summary: A resident reported that a staff member shoved him in his room, injuring his wrist. The facility was cited N128 and N142 for issues associated with this incident. One staff member was terminated.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 030065
Date of Incident: 5/23/2025
Date Received: 5/27/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, was placed into a PRT due to Resident
punching walls in his bedroom. No emergency medications administered. Respirations
even and non-labored. Upon assessment, Resident noted with bruising to left hand and
wrist. Resident stated to Nurse that Staff shoved him in his room and his wrist went
backwards on his wall. Resident unable to bend wrist and hand. Left wrist and hand
immobilized, evaluated, with ice pack applied. Resident sent to
Resident placed on assault
precautions. Staff member named as alleged offender suspended pending investigation.
Resident, witnessing peer, and alleged offended Staff statements collected.
Camera footage reviewed by Safety team. Resident
returned to the facility at 1220 (12:20 am) from
No distress noted with complaint of pain to left
upper extremity. . Respirations even and non-labored.
Resident noted with splint to upper left extremity, able to move distal fingers. New orders to
follow up with and
per Physician?s orders. Resident assisted to bedroom by MHT staff. Resident is
currently on Line of Sight while splint is in use.
Interim Action Narrative:
Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Program Coordinator received a phone call from an entity regarding
this complaint. Per entity, they were not able to obtain requested documentation from the
facility. Entity was informed that licensing was waiting for the complaint to be submitted
and would inform the entity once received. 5/28/2025, licensing informed entity that
complaint has been received 5.28.25- emailed facility inquiring name of suspended staff and
for facility to retain footage facility replied: With the new information presented today, we
are moving forward with suspending today. . Footage is retained.
Program Coordinator spoke with facility via telephone and explained that the staff member
in question was named in this complaint and that licensing needed to know is employment
status. Facility reported that staff member would be suspended as of today. Program
Coordinator spoke with an entity via telephone regarding documentation received. Entity
was informed that documentation had not been received as of today. 5/29/2025, Program
Coordinator forwarded documentation received to the entity. Program Coordinator spoke
with the entity via telephone who informed Licensing of more information regarding this
complaint. 5.29.25- Uploaded Facility provided intervention packet, body check, and
assessment. Licensing Specialist noted reason for restraint was imminent threat of self-
harm, but staff notes state resident was slamming doors and not willing to obey staff and
stop. Resident was in the restraint from 1911 to 1915, restraint packet was signed at 1914.
Body Assessment shows scratches on inner thigh/groin area as well as markings and
bruising on his upper arms and wrists. There was also no "Supervisor on Duty" signature
on body assessment paperwork. Resident states he does not feel safe due to staff who put
him in restraint being "aggressive both physically and verbally." 5/30/2025, licensing
received documentation from an entity. Documentation uploaded and will be reviewed by
the Licensing Specialist. Management reviewed provided video. 05/30/2025 Licensing
Specialist visited the facility viewed camera footage and met with residents regarding
Licensing concerns. 6.2.25- Licensing Specialist reviewed footage and uploaded narrative
into notes. 6.2.25- Licensing Specialist called and left voicemail. Called
and uploaded interview narrative into notes. 6.3.25- Specialist called
again and left voicemail, will also be sending email. Uploaded interview narrative. 6.6.25-
uploaded PRT Certifications for staff as well as personnel file paperwork

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES Approved 6/30/25 BBM
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A.BUILDING
C
04L115 B.WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 000 Initial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
Complaint #N/A (AR00036313) was in
compliance.
Complaint #N/A (AR00038422) was in
compliance.
Complaint #N/A (AR00038874) was not in
compliance with deficiencies cited at N128 and
N142
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
N 128 PROTECTION OF RESIDENTS N 128 The Resident affected was assessed by Nursing and
CFR(s): 483.356(a)(3) an Order was received by the Physician for further
evaluation of Resident at local Medical center. Staff
Restraint or seclusion must not result in harm or involved were suspended immediately and remain
injury to the resident and must be used only- suspended pending investigation results. Results from
internal investigation yield one Staff member not
returning. The likelihood for this deficiency affecting
This ELEMENT is not met as evidenced by:
other Residents being affected was greatly reduced
Based on observations, interviews, and record
and minimized due to the organization’s response.
and video review, the facility failed to prevent
The Chief Executive Officer oversees the
injury during an Emergency Safety Intervention implementation of this corrective action plan. A
(ESI) for one (Client #3) of three clients reviewed mandated facility-wide retraining for all Mental
for injuries. Health Technicians, Nurses, Dietary Staff,
Maintenance Staff, Clinical staff, and Administrative
The findings include: staff on verbal de-escalation and proper physical
interventions was conducted by the Handle with Care
Instructor June 18th 2025. Retraining included
modeling verbal de-escalation, proper physical
intervention, and scenario based participation. All
attendees signed acknowledgement and attestation of
training on proper Handle with Care technique. The
Director of Quality and Risk Management is the
custodian of the training log. Training records will be
audited weekly by the Quality Risk Director until
100% training compliance is reached for existing
staff. This training is already part of the new hire
orientation process. The ongoing standard six-month

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
Handle with Care refreshers will also continue as
scheduled, conducted by the Handle with Care
Instructor and tracked by the Director of Quality and
Risk Management. Compliance rate and upcoming
trainings will be reviewed in the monthly Committee
of the Whole meeting and reported to the Governing
Board for oversight. For Staff who could not attend
the training, individual training will be provided,
documented, and attestations will be signed. All
training will be completed by July 6th, 2025.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 1 of 16

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 1 N 128
Review of Client #3's " Master Treatment Plan "
dated 05/06/2025, revealed Client #3 had
diagnoses which included major depressive
disorder which was recurrent and severe without
psychosis, generalized anxiety disorder, history of
post-traumatic stress disorder, and history of
trauma.
Review of an ESI dated 05/23/25 and completed
by Registered Nurse (RN) #1, revealed that Client
#3 was placed in a physical restraint at 7: 11 PM
and was released at 7:15 PM, due to the resident
being out of control and uncooperative with staff .
ESI documentation included check marks under
the section that listed interventions attempted
before restraints were implemented as,
emphasized need for self-control, attempted to
redirect, and allowed patient other ways to vent
anger.
Review of the " Client Debrief Form" contained in
the ESI packet revealed Client #3 reported that
staff gave no warnings before the restraint was
initiated. While in restraint the client reported that
staff "just broke my arm."
Review of a " Body Check Form " contained in
the ESI packet under the comment section dated
05/23/2025 at 7:17 PM, signed by RN #1,
revealed that per staff, Client #3 was placed in a
personal restraint due to being uncooperative with
staff and slamming the bedroom door in another
resident's face. Client #3 was sent to the
emergency department for an X-ray of the left
wrist. A body assessment was completed by RN
#1, that included a body diagram, which indicated
a bruise on Client #3's upper area of both arms,
and bruising on the left hand and wrist. The ESI
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 2 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 2 N 128
included Client #3 ' s complaints of pain and
inability to move their left hand.
Review of a " Nurse's Note " dated 05/23/2025
at 7:16 PM, revealed Client #3 reported that
Mental Health Technician (MHT) #1 shoved Client
#3 inside the bedroom causing the client's wrist
and hand to go backwards. Client #3 was unable
to move the upper left extremity, and bruising was
noted to the entire wrist and hand. Review of an
additional " Nurse's Note " timed 7:30 PM,
indicated the client was transferred to the
emergency department for evaluation and
treatment. Both nurse ' s notes were signed by
RN #1.
Review of a " Nurse's Note " signed by RN #1,
dated 05/24/2025 at 12:20 AM, indicated Client
#3 returned from the hospital with a splint to the
upper left extremity.
Review of a handwritten witness statement by
MHT #1, dated 05/23/2025, contained within the
" Facility Investigation Packet " revealed Client
#3 had called MHT #1 a derogatory name after
she stepped on a bug that Client #3 was trying to
put in a "container and save." Client #3 then went
into the bedroom and slammed the door and was
banging their hands on the clothes shelf. MHT #1
reported she told Client #3 to come out of the
bedroom, but Client #3 was " resisting staff Client
#3 finally came out and was placed in a primary
restraint technique (PRT). Client #3 stated their
wrist was hurting but staff had their arms and put
them in a PRT with one hand so the client
wouldn't say the staff was holding them too tight. "
Review of a " witness statement, " of the incident
transcribed and written by the Quality and Risk
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 3 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 3 N 128
Manager and signed by the resident on
05/26/2025, revealed Client #3 reported finding a
bug then MHT #1 stepped on it and both Client #3
and MHT #1 began calling each other derogatory
names. Client #3 went into their bedroom and
slammed the door, then MHT #1 came into the
room, slammed the door, screamed, "Don't slam
this [expletive] door!" Client #3 stated, "I won't
slam this [expletive] door in a sassy way." The
client reported being shoved into the " cubby "
by MHT #1, and then being put into a PRT and
taken out into the hallway. Client #3 stated they
asked MHT #1, "Could you release the pressure
on my left arm because I think you broke it."
Review of video footage dated 05/23/2025, time
stamped beginning at 7:11:47 PM and ending at
7:16:22 PM, revealed the following events:
At 7:11:49 Client #1 was seen noticing something
on the floor by the double doors, turned and went
quickly back to their bedroom, returned five
seconds later with a red container and went back
to the door and was seen bending down. MHT #1
arrived at the door and stepped in front of Client
#3. Client #3 went back to their room and shut the
door at 7:12:15. One second later, MHT #1 was
seen aggressively pushing past Client #4 who
was standing in the doorway. Client #4 continued
to look into the open doorway and then the door
closed again at 7:12:26 PM. One second later,
Client #3 was seen coming out of the room with
MHT #1 holding the client's left upper extremity
around the biceps area with her left hand. MHT
#1's arm was hooked under the client's right
armpit which resulted in the right arm being held
behind the client's back. MHT #1 then forcefully
put Client #3 against the hallway wall pulling the
client's elbows at an approximate 90-degree
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 4 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 4 N 128
angle to the client's body up and behind the
client's back, forcing the client up on their tiptoes.
MHT #1 was seen leaning on Client #3 with her
upper body into the client's upper body area
pressing Client #3's chest against the wall. Client
#3 was seen having to turn their head to the side
with cheek against the wall. This hold was
maintained for 23 seconds then MHT #1
repositioned her arms and continued to hold the
client's arms behind their back, Client #3
remained against the wall and on their tiptoes.
Client #3 and MHT #1 were seen having a verbal
exchange, but the video did not have audio. At
7:13:26 PM, MHT #2 entered the hallway,
approached the client, and took over the restraint
by placing his arms under the client's armpits and
pulling the elbows up and behind the client, lifting
the client back up on their tiptoes. MHT #2
interlaced his own fingers together while pulling
Client #3's elbows toward each other behind the
client's back. MHT #2 leaned his upper body into
the back of the client's upper body resulting in the
client's chest being pushed against the wall. RN
#1 arrived at 7:14:24. MHT #2 readjusted his
position standing more upright. MHT #2 stepped
back maintaining the physical hold but no longer
leaned on Client #3 and lowered the client
enough that Client #3's feet were in a flat position
on the floor. At 7:16:09 Client #3 was released
from the physical restraint. RN #1 looked at Client
#3's arm and the client was seen exiting the
hallway at 7:16:27 PM. Client #3 was not seen
struggling at any time during the physical restraint
hold which was referred to as a PRT by the staff.
During a telephone interview on 06/04/2025 at
10:23 AM, MHT #1 reported that Client #3 had
gone to their room and slammed the door after
she had stepped on a bug that Client #3 was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 5 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 5 N 128
trying to put into a container. MHT #1 reported
that she heard small plastic blocks hit the floor.
She went into the room and escorted Client #3
out into the hall and placed the client in a PRT.
MHT #1 reported that Client #3 was hitting the
bookshelves with their fists. MHT #1 reported that
the client had told her in the hallway that she had
hurt the client ' s wrist, but she did not report the
complaint to MHT #2 who took over the restraint
later in the hallway. MHT #1 stated she did not
come in on her next scheduled day, "Because I
figured I'd be suspended."
During a phone interview on 06/04/2025 at 10:54
AM, MHT #2 reported that on 05/23/2025 he
responded to the restraint of Client #3 and
relieved MHT #1 because the staff and the client
were arguing. Client #3 stated to MHT #1 "I'm
going press charges on you." MHT #2 stated that
the resident was hurting and crying and when the
nurse arrived MHT #2 stated the client was
released from the PRT. MHT #2 described the
client's wrist as "bent up and purple."
During an interview on 06/04/2025 at 3:00 PM,
Client #4 reported that Client #3 had been hurt
and described the incident stating that Client #3
had got mad when MHT #1 had stomped on a
bug that Client #3 had wanted to catch. Client #4
reported that Client #3 had gone into the
bedroom and slammed the door and was behind
the door when MHT #1 pushed the door open
and it hit Client #3 and hurt their arm. Then, MHT
#1 had brought Client #3 out into the hall and put
them in a PRT. Client #4 stated Client #3's arm
was broken.
During an interview on 06/04/2025 at 3:30 PM,
Client #3 reported that on 05/23/2025, they had a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 6 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 6 N 128
verbal confrontation with MHT #1 and went to the
bedroom and slammed the door after MHT #1
stomped on a bug that the client had wanted to
catch. Client #3 stated that MHT #1 came into the
bedroom, slammed the door and started
screaming and cursing. Client #3 reported turning
toward the cubby to get a " fidget " out to "calm
myself down. As I turned, she pushed me from
behind and my hand hit the cubby and went numb
and then she put me in a PRT." Client #3
reported that their hand and wrist bent backwards
when it hit the cubby. Client #3 reported that MHT
#1 took them out into the hallway and continued
the PRT. Client #3 stated " I felt a ' pop ' and it
felt like it shifted, and the bones rubbed together.
At first, it was numb but then she was putting
pressure on it, and it started hurting really bad. I
told her she had broken it." Client #3 reported that
MHT #2 took over the PRT and "put so much
pressure on my arm that I was on my toes and
then I had a bruise on my arm." Client #3
indicated to this surveyor the upper bicep area as
being where the bruise was located. Client
reported, "Then the nurse came, and they let me
go, on my way to the quiet room my hand was
purple."
During an interview on 06/04/2025 at 4:16 PM,
Client #1 reported witnessing the incident and
stated he heard Client #3 in their room with MHT
#1 saying, "I didn't do anything, why did you put
me in a PRT?" Client #1 stated that Client #3 was
saying, "Stop! Stop! Stop! I feel like my arm is
broken!"
During a phone interview on 06/05/2025 at 7:36
AM, MHT #3 reported being present during the
incident on 05/23/2025, and revealed that Client
#3 was fighting with MHT #1 as she was bringing
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 7 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 7 N 128
the client out into the hallway and was screaming,
"My arm, my arm- you broke my arm!"
During an interview on 06/05/2025 at 3:25 PM,
the Director of Nursing (DON) reported that
unless the client was a danger to self or others,
interventions such as offering coping skills ,
redirection, or removing the audience should be
attempted by staff prior to placing a resident in a
physical restraint. The DON also reported that
staff were taught to call the nurses before putting
clients in a physical hold.
During an interview on 06/05/2025 at 3:45 PM,
the Chief Executive Officer (CEO) stated that
staff should not put a resident in a physical
restraint unless the resident was a harm to self or
others. Staff were to give clients alternatives and
try the coping skills that have been identified as
effective for them. Some have "fidgets" that help
them calm down and when restraints are used it
should be the least restrictive method.
Review of an " Emergency Department Physician
Documentation " dated 05/23/2025, revealed
Client #3 had diagnoses of a break in the larger
wrist bone, about an inch below the wrist joint and
a fracture of both radial and ulnar bones.
Review of a facility policy titled, "Behavioral
Management-General" revised 03/2025, revealed
that restraints are used only in the case of
emergency, when there is imminent risk of harm
to the client or others and when non-physical
interventions would or have been ineffective .
"These techniques are used only after less
restrictive methods have been tried and failed
and all other means of verbal de-escalation
techniques have been expended." The policy
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 8 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 128 Continued From page 8 N 128
indicated if restraints are used, they are to be
used in the least restrictive manner and are to be
discontinued at the earliest time possible.
N 142 ORDERS FOR USE OF RESTRAINT OR N 142
SECLUSION
CFR(s): 483.358(c)
A physician or other licensed practitioner
permitted by the state and the facility to order
restraint or seclusion must order the least
restrictive emergency safety intervention that is
most likely to be effective in resolving the
emergency safety situation based on consultation
with staff.
This ELEMENT is not met as evidenced by:
Based on observations, interviews and record
review, the facility failed to ensure that the least
restrictive interventions were implemented prior to
physically restraining one (Client #3) of three
case mix clients reviewed for restraints.
The findings include:
Review of Client #3's "Master Treatment Plan,"
dated 05/06/2025, revealed Client #3 had
diagnoses which included major depressive
disorder which was recurrent and severe without
psychosis, generalized anxiety disorder, history of
