summary:
A validation survey was conducted from 12/18/2023 through 12/21/2023. The facility was not in compliance with §483, Subpart G – Conditions of Participation for Psychiatric Residential Treatment Center:
N 127 – Facility failed to ensure a physician’s order for a physical restraint was received for 1 (Client #5) of 1 client.
N 142 – Facility failed to ensure an order for physical and chemical restraints were not received at the same time for 3 (Clients #1, #2 and #5) clients.
During a revisit conducted on 2/21/24, the facility was found to be in compliance with program requirements.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
January 4, 2024
Craig Gammon, Administrator
United Methodist Childrens Home
2002 S Fillmore St
Little Rock, AR 72214-4848
Dear Mr. Gammon:
On December 21, 2023 a Recertification survey was conducted at your facility by the Office of Long
Term Care to determine if your facility was in compliance with Federal requirements for Psychiatric
Residential Treatment Facilities participating in the Medicaid (Title XIX) Program. This survey found
that your facility had deficiencies requiring correction/substantial correction prior to a revisit as
specified in the attached CMS-2567.
Plan of Correction
A POC must be submitted within 10 calendar days of you receipt of the Statement of
Deficiencies. Failure to submit a POC may result in termination. Include a completion date for each
deficieny cited.
Theresa Forrest, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 320-6235
email to Theresa.Forrest@dhs.arkansas.gov.
Your Plan of Correction must also include the following:
a. Address how the corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
b. Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
c. Address what measures will be put into place or systemic changes will be made to ensure that the
deficient practice will not recur;
d. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop plan for ensuring that correction is achieved and sustained. This plan must
be implemented, and the corrective action evaluated for its effectiveness.
Craig Gammon - United Methodist Childrens Home - - (AOLTC - PRTF OTC) Page 1]

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

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
A validation survey was conducted from
12/18/2023 through 12/21/2023.
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
N 127 PROTECTION OF RESIDENTS N 127
CFR(s): 483.356(a)(2)
An order for restraint or seclusion must not be
written as a standing order or on an as-needed
basis.
This ELEMENT is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure a physician's order for a physical
restraint was received for 1 (Client #5) of 1 client.
The findings were:
Client #5 had diagnoses of Disruptive Mood
Dysregulation Disorder, Attention Deficit
Hyperactivity Disorder (ADHD) and Child Physical
and Psychological Abuse.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 1 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 127 Continued From page 1 N 127
A Nursing Progress note dated 10/31/23 revealed
Client #5 was placed "...in a restraint at
approximately 16:38 [4:38 PM]..." The Seclusion
and Restraint Form Dated 10/31/2023 at 04:38
PM" revealed Client #5 was placed in a restraint.
During record review, no physician orders were
found for physical restraint on 10/31/23.
On 12/21/2023 at 1:15 PM, the Surveyor
requested the physician orders for the restraint on
10/31/23 from the Nurse Manager.
On 12/21/2023 at 1:53 PM, the Nurse Manager
reported there was not a physician's order for the
restraint. The Surveyor asked the Nurse Manager
if there were supposed to be orders for any type
of restraint. The Nurse Manager stated, "Yes."
A policy provided by the Administrator on
12/18/2023 at 11:35 AM revealed, "Subject:
Procedures for the use of Personal or Chemical
Restraints & Seclusion" with an effective date of
"June 2000" documented, "Section J Orders: 1.
Any restraint or seclusion procedure must be
used and continued pursuant to an order from the
attending physician who is primarily responsible
for the ongoing care of the resident served ...6.
As soon as possible, but no longer than one hour
after the initiation of restraint or seclusion, a
licensed nurse. 1. Notifies and obtains an order
from the physician and, 2. Writes the time/date,
order and who received the order on the restraint
and seclusion form..."
N 142 ORDERS FOR USE OF RESTRAINT OR N 142
SECLUSION
CFR(s): 483.358(c)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 2 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 2 N 142
A physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must order the least
restrictive emergency safety intervention that is
most likely to be effective in resolving the
emergency safety situation based on consultation
with staff.
This ELEMENT is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure an order for physical and
chemical restraints were not received at the same
time for 3 (Clients #1, #2 and #5) clients. The
findings are:
1. Client #1 had diagnosis of Disruptive Mood
Dysregulation Disorder, Reactive Attachment
Disorder, Schizophrenia Spectrum, Attention
Deficit Hyperactivity Disorder, Autism Spectrum
Disorder and Child Neglect.
a. The Seclusion and Restraint Order form dated
11/13/2023 revealed date and time order received
"11/13/2023 02:05 PM" for the personal restraint.
The personal restraint had a duration of "4"
minutes. A chemical restraint order was received
on "11/13/2023 02:05 PM" Medication per nursing
progress note "Zyprexa 5 mg [milligrams] IM
[intramuscularly] and Benadryl 50 mg IM" were
documented as given.
b. The Seclusion and Restraint Order form dated
11/07/2023 revealed date and time order received
"11/07/2023 09:57 AM" for the personal restraint.
The personal restraint had a duration of "1"
minute. A chemical restraint order was received
on "11/07/2023 09:57 AM" Medication given per
nursing progress note "Zyprexa 5 mg [milligram]
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 3 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 3 N 142
and Benadryl 50 mg x [times] 1 was given.
c. The Seclusion and Restraint Order form dated
10/10/2023 revealed date and time order
received, "10/10/2023 01:50 PM" for the personal
restraint. A chemical restraint order was received
on "10/10/2023 01:50 PM" Medication given per
nursing progress note "Zydis 5 mg x 1 and
Benadryl 25 mg x 1 was given.
d. The Seclusion and Restraint Order form dated
10/09/2023 was reviewed and revealed date and
time order received "10/09/2023 09:22 AM" for
the personal restraint. The personal restraint had
a duration of "7" minutes. A chemical restraint
order was received on "10/09/2023 09:22 AM"
Medication given per nursing progress note
"Zyprexa 5 mg IM and Benadryl 50 mg IM was
given.
e. The Seclusion and Restraint Order form dated
10/03/2023 was reviewed and revealed date and
time order received "10/03/2023 09:00 AM" for
the personal restraint. The personal restraint had
a duration of "1" minutes. A chemical restraint
order was received on "10/03/2023 09:00 AM"
Medication given per nursing progress note
"Zyprexa 5 mg IM and Benadryl 50 mg IM was
given.
f. The Seclusion and Restraint Order form dated
10/02/2023 was reviewed and revealed date and
time order received "10/02/2023 04:00 PM" for
the personal restraint. The personal restraint had
a duration of "6" minutes. A chemical restraint
order was received on "10/02/2023 04:00 AM"
Medication given per nursing progress note
"Zyprexa 5 mg was given.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 4 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 4 N 142
g. The Seclusion and Restraint Order form dated
9/27/2023 was reviewed and revealed date and
time order received "9/27/2023 09:10 AM" for the
personal restraint. The personal restraint had a
duration of "9" minutes. A chemical restraint order
was received on "9/27/2023 09:10 AM"
Medication given per nursing progress note
"Zyprexa 5 mg and Benadryl 50 mg was given.
h. On 12/19/2023 at 11:45 AM, the Nurse
Manager was asked to review the physical and
chemical restraint physician's orders for Client #1.
She confirmed that the above listed orders for
personal restraint and a chemical restraint were
received at the same time.
2. Client #2 had diagnosis of Reactive Attachment
Disorder, Disruptive Impulse Control, Bipolar
Disorder, Borderline Intellectual Functioning and
History of Physical Abuse and Neglect.
a. The Seclusion and Restraint Order form dated
10/11/2023 revealed date and time order received
"10/11/2023 at 05:22 PM" for the personal
restraint. A chemical restraint order was received
on "10/11/2023 at 05:22 PM" Medication per
nursing progress note "Zyprexa 5 mg IM and
Benadryl 50 mg IM" were documented as given.
3. Client #5 had diagnoses of Disruptive Mood
Dysregulation Disorder, Child physical,
psychological and sexual abuse.
a. The Seclusion and Restraint Order form dated
09/28/2023 revealed date and time order
received, "09/28/2023 at 09:24 AM" for the
personal restraint. A chemical restraint order was
received on "09/28/2023 at 09:24 AM" Medication
per nursing progress note "Zyprexa 10 mg and
Benadryl 50 mg IM" were documented as given.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 5 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 5 N 142
4. A policy provided by the Administrator on
12/18/2023 at 11:35 AM revealed, "Subject:
Procedures for the use of Personal or Chemical
Restraints & Seclusion" with an effective date of
"June 2000" Section D part 3 revealed, "...3. Use
of personal restraint requires documented clinical
justification. The rationale for the procedure must
address and identify the less restrictive
interventions that were attempted and failed. Less
restrictive intervention would include verbal
de-escalation. time-out. prompts, preventive
teaching. allowing the resident to verbalize
feelings, decrease stimuli in the environment by
removing other residents. ... J. Orders: 1. Any
restraint or seclusion procedure must be used
and continued pursuant to an order from the
attending physician who is primarily responsible
for the ongoing care of the resident served ... 6.
As soon as possible, but no longer than one hour
after the initiation of restraint or seclusion, a
licensed nurse. 1. Notifies and obtains an order
from the physician and, 2. Writes the time/date,
order and who received the order on the restraint
and seclusion form..."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 6 of 6

