed by ENT Doctor. ENT appointment forthcoming.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/18/2024- Licensing followed up with the agency to determine if any
video footage of the incident was available for review. The facility confirmed that there is
video footage. Licensing asked them to retain the footage for review next week. 9/24/2024-
Program manager and licensing specialist visited the facility and reviewed camera footage.
The incident cannot be seen on camera, but the hallway footage shows staff responding and
remaining in ratio. 10.7.24- Licensing Specialist determined incident complete
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 9/25/2024
Home Visit Date: 9/25/2024
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Program Manager and Licensing Specialist visited the facility to review the camera footage and follow up
regarding case 024055.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Camera footage of the "300" hallway was reviewed for 9/17/2024 at17:15-17:18. The residents were seen on
the hallway with staff in ratio. The resident and other boys had entered a bedroom at the end of the hallway.
Staff can be seen entering then exiting a short time later with the resident who is injured. The resident is taken
to the nurse's station for treatment, then sent out to the hospital for an Xray of his nose.
The resident and the peer were placed on peer restrictions and assault precautions following this incident.
Provider Comments:
CCL Staff Signature : Date: 9/26/2024
Provider Signature : Date: 9/26/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Forrest City Medical Center ER due to shaking and tremors.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024010
Date of Incident: 9/16/2024
Date Received: 9/16/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City
Medical Center ER by order of Physician due to shaking and tremors. All vitals normal.
Please see attached d/c paperwork from FCMC. Resident returned to milieu same day at
2143 (4:15 pm) without further complaint, no new issues, or new diagnosis.
Interim Action Narrative: Resident was sent to FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center due to complaints of back pain.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023817
Date of Incident: 9/5/2024
Date Received: 9/6/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City
Medical Center ER by order of Physician due to complaint of back pain. Resident returned
to milieu same day at 1615 (4:15 pm) with no issue.
Interim Action Narrative: Resident was sent for an x-ray at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this incident. 9/19/2024, Licensing inquired how
resident injured his back. Facility reported the resident's back pain was a result of a flare
from Resident was placed on activity restriction until flare subsided.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An officer was dispatched to the facility for a sexual misconduct report.

raw_content:
FORREST CITY Pee 4 [Incident
POLICE DEPARTMENT

225 N. ROSSER ST.
FORREST CITY, AR. 72335

Crime / Incident (Primary, Secondary, Tertiary)
5-14-107 SEXUAL MISCONDUCT

Incident #

2008050005

Attem Date
cl On or Fron| 09/05/2024
C]
LJ

o9/05/2024 | si
09/05/2024

Reported | Thu |
Location of incident 1527 Albert Av, Forrest City, AR

Cross Street § WASHINGTON
'N” = Victim

"RP" = Reporting Party "Ww" = Witness "§" = Suspect "QO" = Other

Hair Eyes | Home Phone
250 |BLK |BRO

State Work Phone
AR_ | (870)
“ _ -_ Pe 0. “
Last, First, Middle (Firm if —_— Race aT Age Hair Eyes | Home Phone
18 216 BLK |BRO

as DL Number aR Work Phone
(870)

City, —— Code — Local ID # State # FBI# . Phone
|| ve — _— MET e eee

Mr pe Number State } Work Phone

City, State, Zip Code Ee Local ID # State # FBI# Gell Phone
|| ee SE ee eee

a Number

mm pe Number | | pcre] Phone
City, State, Zip Code a ae Local ID # State # FBI | | Phone
Synopsis

Continuation PropertyList
Press Domestic Violence
oR 028
Gang Related 5 Victim Senior Citizen E]
Pursuit ["] | Force | Force Used [|| rel Child Abuse [_ |
Solvability County

Report Complete/Ready for Review CADI/CFS Event # 2409050005

<+4—-r-mMPrPcron

Z22z222222222

Assigned To Detective Andrea Hall Date 09/06/2024

Oftcer'D_ Officer James Rice 567 DAVIS, CURTIS 09/05/2024

Printed By/On: 442 / 09/26/2024 08:15:00
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

, FORREST CITY Page 2 incident conta

POLICE DEPARTMENT Narrative Incident # 2409050005
Crime / Incident (Primary) Attempt | Type Seq

On September 5, 2024, at approximately 10:36 A.M., I Officer Rice was dispatched
to 1521 Albert Avenue for a Sexual Misconduct report. Upon arrival I made

contact with is

explained that that she was at work last night at Perimeter Healthcare.
explained that she and MM, one of the kids, were on the
hallway by themselves. [MJexplained that around 8:15 P.M., last night
was trying to pull her in the room and while pulling her in the room he
told her let's have sex. JJexplained that he told her that if she tells
somebody he gone punch her in the face.

I Officer Rice gathered information for the report and let JJsign an
Juvenile Affidavit.