post-traumatic stress disorder, and history of
trauma.
Review of an "Emergency Safety Intervention
Justification" packet (ESI) dated 05/23/25, and
completed by Registered Nurse (RN) #1,
indicated Client #3 was placed in a physical
restraint at 7:11 PM, and was released at 7:15
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 9 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 9 N 142
PM, due to "resident out of control" and
"uncooperative with staff." ESI documentation
included check marks under the section that
listed interventions attempted before restraint as:
emphasized need for self-control, attempted to
redirect, and allowed patient other ways to vent
anger.
Review of the "Client Debrief Form" contained in
the ESI packet revealed Client #3 reported that
the staff gave no warnings before initiating
restraint.
Review of the "Staff Debrief Form" contained in
the ESI packet signed by Mental Health
Technician (MHT) #1 revealed the measure taken
to de-escalate the situation prior to implementing
the restraint was, processed with patient.
Review of a "Body Check Form" contained in the
ESI packet under the comment section dated
05/23/2025 at 7:17 PM, signed by RN #1
indicated that per staff, Client #3 was placed in a
personal restraint due to being uncooperative with
staff and slamming the bedroom door in another
resident's face.
Review of a handwritten "Witness Statement," by
MHT #1 dated 05/23/2025, located within the
facility investigation packet, indicated Client #3
called MHT #1 a derogatory name after she
stepped on a bug that Client #3 was trying to put
in a "container and save." Client #3 then went into
the bedroom and slammed the door and was
banging hands on the clothes shelf. MHT #1
reported she told Client #3 to come out of the
bedroom, but Client #3 was "resisting staff " but
finally came out and was placed in a primary
restraint technique (PRT).
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 10 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 10 N 142
Review of a "Witness Statement" transcribed and
written by the Quality and Risk Manager due to
resident's injury received on 05/23/2025 during an
Emergency Safety Intervention and signed by the
resident on 05/26/2025, revealed Client #3
reported finding a bug but MHT #1 stepped on it
and both Client #3 and MHT #1 began calling
each other derogatory names. Client #3 went into
the bedroom and slammed the door, then MHT
#1 came into the room, slammed the door,
screamed "don't slam this [expletive] door!" Client
#3 stated, "I won't slam this [expletive] door in a
sassy way. " The client reported being shoved
into the cubby by MHT #1 and then being put into
a PRT and taken out into the hallway. Client #3
stated having asked MHT #1 "could you release
the pressure on my left arm because I think you
broke it."
Review of video footage dated 05/23/2025 time
stamped beginning at 7:11:47 PM and ending at
7:16:22 PM, revealed the following events:
At 7:11:49 Client #1 was seen noticing something
on the floor by the double doors, turned and went
quickly back to the bedroom, returned five
seconds later with a red container and went back
to the door and was seen bending down. MHT #1
arrived at the door and stepped in front of Client
#3 and appeared to step on something. Client #3
went back to the room and shut the door at
7:12:15 PM. One second later, MHT #1 was seen
aggressively pushing past Client #4 who stood in
the doorway. Client #4 continued to look into the
open doorway and then the door closed again at
7:12:26 PM. One second later, Client #3 was
seen coming out of the room with MHT #1 holding
the client's left upper extremity around the bicep
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 11 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 11 N 142
area with her left hand. MHT #1's arm was
hooked under the client's right armpit which
resulted in Client #3 ' s right arm being held
behind the client's back. MHT #1 then forcefully
put Client #3 against the hallway wall, pulled the
client's elbows at an approximate 90-degree
angle to the client's body, up and behind the
client's back, forcing the client up on their tiptoes.
MHT #1 was seen leaning on Client #3 with her
upper body into the client's upper body area
pressing Client #3's chest against the wall and
the client was seen having to turn their head to
the side with cheek against the wall. This hold
was maintained for 23 seconds, then MHT #1
repositioned her arms and continued to hold
Client #3's arms behind the client ' s back and the
client remained against the wall and on their
tiptoes. Client #3 and MHT #1 were seen having
a verbal exchange, but the video did not have
audio. At 7:13:26 PM, MHT #2 entered the
hallway, approached Client #3 and took over the
restraint by placing his arms under the client's
armpits and pulling the elbows up and behind the
client, lifting the client back up on tiptoes. MHT #2
interlaced his fingers together while pulling Client
#3's elbows toward each other behind the client's
back. MHT #2 was leaning his upper body into
the back of the client's upper body resulting in
Client #3 ' s chest being pushed against the wall.
RN #1 arrived and at 7:14:24 PM, MHT #2
readjusted his position stood more upright,
stepped back to maintain the physical hold, but
no longer leaned on Client #3 and lowered Client
#3 enough that the client's feet were in a flat
position on the floor. At 7:16:09 PM, Client #3
was released from the physical restraint, RN #1
looked at Client #3's arm and client was seen
exiting the hallway at 7:16:27 PM. Client #3 was
not seen struggling at any time during the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 12 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 12 N 142
physical restraint hold which was referred to as a
PRT by the staff.
On 06/04/2025 during a telephone interview
which began at 10:23 AM, MHT #1 reported that
Client #3 had gone to the room and slammed the
door after she had stepped on a bug that the
client was trying to put into a container. MHT #1
reported that she heard small plastic blocks hit
the floor, and she went into the room and
escorted Client #3 out and placed the client in a
PRT.
On 06/04/2025 during a phone interview which
began at 10:54 AM, MHT#2 reported that he had
responded on 05/23/2025, to the restraint of
Client #3 that was already in progress. He had
relieved MHT #1 because the staff and the client
were arguing and Client #3 had stated to MHT #1
"I'm gonna press charges on you." MHT #2 stated
that the resident was hurting and crying and when
the nurse arrived, the client was released from
the PRT. MHT #2 described Client #3's wrist as
"bent up and purple."
During an interview on 06/04/2025 at 3:00 PM,
Client #4 reported that Client #3 had been hurt by
staff and described the incident. Client #4 stated
Client #3 had gotten mad when MHT #1 had
stomped on a bug that Client #3 had wanted to
catch. Client #4 reported that Client #3 had gone
into the bedroom and slammed the door and was
behind the door, then MHT #1 had pushed the
door open, and it hit Client #3 and hurt the client's
arm. Then MHT #1 had brought Client #3 out and
put them in a PRT. Client #4 stated Client #3's
arm was broken.
During an interview on 06/04/2025 at 3:30 PM,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 13 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 13 N 142
Client #3 reported that on 05/23/2025, they had a
verbal confrontation with MHT #1 and went to the
bedroom and slammed the door after MHT #1
stomped on a bug that the client had wanted to
catch. Client #3 stated MHT #1 came into the
bedroom slammed the door and started
screaming and cursing. Client #3 reported turning
toward the cubby to get a fidget out to "calm
myself down, as I turned, she pushed me from
behind, my hand hit my cubby, bent backwards
and went numb, and then she put me in a PRT."
Client #3 reported that MHT #1 took them out to
the hallway and continued the PRT in the hall
where the client felt a "pop" and stated it "felt like
it shifted, and the bones rubbed together. At first
it was numb, but then she put pressure on it, and
it started hurting really bad. I told her she had
broken it." Client #3 reported that MHT #2 took
over the PRT and "put so much pressure I was
on my toes and had a bruise on my arm." Client
#3 then indicated to this surveyor the upper
biceps area as being where the bruise was
located. Client #3 stated, "Then the nurse came,
and they let me go; on my way to the quiet room
my hand was purple. "
During an interview on 06/04/2025 at 4:16 PM,
Client #1 reported witnessing the incident. Client
#1 stated they heard Client #3 in the room with
MHT #1 saying, "I didn't do anything why did you
put me in a PRT?" Client #1 stated that Client #3
was saying, "Stop! Stop! Stop! I feel that my arm
is broken!"
On 06/05/2025 during a phone interview which
began at 7:36 AM, MHT #3 reported being
present during the incident on 05/23/2025. MHT
#3 stated Client #3 was fighting with MHT #1 as
she was bringing the client out into the hallway.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 14 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
N 142 Continued From page 14 N 142
Client #3 was screaming, "My arm- you broke my
arm!"
During an interview on 06/05/2025 at 1:29 PM,
RN #2 reported that staff were taught to give at
least three verbal prompts and try to de-escalate
the behavior before a client was placed in a
physical restraint.
During an interview on 06/05/2025 at 3:25 PM,
the Director of Nursing (DON) reported that
unless the client was a danger to self or others,
interventions such as offering coping skills ,
redirection, or removing the audience should be
attempted by staff prior to placing a resident in a
physical restraint. The DON stated that staff were
taught to call the nurses before putting clients in a
physical hold.
During an interview on 06/05/2025 at 3:45 PM,
the Chief Executive Officer (CEO) stated that
staff should not put a resident in a physical
restraint unless the resident was a harm to self or
others. The CEO stated staff gave clients
alternatives and the coping skills that have been
identified to work for them. Some have "fidgets"
that help them calm down and when a restraint
was used it should be the least restrictive
method.
Review of a facility policy titled, "Behavioral
Management-General" with a revision date of
03/2025, revealed that restraint is used only in the
case of emergency, when there is imminent risk
of harm to the resident or others and when
non-physical interventions would or have been
ineffective. These techniques are used only after
less restrictive methods of interventions have
been tried and failed and all other means of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 15 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
C
04L115 B. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1521 ALBERT ST
WOODRIDGE OF FORREST CITY, LLC
FORREST CITY, AR 72335
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
The Resident affected was assessed by Nursing and
N 142 Continued From page 15 N 142 an Order was received by the Physician for further
evaluation of Resident at local Medical center. Staff
verbal de-escalation have been expended. If
involved were suspended immediately and remain
restraint is used it is to be used in the least suspended pending investigation results. Results from
restrictive manner possible and discontinued at internal investigation yield one Staff member not
the earliest possible time. returning. The likelihood for this deficiency affecting
other Residents being affected was greatly reduced
and minimized due to the organization’s response.
The Chief Executive Officer oversees the
implementation of this corrective action plan. A
mandated facility-wide retraining for all Mental
Health Technicians, Nurses, Dietary Staff,
Maintenance Staff, Clinical staff, and Administrative
staff on verbal de-escalation and proper physical
interventions was conducted by the Handle with Care
Instructor June 18th, 2025. Retraining included
modeling verbal de-escalation, proper physical
intervention, and scenario-based participation. All
attendees signed acknowledging receipt of training
and attestation of understanding. and attestation of
understanding. For Staff who could not attend the
training, individual training will be provided,
documented, and attestations will be signed. All
training will be completed by July 6th, 2025. The
Director of Quality and Risk Management will be the
custodian of the training log. Training records will be
audited weekly by the Quality Risk Director until
100% training compliance is reached for existing
staff. This training is already part of the new hire
orientation process. The Director of Quality and Risk
Management will continue to review and document
all physical interventions with special emphasis on
physical interventions where a Resident injury was
reported. Observations will be reviewed with the
interdisciplinary Safety committee daily (Monday –
Friday) comprised of the Director of Nursing,
Program Director, Handle with Care Instructor,
Clinical Director, Director of Quality and Risk
Management, and Chief Executive Officer. Proper
reporting to Guardians, Abuse/Neglect hotline, and
other child protective entities will continue to be
notified in accordance with Arkansan and Resident’s
corresponding State guidelines. Cumulative data will
be reviewed in the Committee of the Whole monthly
and reported to the Governing Board for oversight.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 16 of 18

PRINTED: 06/20/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67P111 Facility ID: 3012 If continuation sheet Page 17 of 18

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
June 30, 2025
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
Dear Administrator:
On June 6, 2025, we conducted a Complaint Investigation survey at your facility. You have alleged that
the deficiencies cited on that survey have been corrected. We are accepting your allegation of
compliance and have approved your plan of correction and presume that you will achieve substantial
correction by July 6, 2025.
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: Breanna Marengo at 501-320-6280 or email
to: breanna.marengo@dhs.arkansas.gov.
Sincerely,
for Jeff Rosenbaum
Breanna Marengo, RN QA Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
bbm
Charlotte Lockhart - Woodridge Of Forrest City, Llc -- -- (AOLTC-14) Page 1


state: AR

facility_name: Perimeter Behavioral of Forrest City

summary: Officers were dispatched to Forrest City Medical Center in response to a 13-year-old who needed to file a report about an incident that happened at the facility.

raw_content:
FORREST CITY Pse 1 Incident

len , nesen'* 2505230014

FORREST CITY, AR. 72335

Crime / Incident (Primary, Secondary, Tertiary) = so
5-13-202 BATTERY 2ND DEGREE | On or Fron) 05/23/2025 | 21:45 | Fri |
5-27-207 ENDANGERING THE WELFARE OF A MINOR/ 3RD S [ee leasae [|
[Reported [95/23/2025 | 21:45 | Fri_|

Latitude / Longitude County
ST FRA

Location of Incident 1521 Albert St, Forrest City, AR
Cross Street K/ITTLE RD.

"RP" = Reporting Party

"W" = Witness "S$" = Suspect ‘O" = Other

Last, First, Middle (Firm if Business) Race HT
s || = =
[ms
City, State —— Code ae Local —
=== Last, First, Middle (Firm if Business) ‘sl ie |

—_— | DOB DL Number

—_—<— | o (000) 00.000
City, ———— Zip Code Local ID # State # FBI # Cell Phone
(000) 000-0000

City, State, Zip Code == ————-— Local ID # FBI # Cell Phone

Synopsis

Continuation PropertyList

Press Domestic Violence
wer 640
olvability County
a
Report Complete/Ready for Review [xX] CADICFS Event# 2505230014

Assigned To Detective Andrea Hall ______ Date 05/27/2025

OmcerID Officer Kayla Thomason DAVIS, CURTIS 05/24/2025

222222222222

Printed By/On: 412 / 06/26/2025 12:02:30
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page 2 Incident conta

POLICE DEPARTMENT Narrative inodent# 2505230014
Crime / Incident (Primary) Attempt | Type Seq

On May 23, 2025, I, Officer Thomason was dispatched to Forrest City Medical
Center in reference to a 13-year-old who needed to file a report about an
incident that happened at 1521 Albert St. in Forrest City. I arrived at Forrest
City Medical Center at 9:26PM where contact was made with

works for Perimeter Behavioral Health Located at 1521

Alb aining what led up to him bringing 13-year-old
to the Medical Center. I then spoke to HE who
stated that earlier today one of the employees stepped on a bug and it upset him

because he likes looking at bugs. stated that he was already frustrated
because of some of the kids at the facility and he stated to the employees "Fuck
y'all" and went into his room and slammed the door. QM stated that
came into his room and began yelling at him "Don't slam
that mother fucking door." stated that he responded, "I won't slam that
mother fucking door." stated that then grabbed him behind his
arms to put him in a "PRT" which is a physical restraint and then slammed him
against the cubby's that they put their clothes in. J stated that
then stated to him "Now I'm going to take you into the hallway where

everyone can see you." After being taken into the hallway and put on the wall by

r stated that
grabbed his upper arms and picked him up off the floor while still holding him
against the wall and squeezing him arms as hard as he could and that he now has
bruises from it. Pictures were taken of HS injuries. I then spoke to |
|| and asked if they had already taken x-rays of

arm and if they knew
if his arm was broken or not and she stated yes, arm is broken. [all

MMMM stated that the radial bone and the ulna bone were both broken.

Reviewed By Approved Date
OffcerID Officer Kayla Thomason 575 DAVIS, CURTIS 05/24/2025

YES
Printed By/On: 412 / 06/26/2025 12:02:30
CrimeStar® Law Enforcement Records Management System
Licensed to. FORREST CITY AR POLICE DEPARTMENT

doc_type: Police Report


summary: A resident complained of pain to the right foot after falling during gym time. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029971
Date of Incident: 5/21/2025
Date Received: 5/22/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , reported he hurt his right foot
during gym time (Resident accidentally fell on it). Physician notified and order received to
send Resident to for x-ray of right foot. Complaint of pain
reported 8/10 (10 being the highest) and slight swelling. Resident stated ?I have been trying
to walk on it but it hurts.? Resident returned at 2230 (10:30 pm) from
activity restriction until further evaluation.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.22.25- Uploaded SORF and discharge paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was seen falling in front of the restroom. The resident appeared pale with blue lips and had a low heart rate. The resident was sent for evaluation and returned to the facility afterward.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029967
Date of Incident: 5/21/2025
Date Received: 5/22/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was going to the bathroom
fell in front of bathroom, witnessed by LPN. During Nursing assessment Resident appeared
pale, lips blue O2 98% HR 33 91/64 bp. Order from Physician to send Resident to .
. Resident was given about 32oz of water, Vitals at 0800 (8:00 am)
. Resident was given his breakfast and reports feels ?a
little better?. Resident left facility and 0855 (8:55 am) with evaluation.
Resident A/
Resident returned to facility at 1025 (10:25 am) with staff. Dr. Huynh notified and
medication changes ordered and updated in MAR. Skin intact, all color has returned to
Resident?s face and lips. Resident denies any lethargy.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.22.25- Uploaded SORF and discharge notes
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for an x-ray after daily complaints of pain in both ankles.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029969
Date of Incident: 5/21/2025
Date Received: 5/22/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , sent out to x-ray of both ankles due to
complaints of daily pain, not being able to stand/walk for periods of time. No swelling,
bleeding, tenderness, or bruising. Resident rates pain 8/10 (ten being the highest).
Resident returned at
1154 (11:54 am) from Resident on activity restriction until
further evaluation.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Narrative:
Licensing Narrative: 5.22.25- Uploaded SORF and discharge paperwork


summary: A resident was assessed for injury after punching walls while upset. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029771
Date of Incident: 5/14/2025
Date Received: 5/15/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, night of 05/13/2025 received orders from
Physician for an x-ray morning of 05/14/2025 due to self-inflicted injury to his left hand
from punching a wall. Morning of 05/14/2025, Resident began punching the walls as group
was transitioning to school. Resident would not tell anyone why he was upset. Resident
received ice-pack at No complaint of pain, swelling present.
No new visible injuries. Swelling and red/purple bruising still present. No complaint of
discomfort. Therapist made aware of behavior. Resident returned at 1215 (12:15 pm) from
No new orders. No new skin
issues.
.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.16.25- Uploaded SORF and FCMC paperwork
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain to the right hand after punching a window in the dayroom. The resident was assessed, and an x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029677
Date of Incident: 5/10/2025
Date Received: 5/12/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, punched a window in the
dayroom with his right hand. Right hand was swollen and was
administered for pain. Pain rated 10/10. APRN notified and order received for Resident to
go the for swelling of right hand. . Resident
returned at 2135 (9:35 pm).
instructed to use an Ice
pack as needed. Resident on activity restrictions to reduce likelihood of further injury.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.12.25- Facility emailed copy of nursing notes and serious occurrence
report as well as xray results. Inquired on if window was broken Facility stated: No, it did
not, thankfully.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported pain to his leg after falling while playing basketball in the gym. The resident was assessed, and an x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029682
Date of Incident: 5/9/2025
Date Received: 5/12/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , hopped to the Nurse?s
Station from gym. Compliant of ?I fell and my leg hurt, I can?t walk on it? from playing
basketball in the gym. No visible injuries noted but complaint of pain with very light
palpation. administered and ice pack applied. APRN notified, and orders
received for . Orders received to go to for further evaluation.
Resident returned at 2135 (9:35 pm) with wrap. Wrap is kept at Nurse?s station when not
worn by Resident. ,
Resident placed on activity restriction to
reduce likelihood of further injury.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.12.25- Uploaded SORF and xrays
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain after punching a wall. The resident was evaluated and an x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029510
Date of Incident: 5/2/2025
Date Received: 5/5/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
for x-ray to his right hand. Resident states he was hit in the gym with a
basketball (accidentally from a rebound) and then became upset, punching the wall.
Resident complained of pain, swelling, and loss of feeling in right hand. APRN called and
order received to send Resident for outpatient x-ray. Resident returned from x-ray at
approximately 1750 (7:50 pm). Resident denied pain/discomfort upon return. Findings:
.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.6.25- Facility sent SORF and xrays from
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident presented with markings he said were caused by his roommate. The resident also shared a sexual allegation against the roommate. The facility was cited 907.2 for not performing required 15-minute check ins. A staff member was terminated.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029427
Date of Incident: 4/30/2025
Date Received: 5/1/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Lead Staff brought Resident, , to Director of Nursing
(DON) to show her observed markings on Resident. DON inquired of where the
markings came from and Resident alleged it was from his roommate with whom he was on
unit restriction with at the time. Resident preceded to then share sexual allegations against
said roommate.
An internal investigation was also simultaneously launched. Both Residents were
also seen same day of allegation by their respective Therapist. Footage review of was
completed by the Safety Team and Therapists included. Resident interviewed during daily
Safety Meeting by Safety team and Therapist 05/01/2025. See additional information
section. Resident?s rooms have been changed. Residents are also peer restricted. Unit
restriction for the Sexual Rehabilitative Unit will now be conducted only in the dayrooms.
Staff involved in the supervision of these Residents during the window the behaviors
occurred have been terminated. Upon camera review, stick and poke tattooing from named
peer was evidenced but no signs of forced interaction. Additionally, inappropriate sexual
behaviors were also evidenced upon camera but appears mutual with no evidence of forced
engagement. Resident admitted to behaviors and shares ?I lied on (peer)? because he
?promised me things from his pass.? Once Resident found out the peer had no pass, he
presented these allegations. Resident educated on the dangers of falsely accusing peers and
verbalized understanding.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Narrative:
Licensing Narrative: 5.1.25- uploaded the SORF from facility as well as requested video
footage be retained. 5.2.25- Facility will retain footage 5.13.25- Licensing Specialist went to
Facility. 5.13.25- Facility was cited for 907.2 on failure to supervise, staff involved was
terminated. Details retained in inspection #087043 The case has been closed as founded by
licensing.