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
January 25, 2024
Craig Gammon, Administrator
United Methodist Childrens Home
2002 S Fillmore St
Little Rock, AR 72214-4848
Dear Mr.. Gammon:
On December 21, 2023, we conducted a Recertification survey at your facility. You have alleged that
the deficiencies cited on that survey have been corrected. We are accepting your allegation of
compliance and have approved your plan of correction and presume that you will achieve substantial
correction by January 16, 2024.
We will be conducting a revisit of your facility to verify that substantial correction has been achieved
and maintained.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email
to: Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
Theresa Forrest, Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
tf
Craig Gammon - United Methodist Childrens Home -- -- (AOLTC-14) Page 1

APOC
10/25/24 PRINTED: 01/04/2024
tf
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
1
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
Corrective Action:
The policy and procedure in place already
A validation survey was conducted from
require orders to be obtained for any
12/18/2023 through 12/21/2023. restraint. Upon being notified of the
deficiency in this area additional monitoring
The facility was not in compliance with §483, steps were put in place to insure that he
policy is followed. All clients could potentially
Subpart G - Conditions of Participation for
be effected by this issue so all clients have
Psychiatric Residential Treatment Center. been included in the corrective response. All
N 127 PROTECTION OF RESIDENTS N 127cases were reviewed and no additional negative
findings were identified.The Nurse Manager is
CFR(s): 483.356(a)(2)
responsible for checking that orders are
obtained for all restraints and seclusions and 1-16-24
An order for restraint or seclusion must not be now checks these twice weekly for compliance.
written as a standing order or on an as-needed The residential treatment center (RTC) program
has now enlisted the assistance of the health
basis.
information management (HIM) department, to
monitor the completion of seclusion and restraint
documentation (S&R's) and physician orders
This ELEMENT is not met as evidenced by: as well, and the results of these audits are
reported to administration. The Nurse Manager
Based on record review and interview, the facility
now reports on the accuracy of S&Rs including
failed to ensure a physician's order for a physical completed orders, at the bi-monthly
restraint was received for 1 (Client #5) of 1 client. Department Head Meetings. The Nurse Manager
compares the orders with the critical incident
The findings were:
reports (CIR's) and data collected by the RTC
Office Manager.
Client #5 had diagnoses of Disruptive Mood
Dysregulation Disorder, Attention Deficit Person Responsible: RTC Nurse Manager
with the assistance of the HIM department in
Hyperactivity Disorder (ADHD) and Child Physical
conducting audits of order accuracy and
and Psychological Abuse. completion.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 1 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 127 Continued From page 1 N 127
A Nursing Progress note dated 10/31/23 revealed
Client #5 was placed "...in a restraint at
approximately 16:38 [4:38 PM]..." The Seclusion
and Restraint Form Dated 10/31/2023 at 04:38
PM" revealed Client #5 was placed in a restraint.
During record review, no physician orders were
found for physical restraint on 10/31/23.
On 12/21/2023 at 1:15 PM, the Surveyor
requested the physician orders for the restraint on
10/31/23 from the Nurse Manager.
On 12/21/2023 at 1:53 PM, the Nurse Manager
reported there was not a physician's order for the
restraint. The Surveyor asked the Nurse Manager
if there were supposed to be orders for any type
of restraint. The Nurse Manager stated, "Yes."
A policy provided by the Administrator on
12/18/2023 at 11:35 AM revealed, "Subject:
Procedures for the use of Personal or Chemical
Restraints & Seclusion" with an effective date of
"June 2000" documented, "Section J Orders: 1.
Any restraint or seclusion procedure must be
used and continued pursuant to an order from the
attending physician who is primarily responsible
for the ongoing care of the resident served ...6.
As soon as possible, but no longer than one hour
after the initiation of restraint or seclusion, a
licensed nurse. 1. Notifies and obtains an order
from the physician and, 2. Writes the time/date,
order and who received the order on the restraint
and seclusion form..."
N 142 ORDERS FOR USE OF RESTRAINT OR N 142
SECLUSION
CFR(s): 483.358(c)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 2 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 2 N 142
A physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must order the least
restrictive emergency safety intervention that is
most likely to be effective in resolving the
emergency safety situation based on consultation
with staff.
Corrective Action:
Upon notificaTtioynp oef th tee dxeftic iehnecyr neurses were educated to
This ELEMENT is not met as evidenced by: ensure that no simultaneous orders for physical and
chemical restraints are obtained. This deficiency could
Based on record review and interview, the facility potentially impact all clients, so all current client cases were
reviewed and no additional negative findings were identified.
failed to ensure an order for physical and
chemical restraints were not received at the same Nursing staff are required to indicate that less restrictive
measures have been attempted and failed within the
time for 3 (Clients #1, #2 and #5) clients. The supporting documentation specified on the Seclusion and
findings are: Restraint Form. The less restrictive measures include, but
are not limited to verbal de-escalation, prompts for a
1-16-24
self-time-out, removing other residents from the area to
decrease stimuli, preventative teaching, and allowing the
1. Client #1 had diagnosis of Disruptive Mood resident to verbalize feelings.
Dysregulation Disorder, Reactive Attachment
The Nurse Manager is now responsible for monitoring that
Disorder, Schizophrenia Spectrum, Attention the orders for physical and chemical restraints have not
been received simultaneously. The Nurse Manager also
Deficit Hyperactivity Disorder, Autism Spectrum
reports on the accuracy of orders for restraints and with
Disorder and Child Neglect. regard to the timing requirements in bi-monthly Department
Head Meetings. Education and training on this issue is now
also included in on the job orientation training and
discussed within in-service trainings pertaining to orders.
a. The Seclusion and Restraint Order form dated
11/13/2023 revealed date and time order received
Person Responsible: RTC Nurse Manager
"11/13/2023 02:05 PM" for the personal restraint.
The personal restraint had a duration of "4"
minutes. A chemical restraint order was received
on "11/13/2023 02:05 PM" Medication per nursing
progress note "Zyprexa 5 mg [milligrams] IM
[intramuscularly] and Benadryl 50 mg IM" were
documented as given.
b. The Seclusion and Restraint Order form dated
11/07/2023 revealed date and time order received
"11/07/2023 09:57 AM" for the personal restraint.
The personal restraint had a duration of "1"
minute. A chemical restraint order was received
on "11/07/2023 09:57 AM" Medication given per
nursing progress note "Zyprexa 5 mg [milligram]
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 3 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 3 N 142
and Benadryl 50 mg x [times] 1 was given.
c. The Seclusion and Restraint Order form dated
10/10/2023 revealed date and time order
received, "10/10/2023 01:50 PM" for the personal
restraint. A chemical restraint order was received
on "10/10/2023 01:50 PM" Medication given per
nursing progress note "Zydis 5 mg x 1 and
Benadryl 25 mg x 1 was given.
d. The Seclusion and Restraint Order form dated
10/09/2023 was reviewed and revealed date and
time order received "10/09/2023 09:22 AM" for
the personal restraint. The personal restraint had
a duration of "7" minutes. A chemical restraint
order was received on "10/09/2023 09:22 AM"
Medication given per nursing progress note
"Zyprexa 5 mg IM and Benadryl 50 mg IM was
given.
e. The Seclusion and Restraint Order form dated
10/03/2023 was reviewed and revealed date and
time order received "10/03/2023 09:00 AM" for
the personal restraint. The personal restraint had
a duration of "1" minutes. A chemical restraint
order was received on "10/03/2023 09:00 AM"
Medication given per nursing progress note
"Zyprexa 5 mg IM and Benadryl 50 mg IM was
given.
f. The Seclusion and Restraint Order form dated
10/02/2023 was reviewed and revealed date and
time order received "10/02/2023 04:00 PM" for
the personal restraint. The personal restraint had
a duration of "6" minutes. A chemical restraint
order was received on "10/02/2023 04:00 AM"
Medication given per nursing progress note
"Zyprexa 5 mg was given.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 4 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 4 N 142
g. The Seclusion and Restraint Order form dated
9/27/2023 was reviewed and revealed date and
time order received "9/27/2023 09:10 AM" for the
personal restraint. The personal restraint had a
duration of "9" minutes. A chemical restraint order
was received on "9/27/2023 09:10 AM"
Medication given per nursing progress note
"Zyprexa 5 mg and Benadryl 50 mg was given.
h. On 12/19/2023 at 11:45 AM, the Nurse
Manager was asked to review the physical and
chemical restraint physician's orders for Client #1.
She confirmed that the above listed orders for
personal restraint and a chemical restraint were
received at the same time.
2. Client #2 had diagnosis of Reactive Attachment
Disorder, Disruptive Impulse Control, Bipolar
Disorder, Borderline Intellectual Functioning and
History of Physical Abuse and Neglect.
a. The Seclusion and Restraint Order form dated
10/11/2023 revealed date and time order received
"10/11/2023 at 05:22 PM" for the personal
restraint. A chemical restraint order was received
on "10/11/2023 at 05:22 PM" Medication per
nursing progress note "Zyprexa 5 mg IM and
Benadryl 50 mg IM" were documented as given.
3. Client #5 had diagnoses of Disruptive Mood
Dysregulation Disorder, Child physical,
psychological and sexual abuse.
a. The Seclusion and Restraint Order form dated
09/28/2023 revealed date and time order
received, "09/28/2023 at 09:24 AM" for the
personal restraint. A chemical restraint order was
received on "09/28/2023 at 09:24 AM" Medication
per nursing progress note "Zyprexa 10 mg and
Benadryl 50 mg IM" were documented as given.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 5 of 6