Reviewed By Approved Date
Officer ID Officer James Rice 567 DAVIS, CURTIS YES 09/05/2024
Printed By/On: 412 / 09/26/2024 08:15:02
CrimeStar® Law Enforcement Records Management System | | | | ||
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Call For Service
POLICE DEPARTMENT Event Detail Page

225 N. ROSSER ST. -
Event # Print Date
2409050006 09/26/2024

FORREST CITY, AR. 72335

Date 99/05/2024 |°°Y Thursday | "© 11:27:32 |DisratcrerID ggg [Agency ECPD
i

Address
Location 4594 Al BERT
State AR

City FORREST CITY
po ____ REPORTING PARTY INFORMATION __ |

County ST FRA

. Minutes of all
Officer ID Officer 1D associated Units :
Dispatch Time Dispatch Time 0

Call For Service / Event

CALLDETAILS > oo

Call Type 05 ASSAULT/BATTERY Priority @
Description :
CLIFF WILLIAMS ADVISED HE NEEDS TO SPEAK WITH AN OFFICER AND DO A SEXUAL HARRASSMENT
REPORT. PATIENT HARRASSED AN EMPLOYEE.

Cc CALL CLEARED EMD Code

Disposition

Comments

Printed By/On: 412 / 09/26/2024 08:14:03
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT


summary: Facility received an outside complaint that a resident was slammed into walls and having his head slapped. The complaint also stated that a staff member was threatening to harm the resident’s family and extend his treatment for non-therapeutic reasons. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 023747
Date of Incident: 9/4/2024
Date Received: 9/5/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Dual
Report Description: On 09/05/2024 Director of Quality Risk Management received an email
containing a notification of report of abuse/neglect from . Notice was
forwarded to Licensing Specialist and contact was submitted to
. Written statement from alleged victim, ,
was submitted to and Licensing Specialist that do not
align with allegation.
Interim Action Narrative: The facility requested to moved the staff to another unit and have
him supervised at all times. The staff will not participate in any restraint holds pending
investigation.
Maltreatment Narrative:
DHS/Placement Residential Licensing
Unit received notification of allegation via email from
stating, " is being slammed into walls and having his head
slapped and pushed into the wall, which is a sensitive area, additionally is making
vague and sinister threats to harm his family, making comments to spur on and
threatening to extend his treatment stay for non-therapeutic reasons.? It is unknown the
time and/or day of this allegation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing reviewed report for licensing concerns. Program
Coordinator spoke with facility regarding incident. An email was received from
. Program Coordinator inquired if allegations were called into the
. Per email from , a time nor date were provided of
when the alleged incident occurred. was informed of alleged abuse on 9/5/2024 per
email. reported she was asked to email the courtesy request to
Facility provided a written statement from the resident.
9/6/2024, received an email from stating that she would follow up with
Program Coordinator entered allegation into the
. Program Coordinator visited the facility to obtain documentation
and received confirmation via email that incident was accepted for investigation. Program
Coordinator requested permission from the and informed the of
allegation being accepted. Permission granted. Program Coordinator will request an ICA for
staff member name in this complaint. spoke with the resident who now reports
that he was just mad at the time of the report and that nothing has happened to him while at
the facility. 9/20/2024, Licensing received an email from regarding
additional information. 9/25/2024- Licensing reviewed and approved the ICA for the staff
pending the maltreatment investigation results. 10/1/2024-Maltreatment case was closed as
unsubstantiated. 10/2/2024- Facility requested that the staff be removed the ICA currently
in place. Licensing requested any precautionary retraining records that the facility
performed with the staff. The facility reports that they believe this case was a
misunderstanding and did not require any re-training as no wrongdoing was discovered.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Slade
Person In Charge: Charlotte Lockhart
Record Visit Date: 9/6/2024
Home Visit Date: 9/6/2024
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 12:30 pm to 2:00 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 51
Licensing received a complaint on 9/5/2024 for ELS Case #023747.
Program Coordinator spoke with Mr. Morris, Director of Risk Management regarding this complaint.
Program Coordinator inquired if resident was placed in any restraints for August 2024 that the staff member
named in this complaint participated in. Program Coordinator requested written statement from staff member
and nursing note.
Per nursing note, resident was placed in a restraint due to displaying physical aggression towards his peers and
his bottom lip on the left side was injured.
Mr. Morris informed Program Coordinator that staff member has been moved to another unit for now.
Licensing is not prepared to leave a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 9/6/2024
Provider Signature : Date: 9/6/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Forrest City Medical Center due to tremors and unstable vitals.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 023676
Date of Incident: 9/1/2024
Date Received: 9/3/2024
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to Forrest City
Medical Center ER by order of Physician due to tremors and unstable vitals. Resident was
interviewed by Safety team morning of 09/03/2024 and he shared he refused his medication
for two days but resumed taking them today. He also verbalized the importance of taking
his medications daily as symptoms were from abrupt stop in medications.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Resident received education on the importance of taking his medication.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov