summary: A resident was transported to the emergency room after being found unresponsive and displaying gurgling and choking noises.

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: 028593
Date of Incident: 3/29/2025
Date Received: 3/29/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
) Per staff report on 3/29/25 at approximately 0700: Resident was in his
room, sitting on his bed reading when staff heard an unusual noise. Staff entered the room
to check on the resident and found the resident lying on the bed with his eyes rolled back,
making gurgling sounds. Staff called for a nurse who arrived immediately. Nurse entered
the room and found the resident supine with eyes partially open and eyeballs rolled
backwards. Nurse heard gurgling/choking noises coming from the back of the resident's
throat. Nurse attempted to rouse the resident, but resident was not responsive to voice or
touch. Nurse noted a strong scent of urine and wet areas on the resident's pants and sheets.
Skin diaphoretic and hot to palpation. Capillary refill less than 2 seconds in fingers
bilaterally with no cyanosis noted. Pulse 3+, regular rhythm, rate 130 bpm. Respiratory rate
20 breaths per minute, respirations audible and wet. Nurse attempted to apply pulse
oximeter, but unable to get o2 saturation reading due to diaphoresis. At 0702, the resident
began to groan and move his fingers. O2 saturation immediately obtained, 83% on RA.
Nurse attempted to encourage resident to take deep breaths, but resident was disoriented,
lethargic, and confused. O2 saturation remained between 83% and 90% on RA until 0710. At
0711, APRN was contacted and ordered the resident to be sent to
for evaluation. When resident became oriented, he reported that he did not know what
happened. Resident reported that he did not remember waking up this morning and did not
remember getting dressed. Resident denied experiencing any similar incident in the past.
Resident reported that he may have hit his head the previous day but did not remember.
Resident denied taking any medication that was not his. Resident denied recent use of
drugs or other substances. Resident reported eating and drinking normally the previous day.
Resident reported headache rated 6/10 in severity and reported fatigue. Vital signs obtained.
Consent for transport obtained from biological father and biological mother. Mother reports
resident experienced and was followed by
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

for a short period of time. Mother reports that resident was never
. Resident left with transport staff
and one BHA at 0805. Upon return to facilty he was
We will make him follow-up appointments
with and he will return to if any further seizure like activity.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report. Licensing
specialist received nursing notes and incident report information from the facility. The
documentation was reviewed and uploaded to ELS.


state: AR

facility_name: Yellow Rock Behavioral Health (formerly Piney Ridge)

summary: An x-ray was ordered after a resident complained of left knee pain from an unknown origin.

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: 028574
Date of Incident: 3/27/2025
Date Received: 3/28/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Resident
C/O left knee pain due to unknown injury. He reports pain levels at 3/10
and hurts with bearing weight. He also reports pain on his right foot, plantar surface. There
has been no injury to his right foot. He reports the pain is worse when he bears weight on
the plantar surface. His gait is noted to be limping on his right foot. X-ray was completed in
house on 03/27/25- No fracture or issues noted to x-ray
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist Jarred Parnell reviewed the provider reported
incident. Licensing specialist received nursing notes and incident report information
documentation. The documentation was reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was sent to the hospital after complaining of increasing abdominal pain for several days.

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: 028569
Date of Incident: 3/27/2025
Date Received: 3/28/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Description of report: On 3/27/25 at approximately 1115: Resident was
on the unit complaining of abdominal pain for several days. The resident told the nurse that
the pain had suddenly become sharp and stabbing, rated 10/10 in severity. Resident
reported that the pain is localized to the RLQ and does not radiate. Nurse assessed the
resident and noted
.
Resident grimacing and noted to be rolling around on the ground moaning and
complaining of severe pain. Resident reported to nurse that he had a bowel movement this
morning that was WNL for this patient's baseline. Resident denied straining, denied
constipation, denied hard stool. APRN contacted. APRN ordered resident to be sent to
for evaluation of severe RLQ pain. DON notified. Caseworker
called twice with no answer. Caseworker notified via secure email. Resident returned to
at approximately 1447. Resident dx with and
Interim Action Narrative:
Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report. 4/28/2025 -
Licensing specialist contacted facility to inquire about the residents name, date of birth, and
guardianship status which was not mentioned in the report. Licensing specialist requested
nursing notes for the reported incident. Licensing specialist received nursing notes and
hospital discharge documentation for resident . The documentation was
reviewed and uploaded to ELS.


summary: A resident received a head injury after being struck in the head with a radio. The resident was transported to the emergency room for treatment.

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: 028570
Date of Incident: 3/27/2025
Date Received: 3/28/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: On 3/27/25 at approx. 1730 this
resident was helping to clean the unit when another resident
got upset with and grabbed the radio off the table
and hit him in the head with it. Staff were immediately able to separate the two residents. At
the time of the incident there were 8 residents and 2 staff. had a laceration to the top
of his head. Orders were received to take him to for evaluation.
mother was notified and she met the resident and our staff at the hospital.
. We will keep them dry and clean. He will follow-up with APRN here as
needed and will have the as directed. He returned to the facility
without any further issues.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the provider reported
incident. Licensing specialist received nursing notes from the facility, the notes were
reviewed and uploaded to ELS. The resident was placed on precautions not to wet the hair
or get the area wet where were placed.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct a personnel files review. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: Yellow Rock Behavioral Health

Facility Number: 203

Licensee Address: 2601 HABBERTON RD
SPRINGDALE AR 72764

Licensing Specialist: Jarred Parnell
Person In Charge:

Record Visit Date: 3/26/2025
Home Visit Date: 3/26/2025

Purpose of Visit: Personnel Records

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

3/26/2025 - 12:37 PM - 2:15 PM -Facility Census: 100

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

ARWANSE AS
| DEPARTMENT GF

Cy) j-7 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

Page 1 of 5

Licensing specialist Jarred Parnell conducted a licensing inspection to review personnel files for the
following:

D. Cartwright BHA date of hire 1/6/2025
M. Baumann BHA date of hire 2/3/2025

M. Borter BHA — III date of hire 6/20/2023
R. Cabaracas RN date of hire 8/19/2024

B. Andrews BHA- III date of hire 7/11/2022

The following standards were reviewed:
103.1

The agency shall conduct background checks, as required by the Child Welfare Agency Licensing Act (§
9-28-409), using forms approved by the Licensing Unit. Background checks conducted by or for other
licensing authorities (examples include, but are not limited to, the Office of Long-Term Care or the Division
of Developmental Disabilities Services) do not meet the requirement of this standard.

103.2

The following persons in a child welfare agency shall be checked with the Child Maltreatment Central
Registry in their state of residence (if available), any state of residence in which the person has lived for the
past five (5) years, and in the person’s state of employment, if different, for reports of child maltreatment:

103.2. a

Employees, having direct and unsupervised contact with children

103.2. b

House parents and each member of the household that is fourteen (14) years of age or older;
103.2.¢

Volunteers, mentors, sponsors, and student interns having direct and unsupervised contact with children;
103.2. d

Owners having direct and unsupervised contact with children;

103.2. e

Members of the agency’s board of directors having direct and unsupervised contact with children.
103.3

The Child Maltreatment Registry Check shall be repeated every 2 years.

103.5

The following persons in a child welfare agency shall be checked with the Identification Bureau of the
Arkansas State Police for convictions of offenses listed in Arkansas Code Annotated §9-28-409:

103.5. a

Employees, having direct and unsupervised contact with children

103.5. b

House parents and each member of the household that is fourteen (14) years of age or older;

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 5

103.5. ¢

Volunteers, mentors, sponsors, and student interns having direct and unsupervised contact with children;

103.5. d

Owners having direct and unsupervised contact with children;

103.5. e

Members of the agency’s board of directors having direct and unsupervised contact with children.

103.7

All persons required to be checked with the Department of Arkansas State Police under this subsection shall

repeat the check at a minimum of every five (5) years.
103.8

Child Maltreatment Central Registry Checks and Arkansas State Police and Federal Bureau of Investigation

(FBI) Criminal Record Checks shall be initiated within ten (10) days of employment

105.3

Childcare staff shall complete pre-service training prior to being counted in the staff-to-child ratio. This
training may be counted toward training hours for the first year. This applies to personnel employed on or

after January 1, 2011.

105.4

Pre-service training shall include without limitation:
105.4. a

* Confidentiality

105.4. b

* Resident Grievance process (PRTF Only)

105.4.c

* Fire and disaster plans

105.4. d

* Suicide awareness and protocol

105.4. e

* Behavior Management

105.4. f

* Crisis intervention management

105.4. g

* Agency policies and procedures

105.4.h

* Child maltreatment/mandated reporter policy
105.4. i

* 1 hour of training on the program’s safety plan (SRP only)
105.4. j

* Minimum Licensing Standards for their license type.

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

Page 3 of 5

105.5

All childcare staff shall have a current certificate of successful completion of First Aid and CPR. The training
shall require hands-on and skill-based instruction as well as practical testing. Training and certification that is
provided solely online will not be accepted. Staff shall complete this requirement within ninety (90) days of
hire.

105.6

At least one (1) childcare staff currently certified in hands-on and skill-based CPR and First Aid must be able
to immediately respond to an emergency.

105.8

All full-time childcare staff shall have 30 hours of job related in-service or workshop training each year. First
aid, CPR, and in-service training may be included.

105.9

Childcare staff working 24 hours a week, or less shall have at least 15 hours of job related in-service or
workshop training each year. First aid, CPR, and in-service training may be included.

105.10

All childcare staff in psychiatric facilities shall complete ten (10) hours of psychiatric-specific training before
being counted in the staff-to-child ratio. This applies to employees hired on or after September 1, 2016.

105.11

Sexual rehabilitative program childcare staff shall receive their initial 10 hours of sexual rehabilitative training
within 60 days of employment. (SRP only)

105.12

All childcare staff in a sexual rehabilitative program shall have at least 10 hours of sexual rehabilitative
training annually, which may be included in the required 30 hours of training. (SRP only)

105.13

Documentation of annual training shall include the date, number of hours, the name of the source, and the
topic or title.

105.14

The Administrator, Social Services Director, caseworkers, and therapists shall have 24 hours of job-related
continuing education each year.

105.1

Childcare staff must be at least 21 years of age with a high school diploma or equivalent.
105.15

The agency shall maintain a personnel file for each employee that shall include:
105.15.a

* Resume or application

105.15.b

* Date of hire

105.15.¢

* Verifications of qualifications

105.15.d

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 4 of 5

« Documentation of annual training

105.15.e

* Criminal Record Check and Child Maltreatment Central Registry Check information as required by law;
105.15.f

+ Documentation that applicable employees are informed that they are mandated reporters of suspected child
maltreatment, according to A.C.A § 12-18-402, and are provided the information needed to make a report;
105.15.g

* Functional job description

105.15.h

* 3 positive personal references from non-relatives

107.4

The agency shall document that all staff have been made aware of the need to protect the confidentiality of
children in the use of social media.

No violations of the above Minimum Licensing Standards were identified in the personnel files
reviewed.

*sete* 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 : — Kf / Date: 3/26/2025
Provider Signature : oly Date: 3/26/2025

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 5 of 5

doc_type: Compliance Report


summary: Licensing visited the facility to review children’s records. No deficiencies cited.

raw_content:
ARMRANBEAS
_DEPARTMENT OF

ix, HUMAN
“at 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: Yellow Rock Behavioral Health

Facility Number: 203

Licensee Address: 2601 HABBERTON RD
SPRINGDALE AR 72764

Licensing Specialist: Jarred Parnell
Person In Charge:

Record Visit Date: 3/26/2025
Home Visit Date: 3/26/2025

Purpose of Visit: Children’s Records

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

3/26/2025 12:37 PM - 3:15PM

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 1 of 4

Facility Census: 100

Licensing Specialist Jarred Parnell conducted a visit at the facility to review children's records as part of a
routine monitoring inspection.

Children's records were reviewed for the following:

902.2/ 1002.5 Medical exam no more than | year before admission or a documented appointment date for an
exam within one week after admission.

902.3/ 1002.6 Current Immunizations, a letter of exemption, or a scheduled appointment within one week
after admission.

902.13/ 1002.14 Legal documents should be received within 30 days of admission including birth certificates,
social security cards, and court orders OR documented attempts to obtain them.

902.4/ 1002.7 Written verification of the placing agent’s authority to place the child at the time of admission.
902.5/ 1002.8 Written authority for medical care from the placing agent at the time of admission.

902.7/ 1002.10

*902.9/ *1002.12 Residents must be under 18 at the time of admission and *cannot be under age 5.

AT THE TIME OF ADMISSION

902.10.a/ 1002.13.a Name, signature, and role or relationship of the person who relinquished the child into
care

902.10.b/ 1002.13.b A brief description of the circumstances requiring admission

902.10.c/ 1002.13.c The date and time of the admission

902.10.d/ 1002.13.d A brief description of the child’s history Gf known) including behavioral history
902.10.¢/ 1002.13.e Any known medical history and know current health conditions

902.10.f/ 1002.13.f All medications currently prescribed for the child (if known and available)
902.10.g/ 1002.13.g The child’s current behavior or known emotional condition.

INTAKE INFORMATION

902.11/ 1003.4 Intake information shall be completed on each child in care within 10 working days after
admission.

902.12.a/ 1003.5.a * Demographic information on the child and parent(s), including name, address birth date,
gender, race, and religious preference.

902.12.b/ 1003.5.b « A factual description of the circumstances requiring admission.
902.12.c/ 1003.5.c * A brief social history of the family

902.12.d/ 1003.5.d * Child’s current legal status or custody

902.12.e/ 1003.5.e * History of previous placements

1003.5.f » Description of the offense or sexually maladaptive behavior, including police reports and victim
statements (if applicable)

1003.5.g * Psychosexual assessment (if available)

1003.5.h « Discharge summary from previous sexual rehabilitative-specific treatment (if applicable and
available)

SAFETY AND TREATMENT PLANS
903.2/ 1003.1 A plan of safe care (if applicable) see standard for full description.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 4

903.4/ 1003.11 Treatment plan must be developed within 30 days after placement and must include:
1003.11.a A diagnosis related to their sexually maladaptive behavior.

903.5.a/ 1003.11.b + Specific needs of the child

903.5.b / 1003.11.c * Plan for meeting the child’s needs

903.5.c/ 1003.11.d * Special treatment needs (for example, psychotropic medications, sexual misconduct, and
neurological! disorders) shall be identified with a statement of how the special needs shall be met

903.5.d/ 103.11.e* A plan to ensure that educational needs are met

903.5.e/ 103.11.f+ Date of next review of the treatment plan

903.7 Treatment plan must be reviewed monthly and updated to reflect the child’s progress

1003.13 Treatment plan must be reviewed quarterly and shall be updated to reflect the child’s progress.
903.8 Agency therapist shall visit the child monthly to monitor the progress of the plan

1003.15 Agency caseworker shali visit the child monthly to monitor the progress of the plan

1003.6 A psychosexual evaluation must be completed within the past 12 months or within 7 days following
admission.

1003.7 Must be evaluated for learning disabilities and language disorders within the past 18 months. If not,
the evaluation must occur within 30 days of admission.

OTHER

904.1.j/ 1004.1.i1 Psychological reports, if applicable

904.1.k/ 1004.1.j Educational reports, if applicable

904.1.1/ 1004.1.k Disciplinary and incident reports, if applicable
904.1.m Daily behavioral observations

904.1.n Nightly visual observations24

904.1.0 Medication and physician orders

904.1.p Therapy progress notes

904.1.q Physician notes

904.1.1/ 1004.1.L Documentation of casework services and child contact
BEHAVIOR MANAGMENT

905.11 Chemical restraints can only be used if ordered by a physician.
905.12 Seclusion, mechanical or physical restraints shall only be used if ordered by a physician.

905.13 Each written order for a physical restraint or seclusion is limited to up to 2 hours for children 9-17 or 1
hour for children under 9. A physician, clinically qualified registered nurse or other authorized licensed
independent practitioner shall conduct a face-to-face assessment of the child within 1 hour after the initiation
of the ordered intervention.

905.14 The original order may only be renewed in accordance with these limits for up to a total of 24 hours.
After the original order expires, a physician, clinically qualified RN, or other authorized licensed independent
practitioner shall see and assess the child before issuing a new order.

905.15 Staff Shall search each child before placement in seclusion and all potentially hazardous items shall be
removed,

905.16 Staff shall continually monitor each child in seclusion or restraints and shall document.

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 4

905.17 Documentation of ALL restraints shall be maintained and include the child’s name, date, time, reason,
staff involved, and measures taken prior to the restraint.

There were 5 children's records reviewed to include:

No violations to the Minimum Licensing Standards were identified during the review,

*e*** 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.

_ Kf / Date: 3/26/2025
Date: 3/26/2025

Provider Comments:

CCL Staff Signature :

Provider Signature

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 4 of 4


summary: A resident was transported for acute care due to suicide behaviors.

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: 028418
Date of Incident: 3/19/2025
Date Received: 3/20/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Client Name:
Per therapist
report, therapist appeared withdrawn and had been sleeping in class. Therapist spoke to
resident, at which time resident stated he would "continue with suicide behaviors until
placed in or removed from ." Resident scored high on CSSR, on call MD
notified via phone. Resident to remain line of sight at all times, must have bathroom door
cracked while in bathroom and will on cot outside bedroom at night. Resident to be re-
assessed in 24 hours. Will be on SI precautions for 24 hours, staff informed of increased
visuals. Due to this report his team decided that an acute referral would be best for him. He
was accepted and transported to via our transportation team on
3/19/25. Resident went to without any issues
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report and will inquire
from the facility if the resident will be returning after acute care and what is the safety plan.
4/17/2025 - Facility response received "he is not returning"
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident injured her shoulder in recreational therapy.

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: 028377
Date of Incident: 3/18/2025
Date Received: 3/19/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: On 3/18/25 and x-ray was completed due to this resident
reporting that she hurt her shoulder in RT. While in RT she heard a pop on 3.14.25. X-ray
was completed in house on 3/18/25 with no fracture noted. APRN ordered to help
with the pain. Date of occurrence: 3/18/25 Corrective action taken by the agency or follow
up done: Resident will take medications as prescribed and will follow up with APRN as
needed. Upon assessment resident is currently able to fully use her arm with no issues at
this time.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist Jarred Parnell reviewed the report. Licensing
specialist received nursing notes for the reported incident. Documentation was reviewed
and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was found in the shower with leggings tied around her neck.

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: 028354
Date of Incident: 3/18/2025
Date Received: 3/18/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 03/17/2025 @ 0738
was allowed in the bathroom on for about 10 mins. She
responded when the first staff knocked on the door, the second time she did the resident did
not respond. The staff informed the nurse and the nurse quickly opened the bathroom and
observed the resident was on the floor in the shower with her back up against the wall with
what appeared to be a pair of leggings/pajama pants tied around her neck. Resident face
appeared slightly purple with her eyes closed. The nurse quickly unraveled the
leggings/pajama pants from resident's neck using her hands. Once the item was taken from
around her neck the nurse watch resident face return back to her normal skin tone and
watch her respiration's. The nurse and 2nd staff help resident up off the floor and the nurse
did a risk assessment to which she scored high. The nurse process with resident and
resident explain that she was done because her peers didn't want to talk to her because she
has went back on having self harm behaviors. Resident stated 10/10 emotional pain and
resident had an unopened red mark around her neck that was slowly fading away. Once the
nurse return resident back to the day room the nurse told resident's therapist what happen
and got an order from APRN at 0841 to have the door crack open till she is off precaution
along with being RTU X 24 hours. We made referrals to placements per APRN order
at 1022 am. She was accepted on 3/18/25 to and went there mid
morning.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report, requested
nursing notes and inquired if the resident will be returning after acute care. 3/25/2025 -
Licensing specialist received nursing notes and plan of return from for the
resident. Documentation was reviewed and uploaded to ELS.


summary: Three residents eloped from the facility by breaking the lock on a gate. Staff stayed with the residents and notified police, who arrived to escort the residents back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028356
Date of Incident: 3/17/2025
Date Received: 3/18/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 3/17/25 at approxPer staff
were outside in obsidan pod courtyard when residents pushed through the
court yard gate after one of them broke the lock. Staff followed the three residents
attempting to convince them to return. stayed close by staff through the brush and
thorns. were called and
came and brought back residents. After arriving back to the facility resident was asked to do
a search to make sure resident did not bring contraband to the facility, agreed and did
search and after was sent to resident unit and no further incident occurred. Per facility
policy resident will be placed on 24 hour elopement precautions and be RTU for 24 hours
due to eloping and pushing through staff. after the
and escorted all the three boys back to the building (Yellow
Rock Behavioral Health). After residents arrived back on the facility, they were placed in the
admissions office awaiting gown search. One of the residents agreed to return to the unit
while started to take off their soiled wet clothes. They began to slap
staff in the face and other areas of the body. They threw their dirty clothes at staff. They
both began to flip chairs, tables and ripped the phone out of the wall and cord out of the
phone. After everything was removed from the room, the two residents took off their shirts
and began being SAO by ?shaking their chests and bellies.? Resident pulled down his shorts
and exposed his genitals to staff and nurses. Staff called for extra nurse support and
emergency medication administered for resident and staff safety. No injury noted or
reported, Notified guardian and DON. Placed resident on RTU and SAO precautions for 24
hours. Mitigation of fixing the lock occured immediately and all primary therapists will
process with residents.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist Jarred Parnell reviewed the report, requested
nursing notes and inquired about the damaged phone. 3/21/2025, police documentation
requested. 3/24/2025 - Licensing specialist received nursing notes and email confirmation
that repairs have been made to the phone and gate lock. 3/26/2025, documentation
received and Licensing Specialist informed. Police report was reviewed by licensing
specialist.


summary: A resident was transported for acute care after making homicidal statements and displaying violence toward others.

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: 028325
Date of Incident: 3/14/2025
Date Received: 3/17/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 3/14/25 ) was
transfered to . She had been making severe homicidal
statements with intent and plan towards another resident. In addition she was displaying
violence toward others. It is unknown at this time if she will return to upon being
released from care.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist Jarred Parnell reviewed the report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported for acute care after expressing suicidal ideations and self-harming by punching himself repeatedly in the nose.

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: 028326
Date of Incident: 3/14/2025
Date Received: 3/17/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 3/14/25 at approximately 1936,
was transferred to for care after suicidal ideation
with intent and plan. In addition he the day before punched himself in the nose repeatedly
to draw blood to smear around. He had also grabbed a cable cord from computer in the
classroom in an intent to hurt self. It is unknown at this time if he will return to upon
completion of acute care.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist Jarred Parnell Reviewed the report. Licensing
specialist will follow up with the facility for nursing notes. 3/24/2025 - Nursing notes
received. Licensing specialist reviewed notes and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that he fell and injured his left ankle while playing soccer. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028262
Date of Incident: 3/13/2025
Date Received: 3/14/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: reported to nursing that he
fell and injured his left ankle in the gym playing soccer. Upon nursing assessment,
significant pain and swelling caused concern. The APRN was notified and gave orders for
an XRAY. XRAY was completed and
Guardians were notified via secure message. Resident taken to
on 03/14/2025 where the . Risk management spoke
with who stated that he was running and accidentally stepped on the ball and rolled
his ankle. Resident returned to the facility with crutches and orders to remain non-weight
bearing until his follow up appointment on 03/19/2025 where they may .
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing specialist Jarred Parnell reviewed the report. Licensing
received specialist received incident report documentation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident hit a wall with his left hand after being hit in the face by a peer. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028247
Date of Incident: 3/12/2025
Date Received: 3/13/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Resident Jordan Palone (DOB 03/13/2009) (AR resident in DHS
custody)- On March 12th a peer hit the resident on the face with an open hand and the peer
stepped on the resident?s glasses. The resident hit a wall with this left hand. Nurse on duty
noted swelling to the knuckle. was offered to the resident which the resident
refused. Ice applied to the left hand. Nurse on duty notified the APRN and received an
order for an x-ray of the left hand. X-ray completed on 03/12/2025. X-ray results: No acute
fracture or soft tissue swelling.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report. Licensing specialist Jarred Parnell
received nursing notes, serious injury incident report, and medical instructions from the
facility. Licensing specialist reviewed the documentation and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported right wrist pain and left ankle pain from an unknown source. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028174
Date of Incident: 3/9/2025
Date Received: 3/11/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Resident
- On March 9th the resident reported right wrist pain and left ankle pain to the
APRN. Unknown source of pain. Splint ordered for the left ankle during sports. X-ray order
for the right wrist. X-ray completed on March 9th. X-ray report: No acute fracture or
dislocation. No further follow up ordered at this time.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report. Licensing was
notified on 3/10/2025 by phone 479-466-0137 text message from facility staff Ronissa Adams
that they were having technical issues logging into the portal and sending emails. The
report was submitted late as a result of these technical issues. Licensing specialist Jarred
Parnell received nursing notes from the facility on 3/11/2025. The document was reviewed
and uploaded to ELS..
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported left wrist pain originating from an unknown source. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028173
Date of Incident: 3/9/2025
Date Received: 3/11/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Resident
On March 9th the resident reported left wrist pain to the APRN. Unknown source
of pain. X-ray order for the left wrist. X-ray completed on March 9th. X-ray report: No acute
fracture or dislocation. No followup at this time.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report. Licensing
Specialist Jarred Parnell reviewed the report. Licensing was notified on 3/10/2025 by phone
479-466-0137 text message from facility staff Ronissa Adams that they were having technical
issues logging into the portal and sending emails Licensing specialist recieved nursing
notes and medical documentation. The documents were reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to a caller needing to confirm the location of a patient.

raw_content:
Incident Report
Print Date/Time: 03/18/2025 13:12 Fayetteville Police Department
Login ID: aarcher ORI Number: AR0720100
Incident: 2025-00015110
Incident Date/Time: 3/7/2025 8:34:14 AM Incident Type: ASSIST AGENCY
Location: 4253 N CROSSOVER RD Venue: FAYETTEVILLE
FAYETTEVILLE AR 72703
Phone Number: (352)661-8191 Source: Phone
Report Required: No Priority: 3-Low
Prior Hazards: No Status: Not In Progress
LE Case Number: Nature of Call:
Unit/Personnel
Unit Personnel
409 409-JENEY
Person(s)
No. Role Name Address Phone Race Sex DOB
1 Caller PETERSON, KAYLA (352)661-8191 Female 01/01/2001
Vehicle(s)
Role Type Year Make Model Color License State
Disposition(s)
Disposition Count Date/Time
Unit:409
Disposition Count Date/Time
02GONEONARRIVAL 1 03/07/2025 08:45
Property
Date Code Type Make Model Description Tag No. Item No.
Page: 1 of 2

CAD Narrative
03/07/2025:08:44:19gabbickNarrative:409ADVPINEYRIDGEISNOWYELLOWROCKBEHAVORIALHEALTHAT2601
HABERTONRDSPRINGDALE
03/07/2025:08:38:08llangNarrative:REQCALLBACKFROMOFCR
03/07/2025:08:38:03llangNarrative:CALLERJUSTNEEDINGTOVERIFYTHATHEISHERE
03/07/2025:08:37:16llangNarrative:KP10375ISCALLER'SBADGENUMBER
03/07/2025:08:36:59llangNarrative:2025-080402ISCALLER'SCASENUMBER
03/07/2025:08:36:43llangNarrative:HEISLISTEDASASUSPECTACASECALLERRECREGARDINGSEXUALCONTACT/
CHILD-ON-CHILDCASE
03/07/2025:08:36:07llangNarrative:CALLERNEEDINGTOVERIFYTHATHE'SACTUALLYHEREANDWELL
03/07/2025:08:35:36llangNarrative:ATC
03/07/2025:08:35:09llangNarrative:CALLERWORKSW/DEPTOFCHILDRENANDFAMILIESINFLORIDA
Page: 2 of 2

doc_type: Police Report


summary: A resident complained of pain after a peer stepped on his foot. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028170
Date of Incident: 3/7/2025
Date Received: 3/11/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Resident
- On March 6th while playing basketball a peer accidently stepped on the
resident?s right foot per nursing note. RN on duty provided
Resident was seen by the APRN on March 7th, x-ray ordered. X-ray completed on
03/07/2025. X-ray report: No acute fracture or dislocation. No follow up needed at this
time.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report. Licensing
Specialist Jarred Parnell reviewed the report. Licensing was notified on 3/10/2025 by phone
479-466-0137 text message from facility staff Ronissa Adams that they were having technical
issues logging into the portal and sending emails. Licensing specialist received nursing
notes and medical information documentation from the facility. The documentation was
reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident complained of pain to the left hand.

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: 028171
Date of Incident: 3/7/2025
Date Received: 3/11/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Resident
On March 7th the resident was seen by the APRN for the left hand. Unknown
source of pain. APRN ordered an x-ray which was completed on 03/07/2025. X-ray report:
No acute fracture or dislocation. No follow up ordered
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing Specialist Jarred Parnell reviewed the report. Licensing
Specialist Jarred Parnell reviewed the report. Licensing was notified on 3/10/2025 by phone
479-466-0137 text message from facility staff Ronissa Adams that they were having technical
issues logging into the portal and sending emails Licensing specialist received nursing
notes, incident report and medical progress notes documentation for the report on
3/11/2025 The documentation was reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident reported that she twisted her ankle running around the dayroom.

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: 028084
Date of Incident: 3/5/2025
Date Received: 3/7/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
Description of report: This resident reported to nurses on 3/5/25 at 1928
that she had been running around in the dayroom and twisted her ankle. The nurse assesses
and at that time, slight swelling noted but no bruising noted. On 3/6/25 The resident said
she re-injured it and is not complaining of worse pain. She received , she had
bruising noted to the lower part of the ankle. Orders were received from APRN to complete
an x-ray. X-ray was completed in house with no fracture or dislocation noted. Resident will
be on no sports until she is able to walk without pain.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain to her left hand after self-harming and punching and slapping staff members. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028083
Date of Incident: 3/5/2025
Date Received: 3/7/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: - On
3/4/25 Resident started throwing shoes, trash and attempt to throw a chair at staff.
Resident began walking up to multiple staff and nurses punching and slapping them. Staff
were trying to give resident her personal space but resident refused and kept targeting staff
and nurses. Resident was able to force her way into the utility closet were she than sat on
the floor trying to hit her head on the wall. Staff place their hand behind her head to keep
resident from hurting herself and resident started punching using closed fist both staff and a
nurse. She later complained of pain to her L hand after hitting staff members. This was
reported to the APRN, order for x-ray was obtained. X-ray was completed in house on
3/6/25, X-ray results are negative for fracture or dislocation. Upon assessment today,
resident is able to use her hand without any issues. Primary therapist met with resident on
3/6/25 to review behavior contract and agression toward staff and peers.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report. Licensing Specialist Jarred Parnell
received injury documentation and incident report documentation. Documentation was
reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A visit was conducted to perform a full walkthrough of all buildings and grounds for the new facility. All areas inspected were free from construction equipment. All bedrooms and pods are furnished.

raw_content:
Vad / 7 HUMAN
ms “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

521 Visit Compliance Report

Licensee: Piney Ridge Treatment Center

Facility Number: 203

Licensee Address: 2805 E ZION RD
FAYETTEVILLE AR 72703

Licensing Specialist: Jarred Parnell
Person In Charge:

Record Visit Date: 2/24/2025

Home Visit Date: 2/24/2025

Purpose of Visit: Subsequent Building and Grounds

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

Regulations Not Correctable:

Narrative:

A visit was conducted on 2/24/2025 to do a full walkthrough of all buildings and grounds for the new Yellow
Rock/Piney Ridge facility.

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

Areas inspected during the walkthrough were all resident pods, bedrooms, bathrooms, common areas, outdoor

recreation areas, education classrooms, gymnasiums, cafeterias, kitchen, hallways, library, nursing stations,
and administration offices.

All areas inspected were free from construction equipment. All bedrooms and pods are furnished with beds,
and seating with age appropriate furniture and free of hazards.

Provider Comments:

CCL Staff Signature : wwf. S/ Date: 2/24/2025
Provider Signature : ©) Date: 2/24/2025

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


summary: An x-ray was ordered after a resident reported that he injured his left foot by tripping on his jacket.

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: 027782
Date of Incident: 2/24/2025
Date Received: 2/24/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: ( Resident in
Parental Custody) Resident's guardian called and stated that Resident reported to her
during visitation that he injured his left foot on Wednesday 02/19/25 while playing soccer,
tripped on his own jacket and bent toes backwards. Assessment was completed and
Resident's and , Resident is mobile,
APRN made aware and gave order to complete X-ray of , no sports until assessed on
Monday but Resident became upset and stated does not hurt and wanted to play in
the gym. X-Ray was completed in house, X-ray results show no fracture or other
pathology. Mom was made aware of results. APRN reassessed this morning (2/24/25) and
resident was released from his no sports.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report and received nursing notes and incident
report information from the facility. The documentation was reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain after rolling his right ankle while playing football. The resident was sent for an x-ray.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027832
Date of Incident: 2/24/2025
Date Received: 2/25/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 2/24/25 at approximately 1452,
private) the resident was in recreational therapy playing football. The resident was running
to catch the ball and rolled his right ankle. Nursing was called to the gym. Upon
assessment, the resident?s ankle was red and swollen. Resident was sent to
to get an x-ray. The consult says
. Guardians was notified by phone. Voicemail left for . DON notified. All
appropriate parties notified. He will follow up in two weeks. He has a tall walking boot. We
are reaching out to to clarify what " " means.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report. Nursing notes and incident report
documentation has been received, reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was referred for acute placement after trying to hang himself with a pair of pants.

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: 027805
Date of Incident: 2/23/2025
Date Received: 2/24/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name:
( resident in parental custody) A peer approached a staff and informed them of the
following incident: The peer left the bathroom of room 208 and this resident entered with an
extra pair of jeans in hand. As the resident was attempting to close the bathroom door, the
resident hung the bottom of the pants legs on the top of the door. The groin area of the
pants were left hanging upside down and as the resident placed his head in the loop,
attempting to hang himself from the pair of jeans. The door did not close completely and
caught the attention of the peer, the peer opened the bathroom door completely and
removed the pants from the peer and alerted staff outside the bedroom door. A supervisor
and nurse went to the situation and observed the resident sitting on his bed. When nursing
began asking the resident about this incident, the resident disclosed that his actions were to
"End the pain" that he reports constantly feeling and that he was upset with peers that had
been verbally bullying him all day. The resident was cooperative in removing all items from
his bedroom and placing his mattress in the hallway for continuous observation. No ligature
marks, redness or any injury noted on the resident's neck by nurse. Resident declined injury
or pain to the area. Nursing completed C-SSRS, contacted provider on call, and resident
placed on suicide precautions for twenty-four hours. Resident's personal belongings placed
in the nurses station. Administrator on call, therapist on call and primary therapist notified
via secure message @2035. Upon assessment today and after the resident spoke to the
Therapist and physician it was decided to make a referral for He was accepted to
and will be transported tonight by our transportation team. Residents guardians
have been notified of the transfer.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Narrative:
Licensing Narrative: Licensing reviewed the report and will request nursing notes and
resident status if they will return after . Nursing notes and incident report received
from facility, documentation reviewed and uploaded to ELS. 2/27/2025- Licensing
specialist sent follow up inquiry if the resident will be returning after . Facility
response received " the resident will be returning after ."


summary: A resident complained of pain after an altercation with a peer. The resident was sent for an x-ray. Both residents were placed on 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: 027354
Date of Incident: 2/5/2025
Date Received: 2/6/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 2/5/25 Staff reported that while outside,
) walked up to private and threatened
and punched her, which made both residents to fall down to the ground, landed
on her right arm in the process and kicked this in the face while down on the
ground, staff intervened immediately and separated residents. c/o intense pain to
right arm, no swelling noted but resident c/o not able to move the extremity, APRN notified
and gave order to send patient to , came back with but to
follow up , . MC Supervisor met with both residents
upon her return to discuss the situation and both residents resolved the issue with the
supervisor. Both residents placed on precautions to be reassessed in 24 hrs. Primary
Therapists made aware of situation.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report. Facility sent incident report
documentation and nursing notes, reviewed and uploaded to ELS Staff to resident ratio was
2:12.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that he was having sexual relations with his therapist outside of the facility. The facility was cited 109.1.g as a result of this complaint. The staff member was terminated.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029103
Date of Incident: 2/2/2025
Date Received: 4/18/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: AV is . AOs a female therapist and a female staff
member at Piney Ridge Treatment Center, ages/names unknown. AV reported that while at
Piney Ridge his therapist gave him her business card and told him to call her if he needed
anything. AV disclosed that he wanted money, so he called the therapist. AV was told to
come over to the therapist?s home, and the therapist made the comment like AV ?took the
bait? and that he was the first one to ?take the bait.? AV has been having sexual relations
with the therapist after this initial encounter. AV has had multiple sexual encounters with
this therapist. Unknown how long this has been going on. AV and the therapist stopped
seeing each other on 02APR2025 due to AV being placed in the .
AV also reported that another staff member at Piney Ridge was trying to flirt with him. AV
reported that the staff member was sitting on the edge of his bed, and AV was startled by
this. AV stated that he had to turn down a sexual advance from this staff member. Both the
therapist and the staff member are still employed at Piney Ridge as far as AV is aware. AV
was admitted to Piney Ridge due to suicidal ideations. AV also has issues with anger. AV is
currently at and will be there for five to six
months. Both AOs work during the day at Piney Ridge.
Interim Action Narrative: suspended pending
the investigation
Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing specialist Jarred Parnell reviewed the report. Licensing
specialist reached out to investigator for the names of the therapist and staff
alleged in the report. Licensing specialist scheduled a visit for 4/22/2025 to review resident
file and interview staff members. Licensing specialist received information from investigator
, the staff members alleged in the report are for and
, licensing specialist notified the facility that an ICA is needed for the named
staff. 4/22/25-The PRLU received an ICA request for staff . and it was reviewed. The
PRLU requested the ICA be revised to include how the facility will ensure . does not
have any unsupervised contact with the residents and who will be responsible for their
supervision during their shifts. The facility reports that the therapist was placed on
suspension, and they are unsure if they will be requesting an ICA at this time. 4/22/2025 - A
visit was conducted to review files for personnel and
Personnel files were reviewed for back ground checks and on-the-job
write ups, trainings, and licensure for . Children records review for
- Licensing specialist
Jarred Parnell interviewed | 9:20
AM - 9:44 AM I introduced myself with and told her I was with Licensing. I let her
know we had received a report and I confirmed if she could speak with me. I asked
if she remembers a resident named said yes. I asked to
tell me about that resident. said he was a troubled kid and had family issues.
stated he had mood issues as well. I asked when did this resident
discharge. said October or November of last year. I asked if this resident
has ever been to her personal residence. stated yes, the resident came to their
house, but it was months after they discharged. I asked when was this?
said November of last year. I asked again to confirm when the resident
discharged. stated she thinks maybe August or July. I asked what did
the resident do while at her personal residence. stated he mostly hung out with her
husband and did door dash, while rode along. I asked what was the
purpose of this? said her husband was just trying to be a good role model and
have positive interactions with . I asked to tell me how these interactions
started? stated found her husband on facebook and reached out, but this
was months after he discharged. I asked to provide her husbands name and
contact number - said his name is I asked
if ever hung out her residence while she was there. said yes but
never alone, my husband or children were always present. I asked if it was
common for her to have residents come over to her personal residence? said no
that it was not common. I asked if there was anything else she wanted to tell me,
asked if anyone else was going to call her because she hasn't heard anything. I let
know that investigations can sometimes last thirty days. I asked if i
could call her back if I need any more information, she said that's fine. The interview was
terminated. Licensing specialist staffed case with C. Vardell and K. Slade. Licensing
specialist sent an email to detailing the information obtained in the
interview. Licensing specialist spoke with . is awaiting an

interview from for the report. 4/25/2025 - Licensing specialist staffed
case with C. Vardell and K. Slade. Licensing specialist sent an email to
and requested to sit in and observe the interview with . Licensing specialist
Jarred Parnell received notification from is no longer
employed at Yellow Rock Behavioral Health. Licensing specialist requested the termination
documentation be sent to licensing. Licensing Specialist received termination
documentation from the facility, documentation was reviewed and uploaded to ELS.
terminated effective date is /2025. 4/30/2025 - Licensing Specialist
Jarred Parnell staff case 029151 with C. Vardell and K. Slade. Licensing specialist will obtain
information in regards to the guardian the resident was discharged to as well as the contact
information for the guardian. Licensing specialist attempted to contact at
the facility, a voicemail was left at 10:00 AM. Licensing Specialist sent an email to facility
staff letting her know i need the guardianship information for which the
resident was discharged to and the contact information for the guardian. Licensing
Specialist spoke with over the phone on 4/30/2025 at 11:10 AM - Ronissa
stated the resident was discharged to his
Licensing specialist
attempted to contact - I was not able to leave a voice mail.
The phone recording stated "this person is not accepting voicemails at this time, try to send
a text message". I texted the number this is Licensing Specialist Jarred Parnell with
Arkansas DHS, I need to speak with you concerning Yellow Rock Behavioral Health, please
call me at 479-313-3240. Licensing Specialist Jarred Parnell spoke with
was discharged from Yellow Rock Behavioral
Health. over the phone on 4/30/2025 at 11:45AM - 12:20PM Licensing Specialist Jarred
Parnell spoke with was
discharged from Yellow Rock Behavioral Health/Piney Ridge. I interviewed over
the phone . on 4/30/2025 at 11:45AM - 12:20PM - I introduced myself to
and told her i work for Licensing with Arkansas DHS. I told I was calling
to speak with her about Yellow Rock Behavioral Health. stated she wasn?t familiar
with Yellow Rock. I asked if she was aware of Piney Ridge? confirmed
and i let her know they are now Yellow Rock. I asked if she was familiar with
Piney Ridge, stated yes, her son was there last year. I asked to confirm
her son's name and she stated I asked was discharged from
Piney in her care. stated yes, around last year was discharged from
Piney and he came to live with me from when he was arrested.
I asked if during that time period he visited Arkansas. stated yes, he
would visit Arkansas to see some friends. I asked to tell me who the friends are.
said it was his therapist from Piney
. I asked if she gave consent to to visit
in Arkansas. stated yes. I asked how did get in
contact with once he was living back home. stated she thinks
he may have been in contact with mostly over Facebook because has his own
cell phone. I asked if she is the account holder for cell phone.
stated yes, she pays the bill, it is turned off but she has it in her possession. I asked

if she is able to access phone and see messages between
, and if she could send me the date of when those messages began.
stated she would have to charge the phone but would send me photos of the
conversation with the date and time stamp when the text conversations between
started. stated for the most part they were just hanging out
and working on a truck and a small mini motorcycle. I told that I didn't have any
further questions. I asked if she had any questions for me. wanted to
know what this was about. I told Licensing received a report and we are
investigating Piney Ridge for a standard concern. I also informed her there was an open
, and she may be contacted . I asked
if I had further questions, could I call her. stated yes. The interview was
terminated. Licensing Specialist received a text message from with photos
of text message conversation over facebook.
The photos were reviewed and uploaded to ELS. Licensing specialist received a text
message from with photos of phone with text messages and
facebook messages with . Licensing Specialist sent the interview
information with and photos from to
5/2/2025 - Licensing specialist received information from in
regards to . The email was uploaded to ELS. Licensing specialist received
notice of termination for documentation uploaded to ELS. 5/27/2025 -
Licensing Specialist Jarred Parnell staffed the case with supervisors K. Slade and C. Vardell,
licensing specialist followed up with the facility for a copy of the personnel file page that
shows received the facility policies, licensing specialist
requested a copy of the facility policy for the exploitation. 5/28/2025 - Licensing Specialist
received a copy of the "zero tolerance" policy from the facility. The policy was reviewed and
uploaded to ELS. This document does not have information regarding what is expected of
the "zero tolerance" practiced by the facility. Licensing specialist requested information
and content of what is communicated to employees in regards to "zero tolerance" for abuse
and neglect as communicated by facility risk management. Licensing specialist attempted
to contact for a case update. The call was not answered, a
voicemail was left. Licensing specialist received training documentation for
. The documentation was reviewed and uploaded to ELS. 5/30/2025- The
facility management requested a meeting with the DPSQA Director to discuss the findings
in this report further.

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: Yellow Rock Behavioral Health
Facility Number: 203
Licensee Address: 2601 HABBERTON RD
SPRINGDALE AR 72764
Licensing Specialist: Jarred Parnell
Person In Charge:
Record Visit Date: 4/22/2025
Home Visit Date: 4/22/2025
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulation Number: 100.109.1.g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Finding Description: A staff member maintained a personal relationship with a former resident while they were
still employed at the facility.
Action Due Date: 2025-05-30
Action Due Description: The employee was terminated 5/1/2025.
Comply Date:
Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 4

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
4/22/2025 - A visit was conducted at the facility by Licensing Specialist Jarred Parnell for case #
029103. The report alleged that a therapist at Yellow Rock Behavioral Health had given a resident
their business card. The report alleges this resident contacted the therapist and began visiting their
private home to have sexual interactions. The resident from the report also claims another staff
person at the facility used to flirt with him.
The following standard was reviewed as part of the investigation:
109.1.G Unprofessional conduct in the practice of child welfare activities shall include
without limitation:Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.
108.1.C The Arkansas Child Welfare Agency Review Board sets forth this section as a Code
of Ethics and Standards for Practice for all child welfare agencies within the State of
Arkansas Violations of the following shall be grounds for disciplinary action:c. Client
Relationships: Relationships with clients shall not be exploited by the child welfare agency
staff for personal gain.
Personnel files were reviewed for the staff people alleged in the report for updated background
checks, training, on-the-job write-ups and disciplinary actions.
The record for the resident alleged in the report was reviewed as part of the investigation.
Staff Interviews
4/23/2025 - Licensing specialist Jarred Parnell interviewed Staff 1 over the phone - | 9:20 AM - 9:44
AM
I introduced myself with Staff 1 and told her I was with Licensing. I let her know we had received a
report and I confirmed if she could speak with me. I asked Staff 1 to tell me about resident 1. Staff 1
said he was a troubled kid and had family issues. Staff 1 stated he had mood issues as well. I asked
Staff 1 when did this resident discharge. Staff 1 said October or November of last year. I asked Staff
1 if this resident has ever been to her personal residence. Staff 1 stated yes, the resident came to
their house, but it was months after their discharge. I asked Staff 1 when it was this that the resident
went to their home. Staff 1 said November of last year. I asked Staff 1 again to confirm when the
resident was discharged. Staff 1 stated she thinks maybe August or July of 2024. I asked Staff 1
what did the resident do while at her personal residence. Staff 1 stated he mostly hung out with her
husband and did door dash, while Resident 1 rode along. I asked Staff 1 what was the purpose of
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 4

this contact with the resident. Staff 1 said her husband was just trying to be a good role model and
have positive interactions with Resident 1. I asked Staff 1 to tell me how these interactions started.
Staff 1 stated Resident 1 found her husband on Facebook and reached out, after he was
discharged. I asked Staff 1 to provide her husband’s name and contact number - Staff 1 provided
the information. I asked Staff 1 if Resident 1 ever hung out at her residence while she was there.
Staff 1 said yes but never alone, my husband or children were always present. I asked Staff 1 if it
was common for her to have residents come over to her personal residence. Staff 1 said no that it
was not common. I asked Staff 1 if there was anything else she wanted to tell me. Staff 1 asked if
anyone else was going to call her because she hasn't heard anything. I let Staff 1 know that
investigations can sometimes last thirty days or more. I asked Staff 1 if I could call her back if I need
any more information, she said that's fine. The interview was terminated.
Guardian Interview
Licensing Specialist Jarred Parnell spoke with Guardian – 1. Resident 1 was discharged from
Yellow Rock Behavioral Health into Guardian – 1’s care. Licensing Specialist spoke with Guardian-
1 over the phone on 4/30/2025 at 11:45AM - 12:20PM
I introduced myself to Guardian - 1 and told her I work for Licensing with Arkansas DHS. I told
Guardian - 1 I was calling to speak with her about Yellow Rock Behavioral Health. Guardian - 1
stated she wasn’t familiar with Yellow Rock. I asked Guardian - 1 if she was familiar with Piney
Ridge. Guardian - 1 confirmed and I let her know they are now Yellow Rock. Guardian - 1 stated
yes, her son was there last year. I asked Guardian - 1 to confirm her son's name. I asked Guardian -
1 if Resident - 1 was discharged from Piney in her care. Guardian - 1 stated yes, around August last
year Resident - 1 was discharged from Piney and he came to live with me from August 2024 to
January 2025 when he was arrested. I asked Guardian - 1 if during that time he visited Arkansas.
Guardian - 1 stated yes, he would visit Arkansas to see some friends. I asked Guardian - 1 to tell
me who the friends are. Guardian - 1 said it was his therapist from Piney (Staff-1) and her husband.
I asked Guardian - 1 if she gave consent for Resident - 1 to visit Staff-1 and her husband in
Arkansas. Guardian - 1 stated yes. I asked Guardian - 1 how did Resident - 1 get in contact with
Staff - 1 and her husband once he was living back home. Guardian - 1 stated he may have been in
contact with Staff – 1’s husband mostly over Facebook because Resident - 1 has his own cell
phone. I asked Guardian - 1 if she is the account holder for Resident – 1’s phone. Guardian - 1
stated yes, she pays the bill, it is turned off, but she has it in her possession. I asked Guardian – 1 if
she can see resident-1’s messages and tell me the date of when Staff-1 and resident-1 started
texting. Guardian – 1 stated she would send me a photo of the conversation as so as possible. I told
Guardian - 1 that I didn't have any further questions. I asked Guardian - 1 if she had any questions
for me. Guardian - 1 wanted to know what this was about. I told Guardian - 1 Licensing received a
report and we are investigating Yellow Rock Behavioral Health formerly Piney Ridge for a licensing
complaint. I asked Parent - 1 if I had further questions, could I call her back. Parent - 1 stated yes.
Licensing specialist terminated the interview.
Information obtained through the investigation showed that Staff 1 had personal contact over the
phone and in person with resident 1 while still employed at Yellow Rock Behavioral Health. Phone
logs and social media account message logs were received and reviewed by the specialist. The
logs show that resident 1 had regular contact with staff 1 and her husband, which occurred as early
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 4

as October 25, 2024, while staff 1 was still employed.Licensing Specialist Jarred Parnell received
notification on 5/2/2025 from facility risk manager that Staff 1 has been terminated effective
4/25/2025 due to having personal contact with a resident after being discharged from the facility.
Complaint case 029103 has been FOUNDED by Licensing.
The facility is being issued a citation for standard 1091.GUnprofessional conduct in the
practice of child welfare activities shall include without limitation:Engaging in behavior that
could be viewed as sexual, dangerous, exploitative, or physically harmful to children.
***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration
must be in writing and delivered to the Department by certified mail within twenty (20)
business days of receipt of the notice of noncompliance. The request must specify the parts
of the notice that are alleged to be in error, explain why you believe those parts are in error,
and include documentation to support the allegation of error. Once received the Department
shall issue a decision on your request within twenty (20) days after receipt of the request.
Provider Comments:
CCL Staff Signature : Date: 4/22/2025
Provider Signature : Date: 4/22/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 4 of 4


summary: A complaint triggered Inspection of Care review was conducted at the facility. Deficiencies were cited.

raw_content:
▪ AFMC staff noted that the staff member listed as the alleged offender was not listed on staff
debriefing documentation page for the physical restraint that occurred on January 12, 2025, at 11:58
a.m. The facility staff stated that the alleged staff member’s personal keys fell out of their pocket
while they were assisting another staff member in physically restraining the client. After releasing
the restraint, the alleged victim and another client grabbed the staff member’s keys and played
“keep away” with keys. Once the staff member obtained keys back from the clients it was reported
to facility management staff that staff member was very upset and left their shift early without
completing the staff debriefing.
o Training requirements within the Emergency Intervention policy are outlined as follows, Staff will complete
Handle with Care recertification training annually. Direct care staff also participate in a Handle with Care
refresher training within six months of certification/recertification.
• The Incident Reporting-Risk Management Program Policy:
o Section IV.C. PROCEDURES states, an ‘incident’ is an unanticipated event, which results in, or nearly
causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term,
or permanent and range in severity from no obvious or significant injury, up to death.
▪ Supervisor will review the Incident Report for legibility, completion, and date. Supervisor will
notify facility Risk Manager of a serious incident as well as take the lead in investigating non-
serious incidents.
▪ The Incident Report will be routed to the facility Risk Manager within 24 hours of incident.
▪ Completed, reviewed, and signed Incident Reports must be entered into the Risk Management
Information System ("RiskQual/HAS" incident reporting system). The “Level l" and "Level Il"
incidents must be entered within 24 hours. 'Level Ill" and "Level IV" incidents must be entered
within 5 calendar days.
▪ If the incident involves a patient, staff must chart relevant and factual information in the patient's
medical record. When documenting incidents in the medical records, staff will chart precisely what
happened without referring to an "error" or that an Incident Report was completed. Staff should
not attribute any cause to the unanticipated event.
o Section VI. INCIDENT TYPE CATEGORIZATION states,
▪ A. Patient Care Treatment: Incidents involving a patient while they are actively participating in
treatment that can or does cause harm or disruption.
• 5. O1E. Verbal or mental/psychological abuse by staff allegations.
▪ B. In states where the facility is required to report certain adverse events to an outside regulatory
agency, it must be done within state/agency requirements with notification of such external
reporting obligations to Corporate Risk Management and Corporate Quality and Compliance.
• 1. All incident Reports received by the facility Risk Manager will be assigned an initial
severity classification level in accordance with established Corporate Risk Management
criteria, approved by the facility leadership and Governing Board.
• 2. The severity level index will be utilized by the facility Risk Manager and facility
leadership to identify significant incidents in an effort to facilitate referral of issues needing
further evaluation and/or action to address and monitor failures in systems to improve the
quality of care.
• 3. The following severity level classifications shall be assigned in incident reporting:
o A. Level 1 (Major): Incidents which are considered serious events. This may
include sentinel events.
o B. Level II (Moderate): Injury or impairment in which a patient or visitor’s
function may be altered with treatment limited to first aid.
o C. Level III (Minor): Injury or impairment in which a patient or visitor’s function
may be altered with treatment limited to first aid.
o D. Level IV (Inconsequential): Events which do not otherwise qualify as a Level I,
II, or III and where no injury or outcome alters a patient or visitor’s function.
• 4. Extra event identifiers for qualifying incidents
o A. Near Miss Event: Identifies an incident or process variation that carried a
significant change of being recognized as a Sentinel Event, but is outside the scope
of a Sentinel Event description.
o B. Sentinel Event: Identifies a patient safety related incident (no primarily related
to the natural course of an illness or underlying condition of an individual served)
Piney Ridge Treatment Center, LLC- Fayetteville, AR. - IOC Report 2 | P ag e

the alleged victim and offender during the physical restraint incident on January 13, 2025. All
employees interviewed stated that they did not hear the alleged statement made by the alleged
offender.
▪ On January 16, 2025, the alleged offender was cleared of the allegations by Piney Ridge Center
based on the results of the internal investigation.
▪ On January 17, 2025, the Risk Manager and Director of Nursing received an email from PRLU
that a l had been received regarding the incident occurring on January 12, 2025. The
facility’s Risk Coordinator, who was not involved in the restraint, was named in the
as the alleged offender in the incident occurring on January 12, 2025. The Risk Coordinator was
suspended on January 17, 2025.
▪ On January 17, 2025, the Washington County DCFS Investigator visited the facility and
interviewed the alleged victim. The facility’s Risk Manager informed the Washington County
DCFS Investigator at this time that they had the wrong alleged offender.
▪ On January 21, 2025, the Risk Coordinator was released of the suspension by PRLU and Piney
Ridge Treatment Center and was allowed to return to work on January 22, 2025.
▪ The alleged offender was suspended on January 19, 2025, via phone, for a pending investigation
of inappropriate comments made during a restraint on January 13, 2025.
▪ The alleged offender was terminated January 20, 2025, due to legal issues outside of
employment, that did not relate to the incident.
▪ On January 24, 2025, PRLU visited Piney Ridge Treatment Center. At the time of the AFMC
IOC the facility had not received the 521 Form from the PRLU.
• Upon review of the alleged victim’s chart the following observations were noted:
o The client was admitted to Piney Ridge Treatment Center, LLC on , 2024, and remains a client
in the facility.
o The psychiatric evaluation was completed on October 25, 2024, at 2:55 p.m. but was not signed by the
provider until January 23, 2025, at 9:39 a.m.
o The client had the following episodes of restraints documented. Most incidents are documented as
unprovoked outbursts of behavior resulting in the alleged victim assaulting peers and staff members.
▪ Physical Restraint on November 11, 2024, at 7:45 a.m. - 7:51 a.m.
▪ Physical Restraint on January 11, 2025, at 4:09 p.m. - 4:12 p.m.
▪ Physical Restraint on January 12, 2025, at 11:58 a.m. - 12:06 p.m.
▪ Physical Restraint on January 13, 2025, at 8:08 p.m. - 8:22 p.m.
▪ Physical Restraint on January 15, 2025, at 6:50 p.m. - 6:54 p.m.
▪ Physical and Restraint on January 15, 2025, at 7:25 p.m. - 7:37 p.m.
▪ Physical Restraint on January 18, 2025, at 8:45 a.m. - 8:55 a.m.
▪ Physical Restraint on January 18, 2025, at 7:15 p.m. - 7:27 p.m.
o Each restraint episode was documented using the facility’s restraint packet. Restraint documentation was
reviewed, and the following observations were noted:
▪ All orders for physical and chemical restraints were obtained in a timely manner via
verbal/telephone orders. Orders for episodes of restraints were noted to be signed anywhere from
3 days after the initial order received to 13 days after the initial order is received. No orders
signed within 24 hours of receiving the initial order.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Piney Ridge Treatment Center, LLC- Fayetteville, AR. - IOC Report 5 | P ag e

doc_type: IOC Report


summary: While being seen by the foot doctor for a separate issue, an x-ray performed showed a fracture. The resident does not know how the injury occurred and denied any 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: 027109
Date of Incident: 1/27/2025
Date Received: 1/28/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: HE is
out of state in parental custody Description of report: On 01/27/2025 this resident was
seeing the foot Dr. for an . Upon assessment they did an x-ray that showed a
. The resident does not know how this
happened, he denied any pain with this, or any knowledge of him hurting it. He will
be in until his return visit on 02/24/25. He is also on no
sports or high impact activity until his return appointment.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report. Facility sent nursing notes and serious
injury report. The documentation has been reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that he twisted his ankle while playing basketball with peers. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026959
Date of Incident: 1/17/2025
Date Received: 1/21/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: Description of report:
On 01/16/2025 this resident was playing basketball with peers, he later reported to nurses
that he ?twisted his ankle? while he was playing. APRN was notified and she did
assessment on 01/17/2025, she ordered x-ray to the left foot/ankle. No sports x 6 weeks and
he is to only do stretches during RT. X-ray was completed in house, came back no injury.
We will continue with other physician orders at this time.
Interim Action Narrative:
Narrative:
Licensing Narrative: Licensing reviewed the report and received nursing notes and injury
information regarding the resident. Nursing notes and injury documentation reviewed and
uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was upset that a peer broke his pencil and punched a wall. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026841
Date of Incident: 1/15/2025
Date Received: 1/15/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: On 1/15/25 ) Per staff
report, resident was upset a peer broke his pencil. Resident proceeded to punch a wall, right
hand was assessed by APRN. Xray ordered per APRN. WCTM. Guardian and DON
notified via email. Xray was negative for fracture or dislocation.
Interim Action Narrative:
Narrative:
Licensing Narrative: 1/17/2025 - The report was reviewed by licensing. Injury report and
nursing notes documentation received, reviewed and uploaded to ELS.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident eloped from facility grounds by breaking a lock on a door. Police were called and escorted the resident back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026839
Date of Incident: 1/14/2025
Date Received: 1/15/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: At approx. 1920, ) broke the
lock on the door at the Crossover unit by ramming it with his shoulder and went into the
parking lot where he attempted to turn on a golf cart nearby. was unsuccessful
and walked off grounds and went toward a nearby gas station with a Supervisor following
him. He hit said staff member who tried to talk him into returning to the facility, and
continued on towards the gas station on Zion Rd. The police were called at 1932 and arrived
at 1945 to escort him back to the facility at 1952. No injuries reported. was moved
to unit upon his return and was never out of staff's line of sight.
Mitigation includes moving resident to unit off of Crossover, reviewing his safety
plan with his primary therapist, reassessing his return to Crossover unit in the future, and
elopement precautions to be assessed x 24 hours.
Interim Action Narrative:
Narrative:
Licensing Narrative: 1/17/2025 - Licensing reviewed the report. Incident report
documentation received, reviewed and uploaded to ELS. Licensing specialist inquired if the
door was repaired. Police documentation requested. The door has been repaired. 1/31/2025,
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