summary: A resident complained of hip and leg pain with no specific onset. The resident was assessed, and an x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029386
Date of Incident: 4/29/2025
Date Received: 4/30/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
for x-ray on right hip and leg per Physician orders. No deformities
noted. Resident denies any pain at this time. Able to walk independently without any
assistance. Steady gait. No bruising or dislocation noted. No specific onset for complaint
for the past couple of weeks. Resident returned from x-ray at approximately 1114 (11:14 am).
Findings: No acute fracture or dislocation. The right femoral acetabular joint is intact.
Impression: No acute osseous abnormality of the right hip.
Interim Action Narrative:
Narrative:
Licensing Narrative: 5.1.25- uploaded SORF and discharge summary. Also inquired on
need for resident to go to . Facility stated: His complaint. There was no specific
onset identified by the Resident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the emergency room after experiencing an elevated heart rate.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029331
Date of Incident: 4/26/2025
Date Received: 4/28/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , sent out to
x2 EMTS via ambulance and MHT Staff for further treatment and
evaluation per order of Physician due to elevated heart rate of .
Resident stable/responsive upon departure from facility. Resident returned from the at
0705 (7:05 am) with
. Resident placed on activity restriction until further
evaluation.
Interim Action Narrative:
Narrative:
Licensing Narrative: 4.29.25- Specialist uploaded nursing notes and Serious occurrence
form.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of dizziness, shakiness, vomiting, and malaise. The following day the resident presented with an elevated heart rate and was sent to the emergency room for evaluation.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029330
Date of Incident: 4/25/2025
Date Received: 4/28/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to Nurses
station with complaint of feeling dizziness, shaky; state he has vomited and doesn?t ?feel
well.? Vital signs: BP 115/76, temperature of 98. Oxygen saturation 96 at room air. Pulse 147.
Resident started new medication today, Physician notified and asked to
send out to for evaluation and to hold Resident
sent out to accompanied by transport driver and MHT
Staff. Resident ambulatory, steady gait, and skin intact. No acute distress. Resident
returned from the at 1455 (2:55 pm) with the
He returned with orders
for
Interim Action Narrative:
Narrative:
Licensing Narrative: 4.29.25- Uploaded SORF and requested summary
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident alleged staff members left bruises on his arms by performing restraints incorrectly. This complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029270
Date of Incident: 4/23/2025
Date Received: 4/23/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: A/V is . unknown (unknown1;
facility staff at Perimeter). PRFC is 30yo unknown (unknown2; reporter listed name as
changed to unknown). is in the custody of DHS in he
currently lives at perimeter in Forrest City (st Francis co) he alleges that staff put their
hands on him and left bruises on his arms and that they do the holds incorrectly and hurt
him. reports that on the week of 4/7/25-4/11/25 staff banged his head on the wall.
DHS got reports of an incident stating that was self-harming by banging his head on
4/10/25 when the department picked him up on 4/11/25 he had a small green bruise on his
left temple. The department has not seen any other bruises on him at this time. And is
unaware of who or which staff member is involved in these incidents. has no
parental rights attached and is up for adoption.
Interim Action Narrative: Staff member was suspended pending investigation.
Maltreatment Narrative:
Licensing Narrative: Case was staffed with management Licensing will schedule a visit to
collect documentation. 4/28/2025, Program Coordinator spoke with another entity
regarding this complaint. Licensing was provided with pictures of bruises on the residents.
Per entity, the resident was interviewed on 4/21/2025 and still resides at the facility. 4.29.25-
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Specialist uploaded serious occurrence report form provided by facility. Program
Coordinator visited the facility, reviewed camera footage, interviewed the resident, and
gathered documentaton. 4/30/2025, Program Coordinator uploaded documentation and
share documentation with other entity. 5/5/2025, facility returned 521 signed. 521 uploaded
on 5/12/2025. Case and documentation reviewed. Case complete.


summary: A resident reported that a staff member touched him inappropriately during a routine pocket check. This complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029172
Date of Incident: 4/21/2025
Date Received: 4/22/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to Therapist with
allegation that a Staff member ?touched my dick for five secs? during routine pocket checks
at transition. Therapist called the . The alleged offender was immediately
removed from the Hall once the Program Director was notified. Alleged offender has since
been suspended pending investigation. Camera footage was reviewed by .
came morning of
04/22/2025 and interviewed watched the aforementioned camera footage, and
interviewed alleged offender. then shared he may have had his days mixed up,
nonetheless, all days mentioned were reviewed and no evidence of allegation found. Witness
statements have been collected.
Interim Action Narrative:
Narrative:
Licensing Narrative: 4.22.25- Specialist emailed another entity to request permission to
visit. Spoke with them on the phone regarding complaint. 4.23.25- Specialist went to facility
to review camera footage and conduct interviews. See inspection #086435 5/7/2025 and
5/13/2025, facility inquired if licensing had an update regarding this complaint. 5/15/2025,
facility provided training documentation and inquired if staff member could return to work.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Discussed with Program Manager, staff member approved to return to work. Facility
informed. 5.19.2025- The case has been closed as unfounded by licensing. 5/23/2025, case
and documentation reviewed. Licensing reviewed camera footage aand completed
interviews on 4/23/2025. Complaint unfounded by licensing. Approved by Program
Coordinator. Case complete.