PRINTED: 01/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
04L106 B. WING _____________________________ 12/21/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 5 N 142
4. A policy provided by the Administrator on
12/18/2023 at 11:35 AM revealed, "Subject:
Procedures for the use of Personal or Chemical
Restraints & Seclusion" with an effective date of
"June 2000" Section D part 3 revealed, "...3. Use
of personal restraint requires documented clinical
justification. The rationale for the procedure must
address and identify the less restrictive
interventions that were attempted and failed. Less
restrictive intervention would include verbal
de-escalation. time-out. prompts, preventive
teaching. allowing the resident to verbalize
feelings, decrease stimuli in the environment by
removing other residents. ... J. Orders: 1. Any
restraint or seclusion procedure must be used
and continued pursuant to an order from the
attending physician who is primarily responsible
for the ongoing care of the resident served ... 6.
As soon as possible, but no longer than one hour
after the initiation of restraint or seclusion, a
licensed nurse. 1. Notifies and obtains an order
from the physician and, 2. Writes the time/date,
order and who received the order on the restraint
and seclusion form..."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK11 Facility ID: 3005 If continuation sheet Page 6 of 6

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
March 4, 2024
Craig Gammon, Administrator
United Methodist Childrens Home
2002 S Fillmore St
Little Rock, AR 72214-4848
Dear Mr.. Gammon:
During the Revisit survey conducted on February 21, 2024, your facility was found to be in compliance
with program requirements. Please email the signed CMS 2567 Theresa.Forrest@dhs.arkansas.gov.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email
to: Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
DPSQA/Office of Long Term Care
Survey and Certification Section
tf

PRINTED: 03/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
R
04L106 B. WING _____________________________ 02/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2002 S FILLMORE ST
UNITED METHODIST CHILDRENS HOME
LITTLE ROCK, AR 72214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{N 000} Initial Comments {N 000}
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
The facility was in compliance with §483, Subpart
G - Conditions of Participation for Psychiatric
Residential Treatment Center.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:ZCKK12 Facility ID: 3005 If continuation sheet Page 1 of 1

doc_type: Recertification Survey


state: AR

facility_name: United Methodist Children's Home - Little Rock

summary: An x-ray was ordered after a resident complained of pain and discomfort in her right shoulder.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 12/11/2023
Date Received by DCCECE: 12/12/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On 12/11/23 client
Parent custody complained to the Physical Therapist Specialist of pain and discomfort in
her right shoulder. An x-ray was ordered and findings are: No acute findings, no foreign
bodies to be found, all skeletal structures are intact. Results were sent in today of 12/12/23
Interim Action Narrative:
:
Licensing Narrative: 12/12/23-Received provider reported incident that client
complained of pain in her right shoulder and x-ray was ordered. No
findings. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: Officers responded to a disturbance at the facility. Upon arrival, staff advised that while attempting intake of a juvenile, he became irate and punched a staff member in the head.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2023-141518 JUVENILE INFORMATION Report generated: 12/27/2023 11:25 AM
Redact Before Release
NARRATIVE
ON DECEMBER 15, 2023, OFFICERS RESPONDED TO A DISTURBANCE AT 2002 S FILLMORE. UPON ARRIVAL
OFFICERS MADE CONTACT WITH METHODIST CHILDREN'S HOME STAFF. WHILE ATTEMPTING TO INTAKE JUVENILE
1 (JV1), HE BECAME IRATE AND PUNCHED A STAFF MEMBER, MR. JUSTIN SMITH, IN THE HEAD. MR. SMITH ADVISED
JV1 STATED HE WAS ABOUT TO START BEATING EVERYBODY UP AND JV1 DECIDED TO HIT HIM FIRST. OFFICERS
DID NOT OBSERVE ANY INJURIES. THE METHODIST NURSING STAFF ISSUED MEDICATION WHILE JV1 WAS
RESTRAINED PRIOR TO OFFICERS ARRIVAL TO CALM HIM DOWN. OFFICERS STOOD BY WHILE MEMS
TRANSPORTED JV1 TO THE METHODIST MAUMELLE FACILITY. OFFICERS PROVIDED MR. SMITH WITH AN INCIDENT
NUMBER AND LEFT THE LOCATION WITHOUT FURTHER TO REPORT. BWC IN USE.
Page 6 of 7

doc_type: Police Report


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough and an annual policies review. The facility was cited 110.11 for a missing log of calls to the child abuse hotline.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 11/28/2023
Home Visit Date: 11/28/2023
Purpose of Visit: Agency Checklist
Regulations Out of Compliance:
Regulation Number: 100.110.11
Regulation Description: The agency shall maintain a log or file of all calls to the child abuse hotline.
Finding Description: Initially, no child abuse hotline file or log available for review during today's visit.
Action Due Date: 2023-11-28
Action Due Description: UMCH PRTF Director Kaylynn Bennett created an electronic child abuse hotline log
prior to conclusion of today's visit.
Comply Date:
Action Due Description: UMCH PRTF Director Kaylynn Bennett created an electronic child abuse hotline log
prior to conclusion of today's visit.
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Annual Review/Policies PRTF Checklist completed. All items accounted for except a log or file of all calls to
the child abuse hotline. Facility cited 110.11.
Provider Comments:
CCL Staff Signature : Date: 11/28/2023
Provider Signature : Date: 11/28/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: An x-ray was ordered due to a resident complaining of ankle pain after playing in the gym.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/18/2023
Date Received by DCCECE:11/20/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On 11/18/2023 Client age DOB non DHS
client was playing in the gym with peers. Client complained of some ankle pain. An x-ray
was ordered and the results are: normal x-ray examination of ankle. No findings of any
irregularities.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/20/23 that on
11/18/2023 Client age DOB non DHS client was playing in the
gym with peers. Client complained of some ankle pain. An x-ray was ordered and the results
are: normal x-ray examination of ankle. No findings of any irregularities. No licensing
concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident injured his hand by punching a door.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/14/2023
Date Received by DCCECE:11/15/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: ON 11/13/23 year old DOB , non DHS
client was upset and punched a door that night. Nurse assessed client and client refused ice
packs stating he was fine. APRN came and visited on 11/14/23 and ordered and x-
ray. Results are X-ray results of his left hand were normal (no fractures or abnormalities)
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/15/23 that on
11/13/23 year old DOB , non DHS client was upset and
punched a door that night. Nurse assessed client and client refused ice packs stating he was
fine. APRN came and visited on 11/14/23 and ordered and x-ray. Results are X-ray
results of his left hand were normal (no fractures or abnormalities). X-ray was performed
11/14/23 and this was reported 11/15/23. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident fell on her left knee while playing catch.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/12/2023
Date Received by DCCECE:11/13/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: , dob , she is in private placement.
was in the gym playing catch with a peer. She began running to catch the ball and
fell on her left knee. She was assessed by the nursed and an x-ray was ordered due to a birth
defect that has. Client x-ray was completed on 11/13/2023, Xray results indicates no
findings of an acute fracture.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/13/23 that on
11/12/23 client , dob , she is in private placement.
the gym playing catch with a peer. She began running to catch the ball and fell on
her left knee. She was assessed by the nursed and an x-ray was ordered due to a birth defect
that has. Client x-ray was completed on 11/13/2023, Xray results indicates no
findings of an acute fracture. No licensing concerns identified from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers responded to the facility for a battery. Upon arrival, officers made contact with a staff member who reported that a juvenile resident pushed him into a wall and began poking himself with a pen. When the staff member attempted to take the pen away, the juvenile scraped the staff member’s arm and stomach with the pen.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2023-130851 JUVENILE INFORMATION Report generated: 11/22/2023 10:57 AM
Redact Before Release
NARRATIVE
OFFICERS RESPONDED TO THE LISTED LOCATION ON A BATTERY. UPON ARRIVAL OFFICERS MADE CONTACT WITH
VIC#1(PEARSON). PEARSON ADVISED OFFICERS HE IS AN EMPLOYEE AT THE LISTED LOCATION. PEARSON
ADVISED OFFICERS HE TOLD SUSP#1(JUVENILE 1) IT WAS TIME TO TAKE A SHOWER. PEARSON ADVISED THE
JUVENILE PUSHED HIM INTO THE WALL AND BEGAN POKING HIMSELF WITH A PEN. PEARSON ADVISED HE
ATTEMPTED TO TAKE THE PEN FROM THE JUVENILE AND THE JUVENILE SCRAPED HIS ARM AND STOMACH WITH
THE PEN. PEARSON ADVISED OFFICERS THIS HAS HAPPENED MULTIPLE TIMES IN THE PAST WITH VARIOUS STAFF
MEMBERS. OFFICERS OBSERVED VERY MINOR SCRAPES TO THE STOMACH AND ARM OF THE VICTIM. PEARSON
ADVISED OFFICERS HE WANTED A REPORT MADE SO HE CAN SEEK WARRANTS ON THE JUVENILE, OFFICER GAVE
PEARSON A INCIDENT NUMBER. OFFICER ASKED PEARSON IF HE NEEDED MEDICAL ATTENTION, HE REFUSED.
18C481 IS MVR EQUIPPED AND IN USE.
ON 11/10/2023, AT APPROXIMATELY 2234 HOURS, OFFICERS RESPONDED BACK TO THE LOCATION AND MADE
CONTACT WITH PEARSON. PEARSON ADVISED JUVENILE 1 PUSHED HIM AND HIT HIM AGAIN. HE SAID HE DID NOT
SUSTAINED ANY INJURIES THIS TIME. PEARSON SAID HE WAS LEAVING WORK AFTER HE WAS DONE SPEAKING
WITH OFFICERS AND HIS SUPERVISOR DID NOT WANT OFFICERS SPEAKING WITH JUVENILE 1. MVR AND BWC IN
USE. RUFF 25-19-105 (b)(13
Page 5 of 6


summary: An x-ray was ordered after a resident complained of abdominal pain to the right lower quadrant with nausea and episodes of diarrhea.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/1/2023
Date Received by DCCECE:11/2/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: ON 11/1/2023 client age DOB parent
custody reported abdominal pain to right lower quadrant with nausea and episodes of
diarrhea earlier today, an x-ray was ordered and the results are : were normal; no issues
noted. He did have a moderate amount of stool in his bowels and may just need to have a
BM.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/2/23 that on
11/1/2023 client age DOB parent custody reported abdominal
pain to right lower quadrant with nausea and episodes of diarrhea earlier today, an x-ray was
ordered, and the results are: were normal; no issues noted. He did have a moderate amount
of stool in his bowels and may just need to have a BM. No licensing concerns noted from
this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered due to a resident complaining of knee and hand pain after kicking through some doors.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/1/2023
Date Received by DCCECE:11/2/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On 11/1/2023 client age DOB DHS client
got upset with another peer, walked out of designated area and kicked through some doors,
complained of knee and hand pain, an Xray was ordered and results are: showed no
fractures and normal anatomy of his right hand and right knee. Likely he just has soft tissue
injury/inflammation causing his current discomfort.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility provided report 11/2/23 that on 11/1/2023
client age DOB DHS client got upset with another peer, walked
out of designated area and kicked through some doors, complained of knee and hand pain,
an Xray was ordered, and results are: showed no fractures and normal anatomy of his right
hand and right knee. Likely he just has soft tissue injury/inflammation causing his current
discomfort. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered after a resident complained of abdominal pain.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/31/2023
Date Received by DCCECE: 11/1/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: ON 10/31/23 age DOB DHS client
complained of abdominal pain, an x-ray was ordered. Results of findings are : show normal
examination of the abdomen and pelvis. No acute issues noted
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/1/23 that on
10/31/23 age DOB DHS client complained of abdominal pain,
an x-ray was ordered. Results of findings are : show normal examination of the abdomen
and pelvis. No acute issues noted. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Arkansas Children’s Hospital after she broke a pair of sunglasses, used the screw for self-harm, and then swallowed the screw.

raw_content:
AR KAN S A S&S
DEPARTMENT OF

+4 HUMAN
<a¥ SERVICES

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident

Date of Incident: 10/31/2023

Date Received by DCCECE: 11/1/2023

Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115

Incident Type: Licensing

Report Description: On 10/31/2023 a client J age J DOB J DHS client
was sent out to Arkansas Childrens Hospital because client reported that she broke a pair of

sunglasses, used the screw for self-harm, and then swallowed the screw. An x-ray was
completed at childrens and the findings are, There were no acute findings when client had
an x-ray performed in the ER from nose/mouth to rectum, and no changes in any
medications. Basically, waiting for foreign body to pass in client's stool.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Licensing received provider reported incident 11/1/23 that on
10/31/2023 cen fii agdJDOB P| DHS client was sent out to Arkansas
Childrens Hospital because client reported that she broke a pair of sunglasses, used the
screw for self-harm, and then swallowed the screw. An x-ray was completed at ACH and the
findings are, There were no acute findings when client had an x-ray performed in the ER
from nose/mouth to rectum, and no changes in any medications. Basically, waiting for
foreign body to pass in client's stool. No noted licensing concerns from report. Will follow
up next visit.

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


summary: An x-ray was ordered after a resident complained of ankle pain from falling in the gym.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/30/2023
Date Received by DCCECE: 11/1/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On the night of October 30th client age DOB
DHS client complained of ankle pain of falling the gym, an x-ray was ordered and
results of the findings are; no acute fracture, normal findings
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/1/23 that on the
night of October 30th client age DOB DHS client complained
of ankle pain of falling the gym, an x-ray was ordered and results of the findings are; no
acute fracture, normal findings. Phone call made to Justin King of UMCH to confirm that
the x-ray was performed on 10/31/23. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: An x-ray was ordered due to a resident complaining of pain after kicking a soccer ball.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/29/2023
Date Received by DCCECE: 10/30/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: on 10/29/2023 age DOB parent custody was
in the gym kicking a soccer ball. On 10/30/23 he was complaining of pinky toe pain to the
nurse. An x-ray was ordered and he has an acute nondisplaced proximal phalanx fracture.
(broke pinky toe)
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 10/30/23 that on
10/29/2023 age DOB parent custody was in the gym kicking a
soccer ball. On 10/30/23 he was complaining of pinky toe pain to the nurse. An x-ray was
ordered and he has an acute nondisplaced proximal phalanx fracture. (broke pinky toe). No
licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing received a complaint on 11/1/2023 regarding a child who was picked up from the facility on 10/28/2023 by her guardian for a visit. The child was complaining of ongoing pain in her stomach, so the guardian took her to the emergency room and was then transported to ACH for further treatment of pancreatitis, a blood clot in her spleen, and sepsis. The child reported she was complaining to the nurses about the pain since Wednesday 10/25/2023 and they gave her ibuprofen on Thursday 10/26/2023. The child reported that when she continued to complain of pain, the staff told her to quit faking it. The complaint was UNFOUNDED by Licensing. and UNSUBSTANTIATED by CACD.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 10/28/2023
Date Received by DCCECE: 11/1/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Dual
Report Description: 10/28/23 Member was in Methodist Children Home.
She complained to staff member that she was not taken serious when she complained of
being sick and she was having a hard time breathing. Mother reports: When we picked her
up this morning she looked like death and cried put in agony when she went to get into the
car. Apparently she has been this way since Wednesday, severe pain, vomiting, and white as
a ghost, and no one at Methodist thought it was concerning. We took her to the ER at Saline
memorial. She has a necrosis of her pancreas, splenomegaly, a cyst on her left kidney, a
UTI, fluid filling her abdomen, and is septic. She was transferred to Children's Hospital this
afternoon. Right now they don't know if she is going to make it or not. If she hadn't gotten
medical attention today, she would have not survived through the night. According to
Guardian, ; should have been taken serious when when she stated
she felt like she could not breath instead of being told to stop being so dramatic.
Interim Action Narrative: Resident is currently admitted in care at Arkansas Children's
Hospital.
Maltreatment Narrative: Licensing received a complaint on 11/1/2023 regarding a child
who was picked up from the facility on 10/28/2023 by her guardian for a visit. The child was
complaining of ongoing pain in her stomach, so the guardian took her to the emergency
room and was then transported to ACH for further treatment of pancreatitis, a blood clot in
her spleen, and sepsis. The child reported she was complaining to the nurses about the pain
since Wednesday 10/25/2023 and they gave her ibuprofen on Thursday 10/26/2023.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

However, the resident reports that when she continued to complain of pain the staff told her
to quit faking it. Nursing notes gathered from the facility do show the resident received
800mg of ibuprofen on 10/26/2023, but there were no other nursing notes for the resident
after that time. ref# .
Licensing Narrative: Licensing received email complaint from
on 11/1/23 as follows: 10/28/23
Member was in Methodist Children Home. She complained to staff
member that she was not taken serious when she complained of being sick and she was
having a hard time breathing. Mother reports: When we picked her up this morning she
looked like death and cried put in agony when she went to get into the car. Apparently she
has been this way since Wednesday, severe pain, vomiting, and white as a ghost, and no one
at Methodist thought it was concerning. We took her to the ER at Saline memorial. She has
a necrosis of her pancreas, splenomegaly, a cyst on her left kidney, a UTI, fluid filling her
abdomen, and is septic. She was transferred to Children's Hospital this afternoon. Right
now they don't know if she is going to make it or not. If she hadn't gotten medical attention
today, she would have not survived through the night. According to Guardian,
; should have been taken serious when when she stated she felt like she
could not breath instead of being told to stop being so dramatic. Email sent to facility
11/1/23 requesting all nursing notes from 10/16/23-11/1/23. Nursing notes received 11/1/23
from facility for requested timeframe for client Nursing notes reviewed 11/2/23.
Nothing noted in nursing notes that should have been reported to licensing. 11/2/23-Phone
call made, and text sent to Compliance Director for UMCH Shannon Rouse to ascertain any
updates on client Email was sent by Shannon Rouse copied to CEO Craig Gammon
and Director Kalynn Barrett of UMCH for follow up regarding client's medical status and
placement. 11/3/23-Phone call made to Justin King of UMCH who stated that client
has discharged from UMCH. UMCH has been unable to contact guardians
and . . .
11/3/2023- Program Manager called and spoke with the resident's mother who stated that
the resident was still admitted in the hospital due to her illnesses. The mother reports that
the resident claims she told the nurses she was in pain and was given ibuprofen one time on
10/26/2023, but when she continued to complain of pain they told her to "quit faking it".
11/9/2023- Program Manager spoke to the resident's mother who stated that the resident
was discharged from the hospital on 11/7/2023. The resident is now home and recovering.
The mother reported there was no identified cause for the medical issues the resident
experienced. The mother will send the discharge paperwork to the Program Manager for
review. 11/13/2023- Program Manager received an email from the resident's mother with
attachments showing the resident's diagnosis from her 10 day stay at Arkansas Children's
Hospital along with a timeline of events. Email sent to UMCH 11/14/23 to ascertain what
the plan of action is for UMCH's nursing department to correct any issues (if they have
identified any) to prevent incidents like what happened with client Email received

11/14/23 from Craig Gammon of UMCH as follows: MCH has reviewed the circumstances
leading up to the client being hospitalized with pancreatitis. The client did make
complaints starting the Wednesday prior to her eventual diagnosis on Saturday. These
complaints were of abdominal pain, and she was assessed by the nurse with no other
significant symptoms. The APRN was contacted for consultation and based upon the
symptoms present and did order ibuprofen for pain. While the client was complaining of
stomach pain she was also still participating in other activities, requested to go on the group
outing on Thursday afternoon, and participated in the youth self-government meeting on
Friday. She left Saturday morning, and we were told by her parents that she experienced
increasingly severe abdominal pain and they took her to the emergency room where she was
examined and admitted. The specific symptoms she had are also those of other less serious
ailments. Pancreatitis in adolescents is on the increase according to the National Pancreas
Foundation, but even so it is found at a rate of 1 in 10,000 or .01% of children. Also, while
medication is the most often cited cause, the medications in question are specific and were
not being ordered for this client at the time of the onset. The development of her illness was
over a short period and with a variation in the level of symptoms such that it was not
obvious that a larger issue was emerging. I am not a medical professional but that said, I am
told that the nursing and medical staff would not have reasonably suspected pancreatitis in
the time frame prior to her leaving on pass, and when the pain became severe and
persistent, her parents sought out immediate medical attention. Certainly, the staff now
have a higher level of awareness of this medical issue, however, the fact that it occurs in only
1-13 of 100,000 children, does make the condition very rare and so unlikely to be immediately
suspected. From the information I have it is also not something that can be prevented in
most if not all instances. Considering all these factors there does not seem to be a need for
change or improvement in the performance of nursing staff within the LR RTC. If you need
additional information or the standards require some different form of response, please let
me know. 1/2/24-Received notification that maltreatment ref# was unfounded. No
visit conducted for this case. No licensing citations for this case. Client remains discharged
from facility.


summary: An x-ray was ordered after a resident fell and twisted her ankle while playing in the gym.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/27/2023
Date Received by DCCECE: 10/30/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On 10/27/23 age DOB DHS custody
client was in the gym playing. She fell and twisted her ankle. An x-ray was done and
completed Saturday 10/28/23. Results indicate that there was "No Acute fractures or
dislocations that could be identified. The talar bone is intact. There are no foreign bodies,
the soft tissues are unremarkable.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 10/30/23 that on
10/27/23 age DOB DHS custody client was in the gym
playing. She fell and twisted her ankle. An x-ray was done and completed Saturday
10/28/23. Results indicate that there was "No Acute fractures or dislocations that could be
identified. The talar bone is intact. There are no foreign bodies, the soft tissues are
unremarkable. No licensing concerns noted from this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/24/2023
Date Received by DCCECE: 10/25/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: On 10/24/23 age DOB non DHS resident was
in the gym playing. She was running and fell. She said she twisted her ankle. An X-ray was
ordered. They sent the results. results are: :
None. FINDINGS: Normal visualized distal tibia and medial malleolus. Normal visualized
distal fibula and lateral malleolus. Normal tibiotalar articulation and ankle mortise. Normal
visualized talus. Normal visualized calcaneus. The visualized subtalar, talonavicular,
calcaneocuboid and tarsal articulations are normal. IMPRESSION: Normal x-ray
examination of the ankle.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 10/25/23 that on
10/24/23 age DOB non DHS resident was in the gym playing. She
was running and fell. She said she twisted her ankle. An X-ray was ordered. They sent the
results. results are: : None. FINDINGS:
Normal visualized distal tibia and medial malleolus. Normal visualized distal fibula and
lateral malleolus. Normal tibiotalar articulation and ankle mortise. Normal visualized talus.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Normal visualized calcaneus. The visualized subtalar, talonavicular, calcaneocuboid and
tarsal articulations are normal. IMPRESSION: Normal x-ray examination of the ankle. No
licensing concerns noted from report.


summary: A complaint received states: It was reported to me that my son and one other resident tested positive for THC while in the care of United Methodist Children’s Home. Due to him testing positive for THC, he lost privileges to the outing which led to an aggressive outburst. I am concerned about how drugs entered the facility and the safety of the residents. Since this incident, my son is being discharged within the next 5 to 7 days.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/16/2023
Date Received by DCCECE: 10/17/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: It was reported to me that my son and one other resident tested positive
for THC while in the care of United Methodist Children?s Home. Due to him testing
positive for THC, he lost privileges to the outing which lead to an aggressive outburst. I am
concerned about how drugs entered the facility and the safety of the residents. Since this
incident, my son is being discharged within the next 5 to 7 days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: The incident the complaint is regarding was previously reported to the
PRLU and investigated. The complaint will be combined with case 016739 for
documentation purposes.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. No deficiencies cited.

raw_content:
United Methodist Children's Home Little Rock Campus
2002 SOUTH FILLMORE
LITTLE ROCK AR 72204

ARKANSAS

RS }-¢ 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

Clayton DeBoer
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 115

Date of Visit: 10/12/2023
Visit Type(s): Monitor Visit
Time: 9:00 AM - 11:12 AM

Visit Comment :

Buildings and Grounds conducted from 9:00-11:30AM. Halls A, B, C and D observed. Census: 30

Classroom | staff/client ratio: 2:7
Classroom 2 staff/client ratio: 2:7
Milieu staff/client ratio: 1:2

Gym staff/client ratio: 2:9

All sleeping areas furnished, clean, safe and in good repair. Bathrooms clean and sanitary with functioning

sinks, showers and toilets.

MAR checked for:

Page 1 of 2

All initialed and up to date.

CCL Staff Signature : Date: 10/12/2023
Provider Signature : Date: 10/12/2023
ay (WD

Cas

Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.

Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.

Page 2 of 2


summary: A resident reported to staff that 2 peers had a cannabis pin inside of the building. The resident also reported that a staff member gave the residents the marijuana pin. Both residents were drug tested. Resident 1 tested positive for marijuana and Resident 2 tested negative. When asked, Resident 2 confirmed Resident 1 got the marijuana pin from staff. The staff member was informed of the allegations and stated she would never do anything like that. The staff member was sent to conduct a drug test at AEL and was suspended pending the investigation/drug screen results. Facility cited 109.1.g: Resident tested negative for marijuana upon admission to UMCH 8/23/23 and tested positive for marijuana 10/10/23. Resident has not been on any gate passes since admission. Resident was given access to marijuana whilst at UMCH. There is no definitive evidence at this time to support specified staff provided the marijuana, but it is evident resident had access to marijuana whilst at this facility.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 10/10/2023
Date Received by DCCECE: 10/11/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: , he is in private placement.
a client reported to Demetra Jefferson (staff) that and (client)
had a cannabis pin inside of the building. also reported to Shawanda Martin (staff)
that (staff member) gave and the marijuana pin. The nurse
received an order from the doctor for both clients and to be drug tested.
tested positive for marijuana and tested negative. After speaking with
he informed Justin and me (Sherika Williams) that did have a marijuana pin and
that he got the pin from (staff). Justin and I (Sherika) informed regarding
the allegations, she reported that she would never do anything like that. was sent to
conduct a drug test at AEL, a report was made to the due to the allegation, and she
was suspended due to pending investigation/drug screen results. We are currently awaiting
results, the was not accepted, only documented. I was informed by the that
they no longer give referral numbers at the end of the call and that it will be emailed to me. I
have not received an email from the at this time.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing received provider reported incident 10/11/23 as follows:
, he is in private placement. a client reported to
Demetra Jefferson (staff) that and (client) had a cannabis pin inside of
the building. also reported to Shawanda Martin (staff) that (staff member)
gave and the marijuana pin. The nurse received an order from the doctor for
both clients and to be drug tested. tested positive for marijuana and
tested negative. After speaking with he informed Justin and me (Sherika
Williams) that did have a marijuana pin and that he got the pin from
(staff). Justin and I (Sherika) informed regarding the allegations, she reported that she
would never do anything like that. was sent to conduct a drug test at AEL, a report
was made to the due to the allegation, and she was suspended due to pending
investigation/drug screen results. We are currently awaiting results, the was not
accepted, only documented. I was informed by the that they no longer give referral
numbers at the end of the call and that it will be emailed to me. I have not received an email
from the at this time. Facility visited 10/12/23 in response to provider reported
incident that staff member was accused of giving client a vape pen containing
marijuana. Two other peers reported this to staff. told staff Justin King and Sherika
Williams that he snuck it in his privates. stated that he flushed the vape pen down the
toilet whilst at UMCH. was admitted to UMCH 8/23/23 and drug tested upon
admission which was negative. Drug screen 10/10/23 yielded a positive drug screen for
marijuana. has not been on any gate passes since admission. There is no definitive
evidence at this time to support specified staff provided the marijuana, but it is evident
client had access to marijuana whilst at this facility. Facility cited 109.1g. As to document
sub-regulation g) Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children. Staff has been drug tested which was
inconclusive. Staff will be suspended pending additional drug test results and
pending facility investigation. 10/19/23-UMCH Craig Gammon emailed internal
investigation that stated staff subsequent drug screen was negative, and that the
internal investigation did not support allegation. Per conversation with Program Manager
Chelsea Vardell, Craig Gammon was informed that staff could return to work.

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: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Licensee Address: 2002 SOUTH FILLMORE
LITTLE ROCK AR 72204
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 10/12/2023
Home Visit Date: 10/12/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulation Number: 1. 109. 1 .g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Client tested negative for marijuana upon admission to UMCH 8/23/23 and tested
positive for marijuana 10/10/23. has not been on any gate passes since admission. was given access to
marijuana whilst at UMCH.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 10/12/23 in response to provider reported incident that staff member was accused of
giving client a vape pen containing marijuana. Two other peers reported this to staff. told staff Justin
King and Sherika Williams that he snuck it in his privates. stated that he flushed the vape pen down the
toilet whilst at UMCH. was admitted to UMCH 8/23/23 and drug tested upon admission which was
negative. Drug screen 10/10/23 yielded a positive drug screen for marijuana. has not been on any gate
passes since admission. There is no definitive evidence at this time to support specified staff provided the
marijuana, but it is evident client had access to marijuana whilst at this facility. Facility cited 109.1g. As to
document sub-regulation g) Engaging in behavior that could be viewed as sexual, dangerous, exploitative, or
physically harmful to children.
Staff has been drug tested which was inconclusive. Staff will be suspended pending additional
drug test results and pending facility investigation.
Provider Comments:
We will provide Licensing with an update on the employee's status upon the conclusion of the internal
investigation and a conclusive drug screening. In the event the employee returns an in-service training will be
completed on boundaries.
CCL Staff Signature : Date: 10/12/2023
Provider Signature : Date: 10/12/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Staff advised officer he wanted to make an assault report. Staff stated that on 10/5/23, a juvenile became combative and grabbed an aluminum stick-type object. When staff tried to take the object from juvenile, he stated she struck him in the head with it. Staff advised he took possession of the object after the altercation and did not have any injuries.

raw_content:
LITTLE ROCK POLICE DEPARTMENT INCIDENT REPORT

[_]JUVENILE INFORMATION

INCIDENT

Report generated: 10/27/2023 9:17 AM

INCIDENT NUMBER

2023-116368

UNIT ASSIGNED

2X40

CALL DATE

CALL TIME

10/06/2023

14:53:00

TYPE OF CALL

BATTERY

INCIDENT DATE

LOCATION OF INCIDENT (ADDRESS / BUSINESS NAME)

10/6/2023 2:53:09 PM

2002 S FILLMORE ST

METHODIST CHILDRENS HOME

OFFENSE

INCIDENT OFFENSE TYPE
1 ASSAULT 3RD DEGREE

2
3
4

[_]@) Drugs

VI Unknown

(N) Not Applicable /

TYPE OF CRIMINAL ACTIVITY:

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

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

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

[_]®) Distributing / Selling

[_]@) Possessing / Concealing

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

[1@ Otter Gang
[V]@X) None / Unknown

LOCATION CODE:

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

(03) Bar / Night Club

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

(07) Convenience Store

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

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

(13) Highway / Road / Alley

(14) Hotel / Motel / Etc

[_](15) Jail / Penitentiary

[_](16) Lake / Waterway

[_]7 Liquor Store

[_](18) Parking Lot / Garage

[_](9) Rental / Storage Facility

(20) Residence / House

[_](21) Restaurant

[_](22) School / College

[_](23) Service / Gas Station

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

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

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

[_](44) Daycare Facility

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

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

[_](49) Military Installation

[_](60) Park / Playground

[_](1) Rest Area

[_] (52) School - College / University

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

[_] ($6) Tribal Lands

[_](S7) Community Center

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

(13) Rifle

(14) Shotgun

[_] C5) Other Firearm

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

_U
_U
_ Uo
_U

(FOR BURGLARY ONLY)

NUMBER OF PREMISES ENTERED

METHOD OF ENTRY:

C] @®) Forcible

[_]@) No Force

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

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

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

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

(85) Asphyxiation

(90) Other

(95) Unknown

(99) None

NARCAN USED: | No

Yes

Other

ENTRY DATE REPORTING OFFICER ORIGINAL APPROVING SUPERVISOR .
10/06/2023 22:04:36 | GREGORY REESE - CHAD STANGE - J MVR in use

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

Page 1 of 6

INCIDENT NUMBER 2023-116368 Report generated: 10/27/2023 9:17 AM

JUVENILE INFORMATION

VICTIM
eee

WORK PHONE:

NAME (Last, First, Middle) or BUSINESS

MOBILE PHONE:

SEX: [V](M) Male
[_]® Female [_](U) Unk.

DATE OF BIRTH

ETHNICITY: [_]()Hispanic
(N) Non-Hispanic [—](U) Unk.

RACE: [¥](W) White [](B) Black [_]@ American Indian
[_]@) Asian / Pacific Islander [~](U) Unknown

() Resident
(U) Unknown

RES. STATUS:
Q) Nonresident

4) MENTALLY

(Y) Yes

AFFLICTED?
GN) No

] (U) Unk.

| OCCUPATION / EMPLOYER:

AGE:

Exact Age: |_|
Range: -

NIC: RELATIONSHIP OF THIS VICTIM TO SUSPECTS
SUSPECT(S) VICTIM WAS: (by Suspect Number)
| _————_—S(SE*) Spouse (AQ) Acquaintance
| ee (FR) Friend
(PA) Parent (NE) Neighbor
(SB) Sibling (BE) Babysitter (baby)
(BG) Boy/Girl Friend
(CF) Child of BF / GF
(HR) Homosexual Rel
(XS) Ex-Spouse
(EE) Employee
(ER) Employer
(OK) Otherwise Known
(RU) Relationship Unknown
(VO) Victim Was Suspect

[_] BB) 7-364 Days Old
(NN) Under 24 Hrs. Old ~~ [_] (99) Over 98 Years Old
(NB) 1-6 Days Old [_] @0) Unknown

THIS VICTIM RELATED TO WHICH OFFENSES?

D.L./ID No. (STATE)

5 6

|4 C7 (Cs

[V] @ Individual
[_](G Government

[_]@) Business  [_](F) Financial Inst.
[](R) Religious [_](S) Society / Public

[_]@) Unknown
[_] ©) Other

VICTIM INJURY:
[V] N) None [J Apparent Minor Injury
[_]@ Possible Internal Injury — [__](T) Loss of Teeth

[_] ©) Other Major Injury [_]@) Unconsciousness

({_]@) Apparent Broken Bones

(SS) Stepsibling
[_]@) Severe Laceration

(OF) Other Family
(ST) Stranger

AGGRAVATED ASSAULT / HOMICIDE:
[](04) Gangland

[_](08) Other Felony Involved

[](21) Criminal Killed by Police Officer

(01) Argument

[](05) Juvenile Gang

[_] (09) Other Circumstances
[_]@0) Child Playing w/ Weapon

[_] (02) Assault on Law Enf Officer
[_] (06) Lover's Quarrel

C] (10) Unknown Circumstances
[_]G1) Gun-Cleaning Accident

(03) Drug Deal
[_] (07) Mercy Killings

[_] (20) Criminal Killed by Private Citizen
[](2) Hunting Accident

[_] G4) Other Negligent Killings

C] (33) Other Negligent Weapon Handling
CLOTHING DESCRIPTION

Page 2 of 6

INCIDENT NUMBER 2023-116368 [_] JUVENILE INFORMATION Report generated: 10/27/2023 9:17 AM

SUSPECT #1

2002 S FILLMORE ST LITTLE ROCK AR 72204

NAME (Last, First, Middle)

HOME PHONE: OTHER PHONE:
0000000000

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

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

[_]@) Nonresident [¥](U) Unknown (%) Yes [V](N)No [_](U) Unk.

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

Exact Age: lvy]v1 v2 v3 [J@1) Unarmed
Range: - Llvs v6 vi (an) Firearm (Unk)

(99) Over 98 Years Old DL. /ID No. (STATE) im (12) Handgun

[]0) Unknown He : ~ [Ja3) Rifle
~ (a4) shotgun
~ [)5) Other Firearm

(o neugne --Vy)

THIS SUSPECT RELATES TO WHICH OFFENSES? [_]©) On View Arrest
¥Yji Cj2 [3 4 5 [_](S) Summons / Cited [_](D) Taken Into Custody

[_](6) Megal Cutting Instrument
[]a7 CtubBlackjack/Brass

ARREST LOCATION: | ARREST DATE:

CHARGE: 5-13-207

ARRESTING OFFICERS
OFFICER 1:

OFFICER 2:
OFFICER 3:
OFFICER 4:

Suspect information continued on next page.

Page 3 of 6

INCIDENT NUMBER 2023-116368

[_]JUVENILE INFORMATION

SUSPECT #1

Report generated: 10/27/2023 9:17 AM

SUSPECT #

1

NAME (Last, First, Middle)

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

lv (8) Unknown

[_](1) Long
[_]@) Medium
[_]@) Short
[_](4) Bald@ing)
[_](5) Other

lv] (6) Unknown

HAIR LENGTH:

HAIR STYLE:

[_]@1) Afro

[_] (02) Wavy
[_](03) Straight
[_](04) Curly
[_]@5) Braided
[_](06) Ponytail
JO? Mititary
LJ (08) Processed
[_](09) Wig/Toupee
[_]@0) Other
[V](11) Unknown

BUILD:

(_]q) Light
[_]@) Medium
[_]@G) Heavy
[_]4) Muscular
|v] (5) Unknown

ADDED DESCRIPTION:

n/a

HAIR COLOR:
(1) Black
[_](2) Blonde
(3) Brown
(4) Grey

(5) Red
[_]© Sandy
(7) Other
VY ](8) Unknown

EYE COLOR:
(1) Blue

(2) Brown
(3) Grey

[_ ](4) Green

(5) Hazel

(6) Other
\¥|(7) Unknown

FACIAL HAIR:

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

(10) Other

[V] (11) Unknown

(01) Clean Shaven

DEMEANOR:

L]
L]
L]
L]
L]
L]
L]
L]
L]
L]
L]
Vv

(01) Angry

(02) Apologetic
(03) Calm

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

(07) Professional
(08) Stupor

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

(12) Unknown

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

CLOTHING DESCRIPTION:

HAT

COAT

SHIRT

PANTS/DRESS
SHOES

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

|_| (04) Leg (xt)

(05) Hand (ft)

|_| (06) Hand (rt)
|_| (07) Face

(08) Neck

[|_| (09) Finger(s)

(10) Chest

[_](11) Back

Page 4 of 6

INCIDENT NUMBER 2023-116368 JUVENILE INFORMATION Report generated: 10/27/2023 9:17 AM

NARRATIVE

DELAYED REPORT:

ON 10/06/2023, WHILE WORKING 2X40, OFFICERS MADE CONTACT WITH a AT THE 12TH STREET
SUBSTATION WHO ADVISED HE WANTED TO MAKE AN ASSAULT REPORT.

carreras ADVISED THE ACCIDENT ACTUALLY OCCURRED ON THE MORNING OF 10/05/23. Ve ADVISED
AT METHODIST CHILDREN'S HOME, WHERE HE WAS MONITORING JUVENILE FEMAL AVIOR. MR.
GR fo'seo ONE JUVENILE, JUV1 BECAME COMBATIVE. MR. STATED JUV1 THEN GRABBED AN

M STICK-TYPE OBJECT AND STARTED TO PLAY WITH IT. MR. ADVISED HE TRIED TO TAKE THE
OBJECT FROM JUV1 AND JUV1 STRUCK HIM IN HIS HEAD WITH IT. MR. ADVISED THE STICK-LIKE OBJECT
BROKE WHEN JUV1 STRUCK HIM WITH IT. MR RB ADVISED HE TO TAKE POSSESSION OF THE
OBJECT AFTER THE ALTERCATION AND STAT NOT HAVE ANY INJURIES.

OFFICERS PROVIDED VR rs A COPY OF THE INCIDENT REPORT AND ADVISED IF HE WANTED TO
PRESS CHARGES, HE WO TO SPEAK WITH THE PROSECUTING ATTORNEY'S OFFICE.

Page 5 of 6

INCIDENT NUMBER 2023-116368 [_]JUVENILE INFORMATION Report generated: 10/27/2023 9:17 AM

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

RELATED CASE NUMBER(S)

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

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

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

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

(14) Asian / Pacific Islander (25) Other Religion [_](51) Physical Disability [_](45) Bisexual

[_](15) Multi-Racial Group [__](26) Multi-Religious Group [__] (52) Mental Disability
[_](27) Atheist/A gnostic

Page 6 of 6


summary: An x-ray of the finger was ordered after complaints of pain from a resident.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/3/2023
Date Received by DCCECE: 10/3/2023
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: age DOB , parent custody non DHS had an
xray on a finger that he complains of pain. There was no findings of dislocation or fracture.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 10/3/23 that on 10/3/23 client
had an x-ray on a finger that he complains of pain. There was no findings of
dislocation or fracture. No licensing concerns noted in this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital for evaluation after fracturing his hand by punching a window.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 9/27/2023
Date Received by DCCECE: United Methodist Children's Home Little Rock Campus
Facility Name: United Methodist Children's Home Little Rock Campus
Facility Number: 115
Incident Type: Licensing
Report Description: , he is in private placement.
was sitting in the courtyard listening to his MP3 player, all of a sudden, he gets out of his
seat and throws his MP3 players down. walked toward the cafeteria door, while
walking into the cafeteria, he punches the window with his right hand. An in-house x-ray
was ordered due to having pain in his right hand and completed on 9/27/23 around
9:10 p.m. The finding is a fracture of the neck of the fifth metacarpal with angulations, acute
(Boxer's fracture). was transported to Arkansas Children's Hospital, Emergency
Department for further evaluation on 9/28/2023.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/28/23 that on 9/27/23 client
was sitting in the courtyard listening to his MP3 player, all of a sudden, he
gets out of his seat and throws his MP3 players down. walked toward the cafeteria
door, while walking into the cafeteria, he punches the window with his right hand. An in-
house x-ray was ordered due to having pain in his right hand and completed on
9/27/23 around 9:10 p.m. The finding is a fracture of the neck of the fifth metacarpal with
angulations, acute (Boxer's fracture). was transported to Arkansas Children's
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Hospital, Emergency Department for further evaluation on 9/28/2023. Email sent to facility
9/28/23 to notify licensing of any follow-up results when received. No licensing concerns
noted in this report.


summary: Licensing visited the facility to review video of the early morning hours of 9/24/23 and 9/25/23.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
United Methodist Children's Home Little Rock Campus Clayton DeBoer
2002 SOUTH FILLMORE Donaghey Plaza
LITTLE ROCK AR 72204 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 115
Date of Visit: 9/26/2023
Visit Type(s): Monitor Visit
Time: 9:00 AM - 9:31 AM
_______________________________________________________________________________________________
Visit Comment :
Facility visited 9/26/23 and video reviewed of the early morning hours of 9/24/23 and 9/25/23.
9/24/23:
Hall A night visual checks conducted at: 1:57AM, 2:13AM and 2:25AM
Hall B night visual checks conducted at: 2:00AM, 2:15AM and 2:30AM
Hall C night visual checks conducted at: 2:00AM, 2:14AM and 2:30AM
Hall D night visual checks conducted at: 1:59AM, 2:14AM and 2:29AM
9/25/23:
Hall A night visual checks conducted at: 2:32AM, 2:42AM and 2:57AM
Hall B night visual checks conducted at: 2:30AM, 2:46AM and 2:59AM
Hall C night visual checks conducted at: 2:28AM, 2:44AM and 2:58AM
Hall D night visual checks conducted at: 2:30AM, 2:44AM and 3:00AM
Page 1 of 2

CCL Staff Signature : Date: 9/26/2023
Provider Signature : Date: 9/26/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


summary: Licensing visited the facility to review video for the late-night hours of 9/15/23 and 9/16/23.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
United Methodist Children's Home Little Rock Campus Clayton DeBoer
2002 SOUTH FILLMORE Donaghey Plaza
LITTLE ROCK AR 72204 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 115
Date of Visit: 9/18/2023
Visit Type(s): Monitor Visit
Time: 10:00 AM - 10:25 AM
_______________________________________________________________________________________________
Visit Comment :
Facility visited and video reviewed for the late-night hours of 9/15/23 and 9/16/23.
9/15/23:
Hall A night visual checks conducted at: 11:00PM, 11:14PM and 11:29PM
Hall B night visual checks conducted at: 10:59PM, 11:14PM and 11:29PM
Hall C night visual checks conducted at: 11:00PM, 11:17PM and 11:29PM
Hall D night visual checks conducted at: 11:00PM, 11:14PM and 11:29PM
9/16/23:
Hall A night visual checks conducted at: 10:59PM, 11:16PM and 11:30PM
Hall B night visual checks conducted at: 11:00PM, 11:16PM and 11:30PM
Hall C night visual checks conducted at: 11:00PM, 11:16PM and 11:29PM
Hall D night visual checks conducted at: 10:59PM, 11:14PM and 11:29PM
All night visual checks conducted within 30 minutes.
Page 1 of 2

CCL Staff Signature : Date: 9/18/2023
Provider Signature : Date: 9/18/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


summary: Staff advised officers that a juvenile pushed a door in his face while being escorted through the facility. In an effort to stop the door from hitting his face, he used his hand to stop the door and his hand was injured. Juvenile was transported by MEMS to acute care for her behavior issues.

raw_content:
Report Contains Juvenile Information
INCIDENT NUMBER 2023-106688 JUVENILE INFORMATION Report generated: 9/24/2023 9:14 AM
Redact Before Release
NARRATIVE
OFFICERS RESPONDED TO THE LISTED LOCATION IN REFERENCE TO AN ASSIST MEDICAL.
FACILITY STAFF ADVISED J1 WAS BEING ESCORTED BY THROUGHOUT THE FACILITY. J1 PUSHED THE
DOOR IN FACE AND IN AN ATTEMPT TO STOP THE DOOR FROM HITTING HIS FACE, HE USED HIS HAND TO
STOP THE DOOR AND HIS HAND WAS INJURED. FACILITY STAFF ADVISED LEFT TO SEEK MEDICAL
ATTENTION FOR HIS INJURIES. WAS TRANSPORTED BY MEMS 711 TO METHODIST BEHAVIORAL
CENTER FOR HER BEHAVIOR ISSUES. FACILITY STAFF WAS ISSUED AN INCIDENT CARD.
BWC/MVR IN USE.
Page 5 of 6