police incident uploaded and Licensing Specialist informed. Licensing specialist reviewed
the police report.


summary: A resident was chewing on Styrofoam and swallowed a piece. The resident was placed on a clear liquid diet and self-harm precautions. An x-ray was completed in-house. No obstruction noted.

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: 026805
Date of Incident: 1/13/2025
Date Received: 1/14/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: resident in
Parental custody Description of report: On 01/13/2025 this resident was chewing on styro-
foam and swallowed a piece. APRN was notified and order for abdominal x-ray was
obtained to rule out obstruction. Resident was placed on a , also
placed on . X-ray was completed in house and
. No obstruction noted.
Interim Action Narrative: Resident was assessed by the nurse and an x-ray was completed.
Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Licensing requested nurse's note. 1/15/2025 - Licensing specialist reviewed the report.
Nursing notes and injury documentation received, reviewed and uploaded to ELS.
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summary: A resident reported that her roommate grabbed her breasts, vagina, and buttocks over clothing multiple times. This 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: 026810
Date of Incident: 1/13/2025
Date Received: 1/14/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type:
Report Description: On 01/13/2025, private)
reported to an when he was speaking to her about something
else that her roommate Private) had grabbed her
breasts, vagina, and buttocks over clothing multiple times. When interviewed by the Risk
department later that same day, could not recall specifics of any time her breasts or
vagina had been groped but stated that had grabbed her buttocks over clothing last
week while they were standing in line. When was interviewed, she stated that she
accidentally touched buttocks in line but that this was the only incident of
touching.
. has been moved to sleep in the hall as a safety
intervention to be reassessed every 24hrs. has been put on a reverse 6ft with staff,
along with a 6ft no-interaction precaution with and a staff has been assigned to her
doorway.
Interim Action Narrative: Facility and residents were placed on 6ft no
interaction precaution.
Narrative: AV is PRFC is . Out of
Home AO is . During a forensic interview, disclosed that her
roommate had touched her on the breast, buttocks, and vagina over the clothes
"many times" and would only stop when would yell at her to stop. advised
that had touched others but could not provide any details on this. denied
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making touch body and denied saying anything to her when
this occurred.
Licensing Narrative: Licensing reviewed complaint for licensing issues. Program
Coordinator checked . Permission requested
for licensing to contact the facility. 1/15/2025 - Licensing specialist reviewed the report and
will follow up with the facility to inquire - Why is the AV the one sleeping in the hallway,
being reassessed every 24hrs, and put on a 6ft with staff? Permission granted to contact the
facility. Facility response received " The AO was the one placed on a 6 foot with staff,
precautions assessed x 24. We are making different bed assignments tomorrow. Because of
the different dynamics on the unit at that time, the precautions put in place and because the
AV readily volunteered to sleep in the hall the decision was made in this manner."
2/13/2025, per . Licensing Specialist informed
2/14/2025 - The report has been unfounded by licensing, 521 sent to facility for signature.
2/27/2025 - Licensing specialist resent the 521 for signature because a response was not
received. Signed copy received and uploaded to ELS. 3/6/2025, a timeframe was not
provided of this complaint. There were no witness statements obtained. The facility put
precautions in place for safety. This is complaint has been unfounded by licensing. Case
complete.


summary: A complaint submitted alleged that a staff member verbally threatened a resident during a restraint. The facility was cited 110.9.a, 905.12, and 905.4.c 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: 026942
Date of Incident: 1/13/2025
Date Received: 1/17/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Dual
Report Description: Av is who lives with mom . Out of
home offender is , a staff member at Piney Ridge. Reporter states that, on
1/13/2025, at 2:55 PM, verbally threatened . said that, during a restraint,
told him, "If you kick me, I'll break your fucking legs." The incident is being
investigated by Piney Ridge.To the reporter's knowledge, the restraint left no injuries.
Interim Action Narrative: Employee suspended pending the maltreatment investigation.
Narrative: Av is , who lives with mom . Out of
home offender is , a staff member at Piney Ridge. Reporter states that, on
1/13/2025, at 2:55 PM, verbally threatened said that, during a restraint,
told him, "If you kick me, I'll break your fucking legs." The incident is being
investigated by Piney Ridge.To the reporter's knowledge, the restraint left no injuries.
Licensing Narrative: Licensing specialist reviewed the report.
. Licensing contacted the facility for ICA safety plan regarding
staff . 1/21/2025-Licensing was made aware that there was an error in the
AO of this case. The name of the AO has been updated and the ICA for has
been lifted. The correct alleged offender, , was placed on suspension on
/2025 /2025 - A visit was conducted at the facility for case to obtain witness
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statements, review the restraint packet for the reported incident, and review staff
personnel file. background checks and handle with care training
certificate showing May of 2024. Work right up documentation was reviewed. The employee
has been terminated. Facility HR department stated the employee has been
terminated because he received a restraining order from a co-worker with whom they were
roommates with. The restraining order was not related to work, but prohibited
from reporting to Piney. has also received write ups at work. Two write ups for
attendance and two write ups for being the AO in two investigations. Facility staff state
was terminated because of work performance issues unrelated to the investigation.
Licensing specialist reviewed multiple Doctor's orders for restraints. The documentation
has been uploaded to ELS. Several of the restraints completed over the course of 1/11/2025 -
1/14/2025 were missing physicians signature. During the inspection the doctor was
completing the signatures. 1/24/2025 - The complaint was founded by licensing. 521
inspection report was sent to the facility for signature. 1/29/2025 - Resident witness
statements received, reviewed and uploaded to ELS. 2/12/2025 - Facility response received
from CEO J. Hoover. Email was uploaded to ELS. 2/27/2025 - As of 2/27/2025 licensing
has not received a signed copy of the 521 inspection report. Per email, CEO requested a call
regarding concerns.


summary: A resident reported he was coughing up blood. The resident was assessed, and a nurse noted a significant amount of blood mixed with mucus. The resident was taken to the emergency room for treatment.

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: 026712
Date of Incident: 1/9/2025
Date Received: 1/10/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: Child?s Name: ) resident
in Description of report: On 01/09/25 this resident reported he was coughing
up blood. Nurse was able to assess and reports he was coughing/vomiting up a significant
amount of blood mixed with mucus. The APRN was notified and she gave instructions to
send him to the to be assessed. He was taken to
. He returned to the facility at approx. 2am on 01/10/25.
. Dr. Hollingsworth recommended resident follow up with PCP in 2 days.
.
Interim Action Narrative: Resident was assessed by the nurse and evaluated at the hospital.
Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this incident and documentation has been uploaded.
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humanservices.arkansas.gov


summary: A resident was transferred to an acute care facility due to suicidal ideations and self-harm behaviors.

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: 026730
Date of Incident: 1/9/2025
Date Received: 1/10/2025
Facility Name: Yellow Rock Behavioral Health
Facility Number: 203
Incident Type: Licensing
Report Description: ) Resident was
transferred to on 01/09/25 at 1400 due to
previous assessment of suicidal ideation and self harm the previous night. It is hoped that
she will have medication stabilization while acute. She denied any pain/discomfort, DON
and AOC aware. She will develop a safety plan upon return to PRTC.
Interim Action Narrative: Resident was transported to acute placement.
Narrative:
Licensing Narrative: Licensing reviewed provider reported incident for licensing concerns.
Facility provided documentation for this provider reported incident. A safety plan will be
developed once resident return to the facility. 1/15/2025 - Licensing specialist reviewed the
report. Documentation received, reviewed and uploaded to ELS.
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humanservices.arkansas.gov