summary: A resident received an x-ray after attempting to have a physical altercation with a peer and punching a wall twice.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028852
Date of Incident: 4/7/2025
Date Received: 4/7/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: The resident punched a wall twice
after attempting to have a physical altercation with another peer but was stopped by staff.
APRN after consulting with the Nurse ordered resident to go to
for a Xray of his lefthand; Prior to visit was administered by the Nurse
for pain. Due to severe weather and the being offline, X-Ray is
currently still pending. Resident sent back to the facility after assessment to use ice pack
and pain medications prn.
Interim Action Narrative:
Narrative:
Licensing Narrative: 4.21.25- uploaded discharge paperwork from
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain, swelling, and bruising of his hand after punching a wall. The resident was assessed, and an x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028757
Date of Incident: 4/2/2025
Date Received: 4/3/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to Nurses? station
with complaint of pain, swelling, and bruising to left hand due to punching a wall in the
gym. Roslyn Perry, APRN, notified and orders were received for x-ray at
. Findings: No acute fracture or dislocation. The proximal and distal carpal
rows are adequately aligned. The soft tissues are grossly unremarkable. Impression: No
acute osseous abnormality of the left hand. Oriented to person, place, and time. Speech
clear, good eye contact, and gait steady. Respirations even and non-labored. Order from
APRN for Resident to be placed on activity restriction for three days to prevent further
injury and ice pack as needed.
Interim Action Narrative:
Narrative:
Licensing Narrative: 4.3.25- requested nursing notes and discharge paperwork facility sent
paperwork requested
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident received a nosebleed and swelling and bruising to his left eye in an altercation with a peer. After complaining of blurred vision, the resident was sent to the emergency room for treatment.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028559
Date of Incident: 3/26/2025
Date Received: 3/27/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , and a peer were playing a
game of dodgeball that escalated into a disagreement, turning into a physical altercation
between Resident and peer. Peer hit Resident in the face. Resident had a nosebleed and
swelling, bruising to left eye. Complaint of blurred vision, states ?he cannot feel the left side
of my face.? Ice pack applied to left eye. Roslyn Perry, APRN, notified and orders were
received from for transport to for further evaluation and
treatment. Resident alert and self-ambulatory, oriented to person, place, time, and situation.
Rates pain a 9 out of 10 (with ten being the highest rating). Staff quickly separated residents.
Resident returned to facility same day. No new injuries.
Resident placed on
activity restriction until reevaluated to reduce likelihood of further injury. Resident and peer
placed on assault precautions as well as peer restriction.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.28.25- emailed facility inquiring about guardianship and nurses
notes Guardian is Uploaded Nursing Notes
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the emergency room after complaining of shortness of breath, cough, and wheezing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028560
Date of Incident: 3/26/2025
Date Received: 3/27/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to the Nurses
station with complaints of feeling short of breath, watery eyes, and nasal congestion.
Resident states he has allergies. Medicated Benadryl 25mg. Sixteen minutes later, Resident
presented to Nurses station with shortness of breath, itchy watery eyes, sore throat, and
cough. Upon assessment, Resident was wheezing. Resident does not have asthma. Roslyn
Perry, APRN, notified and orders were received for COVID test, Flu A and B test, and to
transport to for further evaluation for shortness of breath.
Resident returned to facility same day. No new issues. ,
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.28.25- Emailed facility about nurses notes and guardianship
Guardian is Nursing notes uploaded
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained that he cut his wrist playing kickball. The resident was transported to the emergency room for treatment before being released back to the facility. The resident was placed on 1:1 supervision as a safety precaution.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028521
Date of Incident: 3/24/2025
Date Received: 3/25/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was brought to the
Nurses? station by Staff because of a laceration to his left wrist. Nurse assessment: a very
deep laceration. Scant serosanguineous drainage, light surrounding redness, no increase in
warmth noted. Wound area has been cleaned with wound cleaner and TAO applied.
Resident claims he ?dove to catch the ball (kickball) yesterday and fell on some metal. I
didn?t tell anybody because I didn?t want to be accused of self-harming. It bled a lot, but I
cleaned it and put hand sanitizer down in it.? Roslyn Perry, APRN, notified and orders were
obtained from for transport to for further evaluation and
treatment. Resident returned to facility same day. No new injuries.
Resident placed on 1:1 supervision per order of Physician as a safety precaution
until reevaluated.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.26.25- Emailed facility inquiring on location of the metal Facility
replied: Him falling on metal was the story he told us.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain in the left ring finger after attempting to catch a football. The resident was transported for an x-ray, then released back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028258
Date of Incident: 3/13/2025
Date Received: 3/14/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to Nurses? station with
complaint of pain to his left ring finger with a pain rating of 7 (10 being the highest for
pain). Resident stated he ?I attempted to catch the (foot)ball and I heard my finger pop.?
Nurse assessment: Edema noted and decreased range of motion. Orders were obtained
from Rosalin Perry, APRN for transport to for further
evaluation and treatment. Resident returned to facility at 1403 (2:03 pm). Findings are no
acute fracture or dislocation. Soft tissues are grossly unremarkable. Impression is no acute
osseous abnormality of the left finger. Resident is on activity restriction until further
evaluation to prevent further injury.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.17.25- Facility emailed serious occurrence form as well as medical
paperwork from
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to follow up on renovation progress occurring in the 100-Hall bathroom.

raw_content:
ARM ANE AS
DEPARTMENT OF

HUMAN
a¥ SERVICES

Placement and Residential Licensing Unit

Division of Provider Services and Quality Assurance
P.O. Box 1437, Slot S530, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.682.8155

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Chelsea Vardell

Person In Charge: Charlotte Lockhart

Record Visit Date: 3/13/2025

Purpose of Visit: Corrective Action Visit

Narrative:

The PRLU Program Manager and the Licensing Specialist visited the facility to follow up on the progress of
the renovations occurring to the 100-hall bathroom. The Program Manager and Licensing Specialist were
escorted to the bathroom on the 100 hall and viewed individuals working on the bathroom. The bathroom was
nearly complete, and new tiles were installed over a large portion of the bathroom. The facility is on track to
have the renovations for the bathroom completed prior to the expiration of their current extended corrective
action agreement that is set to expire on 6/9/2025.

Provider Comments:

CCL Staff Signature: Wxhea Axameon a Date:
Provider Signature TH Directs i of omar v Want Date: 03 /ay |aoas

www.arkansas.gov/dhs

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

doc_type: Compliance Report


summary: A resident complained of pain to the left pinky finger after jamming his finger while playing football. The resident was transported for an x-ray before being released back to the facility.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028226
Date of Incident: 3/12/2025
Date Received: 3/13/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, presented to Nurses? station with complaint of
pain to his left pinky with a pain rating of 10 (10 being the highest for pain). Resident stated
?I accidentally jammed my finger while playing football (catch) outside. Nurse assessment:
Left pinky finger in flexed position and unable to move, cool to touch with minimal swelling
noted, Ibuprofen 200 mg (2) given for pain. Orders were obtained from Rosalin Perry,
APRN for transport to for further evaluation and treatment.
Resident returned to facility at 2000 (8:00 pm).
Resident has an appointment /2025 at 0900 (9:00 am) for a
splint. Resident is on activity restriction until further evaluation to prevent further injury.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.13.25- Facility sent SORF as well as medical records from .
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident jammed his thumb while playing basketball in the gym. The resident was assessed, and an x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028204
Date of Incident: 3/11/2025
Date Received: 3/12/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , presented to Nurses with complaint. Resident
jammed his thumb after accidentally running into the wall while playing basketball in the
gym. Orders from Physician for Tylenol, ice pack, and x-ray were received but icepack was
thrown away by Resident. Resident transported to for x-ray.
Resident able to ambulate independently, gait steady. Oriented x4 and skin intact. Resident
returned to facility at 1243 (12:43 pm). Resident is on activity restriction until further
evaluation.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.12.25- Facility sent specialist serious occurrence report as well as
well as discharge documents from
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A complaint received alleged concerns regarding inadequate supervision during phone calls and access to electronic explicit material. The facility was cited 1007.2, 1009.11, and 1008.3 as a result of this complaint.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028162
Date of Incident: 3/11/2025
Date Received: 3/11/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: A report was received alleging concerns regarding inadequate
supervision during phone calls and access to electronic explicit material. Additionally,
concerns were raised regarding medication changes that were not communicated to the
guardian.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.12.25- Specialist uploaded further information into system regarding
the complaint: email from adoptive parent 4.28.2025, Facility provided documentation that
was uploaded to the case. The case has been closed as founded by licensing. Approved by
Program Coordinator. Case complete.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the emergency room after rolling his ankle while playing basketball. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 028078
Date of Incident: 3/6/2025
Date Received: 3/7/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
by order of Physician for an x-ray to left foot. Resident complained of
pain after rolling ankle while playing basketball in the gym. Resident claims ankle only
hurts when he tries to run. Resident able to ambulate independently. Capillary refills less
than 3. No pain to touch. Oriented x4. No acute distress noted. Resident returned same day
at 1017 (10:17 am) with no issues upon return. No fracture/dislocation/abnormalities.
Resident is on activity restrictions until further assessment to prevent further injury/pain.
Resident interviewed morning of 03/07/2025 by Safety team during Safety meeting and
reminded to continue PRN to reduce inflammation. Resident reports pain reducing and
walking better.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.12.25- Specialist reviewed for Licensing Issues. Facility sent medical
records and SORF.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the emergency room due to lethargy after returning from a pass.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027964
Date of Incident: /2025
Date Received: 3/3/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was sent out to
per order of Physician due to presenting lethargic in the milieu after
returning from pass. Resident interviewed by Safety team. Resident stated he drank Sprite
and took over the counter medications provided by his father to help stop vomiting
including Tylenol, BC Powder, and Benadryl. Resident says he took his prescribed
medication as directed and denies taking them improperly. Resident also denies taking any
illegal substances or alcohol while on pass. Resident was Resident on activity restriction
until further evaluation. Resident did complete a drug screen while at
, results pending. Resident will be tested for Flu/COVID. Resident returned from
, same day, at 2100 with no further issues.
Interim Action Narrative:
Narrative:
Licensing Narrative: 3.12.25- Uploaded SORF and Facility responded with the following:
The Flu/COVID test results were negative. The drug screen results have yet to be returned
from ; we can anticipate 3-5 days from what I was informed.
3.13.25- Received results and uploaded them
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct a Buildings and Grounds walkthrough. The following areas were reviewed: 100-400 Halls, Cafe, and Gym. No issues noted during walkthrough.

raw_content:
ARK ANSE A S
DEPARTMENT OF

> HUMAN
“a SERVICES

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of Forrest City

Facility Number: 142

Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335

Licensing Specialist: Andrea Adamson
Person In Charge: Immanuel Morris
Record Visit Date: 2/4/2025

Home Visit Date: 2/7/2025

Purpose of Visit: Subsequent Building and Grounds

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

Regulations Not Correctable:

Narrative:

Licensing Specialist was escorted around the grounds by Mr. Immanuel and Mr. Clifton, alongside OLTC.
The following was observed:

www.arkansas.gov/dhs

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

100 Hall:
°101- good and well maintained
°106- good and well maintained
*Dayroom- Empty, clean and well maintained

200 Hall:
*204- good and well maintained

°207- good and well maintained
*Dayroom- Ratio 1:1 clean and well maintained

300 Hall:
*303- fire sprinkler head had come off; maintenance was already on their way with new one to fix it.
*304- Small spot of drywall missing, maintenance already prepping area for fixing
*308- good and well maintained

400 Hall:

*401- good and well maintained
*406- good and well maintained

Cafewas currently in use for lunch time and the ratio was 4:11.
Gymwas currently in use for rec time and the ratio was 3:13.

Demo starts next weekend on bathroom. They begin on the 11th and should be done by the 19th.

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

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

Provider Comments:

CCL Staff Signature : Date: 2/7/2025

ey > i

Provider Signature : Holic:
YUL, ;

Date: 2/7/2025

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


summary: A resident complained of pain after an altercation with a peer. The resident was sent to the emergency room for an x-ray and is on activity restriction until further evaluation. The residents were separated, and peer restriction and assault precautions were implemented.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027281
Date of Incident: 2/2/2025
Date Received: 2/3/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, , was in a physical altercation
with a peer. presented to Nursing with complaint of pain to Nursing. Resident was
sent out to per order of Physician for x-ray and further
evaluation. Residents were separated and peer restriction as well as assault precautions have
been implemented. Resident returned from with no further
issues. Ice pack will continue and . Resident on activity restriction
until further evaluation.
Interim Action Narrative:
Narrative:
Licensing Narrative: Facility stated there was no footage of the incident and the peers have
had no issues since being on peer restrictions.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident eloped from the premises by climbing to the roof, then leaping off the roof onto the breezeway facing the community. Staff immediately followed and the Forrest City Police Department was notified. The resident was returned safely less than 8 minutes later.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 027033
Date of Incident: 1/23/2025
Date Received: 1/24/2025
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident, eloped from the property at
approximately 15:36:20 after transitioning from the gym. Staff were engaging with Residents
right after transition outside and Resident swiftly walked behind Staff and then ran to the
breezeway. He then jumped onto the breezeway, pulling himself up and went onto the main
residential roof. Staff noticed Resident missing at 15:37:15 (55 seconds later). A code green
was called and Staff support responded. At this time, Resident then went off the residential
roof, onto the breezeway facing the community, leaping off. Staff went in the direction of
the Resident and Forrest City Police Department was notified. Resident was safely returned
at 15:44:00 resulting in a time 7 mins and 40 seconds from elopement to safe return.
Resident placed on elopement precautions and interviewed by the Safety team.
Reinforcement education will be provided to staff involved.
Interim Action Narrative:
Narrative:
Licensing Narrative: 01.28.25- Specialist emailed facility requesting roster for retraining.
01.28.25- Facility replied with the following: Greetings, Katelyn. We are doing a mass
retraining/refresher for all staff . We were already planning recording videos for training and
retraining purposes next week and this topic (among others) will be covered in those videos.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched in response to a juvenile who escaped from the facility.  As they arrived, officers saw a person matching the juvenile’s description. Officers apprehended the juvenile and transported him back to the facility.

raw_content:
FORREST CITY Field Interview

POLICE DEPARTMENT Detail Page
225 N. ROSSER ST. FI# Print Date
FORREST CITY, AR. 72335 2501230009 02/18/2025

Date Day Time Officer ID Agency
01/23/2025 Thursday 16:00 555 DETECTIVE HARRY FORB FCPD

Beat Sector District 1 Event # 2501230009 Force VCOM
Address Albert, Forrest City, AR
X Street J INDAUER

SUBJECT INFORMATION

Address Apartment

Ciy/State/2iP- FORREST CITY AR 72335

Height Weight a Eyes
XXK

VEHICLE INFORMATION

License State VIN #

AR
REASON / DETENTION INFORMATION

On 1/23/25, |; Det Sgt Jamie Forbes #555, responded to a call regarding a juvenile that escaped from
Perimeter.

As | arrived on Lindauer, | saw a person matching the description of the escaped juvenile,
HS! notified Det Sgt Preston Gracey #418. Both of us went on foot towards

erence ae on foot after seeing Det Sgt Gracey. ran right towards me, and /
pulled my Taser giving him commands to get on the ground. followed the command
and got on the ground. (was placed in handcuffs with no further issues.

Field Interview

| transported | RS to Perimeter and released him to the staff at Perimeter.

Printed By/On: 412 / 02/18/2025 10:53:36
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT