summary: Multiple deficiencies were noted during the Complaint Investigation Survey completed on 11/28/2023. A Corrective Action Plan was submitted and approved.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
December 6, 2023
David Napier, Administrator
Youth Home Inc
20400 Colonel Glenn Road
Little Rock, AR 72210-5323
Dear Mr. Napier:
On November 28, 2023, a Complaint Investigation survey was conducted at your facility by the Office
of Long Term Care to determine if your facility was in compliance with Federal requirements for
Psychiatric Residential Treatment Facilities participating in the Medicaid (Title XIX) Program. This
survey found that your facility had deficiencies requiring correction/substantial correction prior to a
revisit as specified in the attached CMS-2567.
Plan of Correction
A POC must be submitted within 10 calendar days of your receipt of the Statement of
Deficiencies. Failure to submit a POC may result in termination. Include a completion date for each
deficiency cited.
Theresa Forrest, Reviewer
OLTC, Survey & Certification Section
PO Box 8059, Slot S404
Little Rock, AR 72201-4608
(501) 320-6235
email to Theresa.Forrest@dhs.arkansas.gov.
Your Plan of Correction must also include the following:
a. Address how the corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
b. Address how the facility will identify other residents having the potential to be affected by the same
deficient practice;
c. Address what measures will be put into place or systemic changes will be made to ensure that the
deficient practice will not recur;
d. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must
be implemented, and the corrective action evaluated for its effectiveness.
David Napier - Youth Home Inc - - (AOLTC - PRTF OTC) Page 1]

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

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 #AR00031282 was not in compliance,
all or in part, with deficiencies written at N132 and
N172.
The facility was not in compliance with §483,
Subpart G - Conditions of Participation for
Psychiatric Residential Treatment Center.
N 132 PROTECTION OF RESIDENTS N 132
CFR(s): 483.356(b)
Emergency safety intervention. An emergency
safety intervention must be performed in a
manner that is safe, proportionate, and
appropriate to the severity of the behavior, and
the resident's chronological and developmental
age; size; gender; physical, medical, and
psychiatric condition; and personal history
(including any history of physical or sexual
abuse).
This ELEMENT is not met as evidenced by:
Based on observation, interview and record
review, the facility failed to ensure a restraint was
conducted in a safe and appropriate manner to
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:HSSL11 Facility ID: 3006 If continuation sheet Page 1 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 132 Continued From page 1 N 132
prevent potential injury for 1 (Client #1).
The findings are:
1. Client #1, had diagnoses of "Reactive
Attachment Disorder and Disruptive Mood
Dysregulation Disorder.
a. An Incident Report, provided by the Record
Compliance Officer, on 10/25/2023, listed the
complaint as "Personal Restraints, Locked
Seclusion, Aggressiveness to Staff and Peers,
Injury to Staff, Threat to Safety, and Property
Destruction." Also described Resident being
rude, hid in closet, refused medications, flipped
over furniture, personal restraint, placed in
seclusion, broke peers cup, exposed sharp
plastic edges, spiting, scratching staff, after
banging her head on walls and front window of
seclusion room. RN (Registered Nurse)
assessment noted after the incident. Resident
reported small abrasion on her palm side next to
her thumb from the restraint, petechiae around
her eyes and cheeks that were not observed on
10/25/2023. A hotline report was made. The
resident was ordered for further evaluation at ER
(Emergency Room) on 10/26/2023 for petechia
rash, on her face and headache, knee pain with a
diagnosis of concussion. Resident was placed on
activity limit for three (3) days.
b. An interview with Chief Clinical Officer on
11/27/2023 at 1:30 PM, stated that QBHP
(Qualified Behavioral Health Provider) #1 had
been let go because, "Video footage showed
[QBHP #1] had initiated a one-person restraint,
jerking patient and had shoved her into seclusion.
Without ensuring that the room was free of
hazards or other occupants."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 2 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 132 Continued From page 2 N 132
c. Physician Orders dated 10/25/2023, at 8:06
PM, read in part, "...Place in locked seclusion for
up to 60 minutes until calm and cooperative and
no longer a threat to safety."
d. On 11/27/2023, at 1:35 PM, a telephone
interview was conducted with RN #1. She stated,
"The resident refused her medication, by
slamming her door, and had stepped away for
three minutes. Upon returning, she heard resident
screaming and being escorted to the seclusion
room by [QBHP #1]." In response to the question,
"What did you observe?" RN #1 stated, "Resident
had picked up a water bottle, left by another
resident, and was banging it on the glass,
banging her head on the floor. There were three,
[QBHP #1], [QBHP #2], and [QBHP #3] holding
her on the floor. I got a pillow for her head and
then she agreed to stop and went to the comfort
room, refused treatment. The resident went to the
hospital the next day."
e. During a lap top video review on 11/27/2023 at
1:50 PM with the Unit Manager #1, he stated that
Client #1 on 10/25/2023 at 8:05 PM, had walked
into the day room, and knocked over two chairs.
"[QHBP #1] aggressively took the resident to the
seclusion room, locked the door as [QHBP #2]
escorted another resident out of the open
seclusion room leaving the plastic empty water
bottle. Then from 8:06 PM to 8:10 PM, the
resident continued to loudly scream and break
the plastic bottle into small pieces, hitting it on the
walls, camera, and the front window of the room
as well as banging her head on walls. At 8:10 PM,
[QHBP #1] with two other employees came into
the room, subdued the resident by holding arms
and legs. [RN #1] began to remove shards of the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 3 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 132 Continued From page 3 N 132
plastic water bottle." In response to the question
"What was wrong with the restraints?" Unit
Manager #1 stated "He snatched her up, not the
CPI [Crisis Prevention Institute] hold we use,
grabbed her and spun her around."
f. On 11/27/2023 at 2:30 PM, QBHP #2 stated, "I
entered the dayroom after Client #1 had been
taken into the seclusion room by [QHBP #1]." In
response to the question, "What did you
observe?" QBHP #2 stated, "She was banging a
plastic bottle on the window door. I stayed at the
door, until they came back to subdue her.
Another resident had been in the open seclusion
room sleeping and I had moved her out." In
response to the question, "Did you see her
banging her head?" QBHP #2 replied, "I did not."
g. On 11/27/2023 at 2:45 PM, QBHP #3 stated
that Client #1 had not been compliant. In
response to the question, "Why was [Client #1]
not compliant?" QBHP #3 stated, "She was
yelling, screaming, and throwing chairs. My
partner, [QBHP #1], grabbed her. I did not get up
as I was eating dinner. [QBHP #1] took her to the
seclusion room and called me to take his place.
[Client #1] was kicking, screaming, scratching,
drew blood from my hand from scratches, and
banging her head. [RN #1] brought a pillow. She
deescalated to a calm state. We released her to a
calm state, she was assessed by the nurse." In
response to the question, did you see a broken
water bottle?" QHBP #3 did not recall the water
bottle.
h. At 11/27/2023 at 3:15 PM, Client #1 arrived
accompanied by her counselor. In response to
the question, "Can you tell me what happened
before going to the hospital on 10/26/2023?"
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 4 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 132 Continued From page 4 N 132
Client #1 stated, "I had left the comfort room
(10/25/2023), after having had locked myself in
my room closet so I could breathe. I went to the
Dayroom and started knocking down chairs.
[QHBP #1] grabbed me by my hoodie and took
me to seclusion. I pinched him because he was
hurting me. I cut my right hand. Another girl was
sleeping, and I got her water bottle. Rather not be
in seclusion so I banged my head and got a
concussion. Banged my head on the walls and
floor. The concussion feels like bolts tightening. I
went to the hospital the next day." In response to
the question, "Why did you go to the hospital the
next day?" Client #1 stated, "Needed doctor's
approval before I could go."
i. During a second laptop viewing of the incident
on 10/25/2023 at 8:07 PM, on 11/28/2023 with
Unit Manager #2. He stated "The video of the
seclusion began at 8:06 PM, shows [QHBP #1],
taking [Client #1] into the locked seclusion room,
and the previous resident is moved out by [QHBP
#2], leaving the water bottle on the floor. The
resident is banging the water bottle on the glass,
camera, and the wall as well as her banging her
head. They should have held her, moved the
broken plastic out of the seclusion room. They
usually talk them down before they lock the
resident in, making sure other residents were not
in the room and free of plastic bottles and debris."
In addition, he said, "[QHBP #1], took her to the
ground, CPI does not take residents to the floor. It
is not a proper technique."
N 172 MONITORING DURING AND AFTER N 172
SECLUSION
CFR(s): 483.364(b)(2)
[A room used for seclusion must] Be free of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 5 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 172 Continued From page 5 N 172
potentially hazardous conditions such as
unprotected light fixtures and electrical outlets.
This ELEMENT is not met as evidenced by:
Based on observation, interview, and record
review, the facility failed to ensure a resident was
protected from physical harm while being placed
in a locked seclusion room (Client #1).
The findings are:
1. Client #1, had diagnoses of "Reactive
Attachment Disorder and Disruptive Mood
Dysregulation Disorder.
a. An Incident Report, provided by the Record
Compliance Officer, on 10/25/2023, listed the
complaint as "Personal Restraints, Locked
Seclusion, Aggressiveness to Staff and Peers,
Injury to Staff, Threat to Safety, and Property
Destruction." Also described Resident being
rude, hid in closet, refused medications, flipped
over furniture, personal restraint, placed in
seclusion, broke peers cup, exposed sharp
plastic edges, spiting, scratching staff, after
banging her head on walls and front window of
seclusion room. RN (Registered Nurse)
assessment noted after the incident. Resident
reported small abrasion on her palm side next to
her thumb from the restraint, petechiae around
her eyes and cheeks that were not observed on
10/25/2023. A hotline report was made. The
resident was ordered for further evaluation at ER
(Emergency Room) on 10/26/2023 for petechia
rash, on her face and headache, knee pain with a
diagnosis of concussion. Resident was placed on
activity limit for three (3) days.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 6 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 172 Continued From page 6 N 172
b. An interview with Chief Clinical Officer on
11/27/2023 at 1:30 PM, stated that QBHP
(Qualified Behavioral Health Provider) #1 had
been let go because, "Video footage showed
[QBHP #1] had initiated a one-person restraint,
jerking patient and had shoved her into seclusion.
Without ensuring that the room was free of
hazards or other occupants."
c. On 11/27/2023, at 1:35 PM, On 11/27/2023, at
1:35 PM, a telephone interview was conducted
with RN #1. She stated, "The resident refused her
medication, by slamming her door, and had
stepped away for three minutes. Upon returning,
she heard resident screaming and being escorted
to the seclusion room by [QBHP #1]." In response
to the question, "What did you observe?" RN #1
stated, "Resident had picked up a water bottle,
left by another resident, and was banging it on the
glass, banging her head on the floor. There were
three, [QBHP #1], [QBHP #2], and [QBHP #3]
holding her on the floor. I got a pillow for her head
and then she agreed to stop and went to the
comfort room, refused treatment. The resident
went to the hospital the next day."
d. During a lap top video review on 11/27/2023 at
1:50 PM with the Unit Manager #1, he stated that
Client #1 on 10/25/2023 at 8:05 PM, had walked
into the day room, and knocked over two chairs.
"[QHBP #1] aggressively took the resident to the
seclusion room, locked the door as [QHBP #2]
escorted another resident out of the open
seclusion room leaving the plastic empty water
bottle. Then from 8:06 PM to 8:10 PM, the
resident continued to loudly scream and break
the plastic bottle into small pieces, hitting it on the
walls, camera, and the front window of the room
as well as banging her head on walls. At 8:10 PM,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 7 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 172 Continued From page 7 N 172
[QHBP #1] with two other employees came into
the room, subdued the resident by holding arms
and legs. [RN #1] began to remove shards of the
plastic water bottle." In response to the question
"What was wrong with the restraints?" Unit
Manager #1 stated "He snatched her up, not the
CPI [Crisis Prevention Institute] hold we use,
grabbed her and spun her around."
e. On 11/27/2023 at 2:30 PM, QBHP #2 stated, "I
entered the dayroom after Client #1 had been
taken into the seclusion room by [QHBP #1]." In
response to the question, "What did you
observe?" QBHP #2 stated, "She was banging a
plastic bottle on the window door. I stayed at the
door, until they came back to subdue her.
Another resident had been in the open seclusion
room sleeping and I had moved her out." In
response to the question, "Did you see her
banging her head?" QBHP #2 replied, "I did not."
f. At 11/27/2023 at 3:15 PM, Client #1 arrived
accompanied by her counselor. In response to
the question, "Can you tell me what happened
before going to the hospital on 10/26/2023?"
Client #1 stated, "I had left the comfort room
(10/25/2023), after having had locked myself in
my room closet so I could breathe. I went to the
Dayroom and started knocking down chairs.
[QHBP #1] grabbed me by my hoodie and took
me to seclusion. I pinched him because he was
hurting me. I cut my right hand. Another girl was
sleeping, and I got her water bottle. Rather not be
in seclusion so I banged my head and got a
concussion. Banged my head on the walls and
floor. The concussion feels like bolts tightening. I
went to the hospital the next day." In response to
the question, "Why did you go to the hospital the
next day?" Client #1 stated, "Needed doctor's
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 8 of 9

PRINTED: 12/06/2023
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
04L107 B. WING _____________________________ 11/28/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(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 172 Continued From page 8 N 172
approval before I could go."
g. During a second lap top viewing of the incident
on 10/25/2023 at 8:07 PM, on 11/28/2023 with
Unit Manager #2. He stated "The video of the
seclusion began at 8:06 PM, shows [QHBP #1],
taking [Client #1] into the locked seclusion room,
and the previous resident is moved out by [QHBP
#2], leaving the water bottle on the floor. The
resident is banging the water bottle on the glass,
camera, and the wall as well as her banging her
head. They should have held her, moved the
broken plastic out of the seclusion room. They
usually talk them down before they lock the
resident in, making sure other residents were not
in the room and free of plastic bottles and debris."
In addition, he said, "[QHBP #1], took her to the
ground, CPI does not take residents to the floor. It
is not a proper technique."
h. The Policy "Use of Seclusion-Intensive
Residential" (Reviewed 07/24/2023), read in part,
"...Seclusion is utilized to protect the patient from
injuring self or others... It is not used as
punishment or for the convenience of team
members. Seclusion is used only for emergency
situations when less restrictive interventions have
not been successful... VIII. Seclusion is not used
in a manner that causes undue physical
discomfort, harm or pain to the patient..."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:HSSL11 Facility ID: 3006 If continuation sheet Page 9 of 9

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
January 3, 2024
David Napier, Administrator
Youth Home Inc
20400 Colonel Glenn Road
Little Rock, AR 72210-5323
Dear Mr. Napier:
On November 28, 2023, 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 December 14, 2023.
We will be conducting a revisit of your facility to verify that substantial correction has been achieved
and maintained.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email
to: Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
Theresa Forrest, Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
tf
David Napier - Youth Home Inc -- -- (AOLTC-14) Page 1

PRINTED: 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & ii]EDICAID SERVICES OM
STAIEMENI OF OEFICIENCIES (X1) PROVIDEF'SUPPLIEF/CLIA (X2) MULTIPLE CONSTRUCTION (X3) OATE SURVEY
ANO PIAN OF CORRECIION IDENIIFICAIION NUMBER A BUILOING COMP!EIED
c
04L107 B !\/lNG 11t2812023
NAME OF PROMOER OR SUPPLIER STR€ET AOORESS CITY STATE ZIPCOOE
2O4M COLOI{EL GLENN ROAD
YOUTH HO E It{C
LITTLE ROCX, AR 72210
(x4)rD SUMMARY S-TATEMENl OE OEFICIENCIES to PROVIOER'S PLAN OF CORRECTION
IEACH DEFICIENCY MUST BE PRECEOED BY FULL PREFIX {EACH CORRECTIVE ACIION SIloULO AE
TAG REGULAIORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCEO TO THE APPROPRIATE
oErrcrENcY)
N 000 lnitial Comments N 000
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document All information must
remain unchanged exc€pt for entering the plan of
correclron, coneclion 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
lnspector General (OlG) for possable fraud lf
rnformatron is inadvertently changed by the
provider/supplrer. the State Survey Agency (SA)
should be notified immediately.
Complaint #AR00031282 was not in compliance
all or in part wrth deficienoes wntten at N132 and
N172
The facility was not in compliance with 5483,
Subpart G - Conditions of Partacipataon for
Psychiatflc Resdentral Treatment Center
N 132 PROTECTION OF RESIDENTS N 132
CFR(s): 483 3s6(b)
Emergency safety interventron An emergency
safety interventron must be performed rn a
manner that rs safe, proportronate and
appropnate to the severity of the behavior. and
the resident's chronological and developmental
age, size. gender. physrcrl. medlcal. and
psychiatnc condition and personal history
(including any history of physical or sexual
abuse)
Thrs ELEMENT rs not met as evrdenced by
Based on observation. interview and record
review. the facrlrty farled to ensure a reslrarnt was
conducted rn a safe and appropnale manner to
u*{
LASORATORY DIRECTOR'S OR PROVIOER/SUPPLIER REPRES6NTAIIVE'S SIGNATURE TITLE b{fir,/'
ila3
/2-
Any dencpncy slale endrno w[h an asterisi (') denoles a delEEncy whrci lhe rnstlulron may b€ 6)cus€d lrom coreclng provdrng
other sategusrds prov suficr€ol protedon to lhe patlents (Soc rnstrucllons ) Erc4pt tor nursrng hom€s. the lindrngs stated ebove 6re drsclosaDlc 90 deys
lollcwng the dalo ol su.vey wfiether or nol a plan ol correcton rs prov(bd For nuBrng homes lh6 above trndno3 end plens ol cofloclton are disclocable 14
day3lollowng the c,ate these documenls are m6d6 avarlabl€ to ths lacility It dalicrsnoes are c 6d an approved plan o, coriecllon r! roqu6rle to contrnuod
progr€m parllcrpalion
E*.r ro FssL 11 l, connnuaton sheel Pag€ 1 ol9

PRTNTED 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTER FOR MEDICARE & MEDICAID SERVICES OMB NO
STATEMENT OT OEFICIENCIES (XI) PROVIDEF'SUPPLIER/CLIA IX?) MULIIPLE CONSTRUCTION IX3) OATE SURVEY
AND PTAN OF CORRECTION IOENIIFICAIION NUMSER A BUITOING- COMPTEIED
c
04L 107 B WNG it2at2023
NAME OF PROVIDER OR SUPPIIER SIREET ADORESS CITY STATE ZlPCODE
2O,tlD COLOI{EL GLEI{N ROAO
YOUTH HOfE tt{C
LITTLE ROCK. AR 72210
(x4) to SUMMARY STATEMENT OF OEFICIENCIES ID - PROVIOER'S PLAN OF CORRECIION
IEACH DEFICIENCY MUST BE PRECEOED AY FULL IEACH CORRECTIVE ACTION SHOULO AE
TA6 REGUlAIORY OR TSC IO€NTITYING TNfORMATION) TAG CROS$REFERENCEO TO THE APPROPRIATE
DEFICIENCY)
N 132 Continued From page 1 N 132 Youlh llontc upgraded our canlcra sl-slenr in l2' l'1121
prevent potential injury for 1 (Client fl) Jull 2030 rvhich corcrs nlosl comnlon areas ol
our carrpus. This cnablcs us Io harc clear qualitl
The frndrngs are picturcs and audio ol iDcidenls thal rrnkes rcvie\\
o, incidcnts morc nreaningt'ul and nrore elllci.lrt.
1 Client #1, had diagnoses of "Reactive
\:ideo lix)tage ol-circh rcslrainl tcclusion ircidcnt
Attachment Disorder and Disruptive Mood
Dysregulation Disorder is rcr icrrcd as quicll) aspossiblch! the ( nil
Managcr. usualll uithin 2.1 houls. rnd b1 Jan.
a An lncident Report, provrded by the Record l. 20:{ lhis \\ill occur on rvcekcnds also. l'lach
Complance Officer, on 10/2512023. hsted the r ideo rer ics ed is docunrenled rr ith dctails ol'
complaint as "Personal Restraints, Locked
the sccnario and kcpt in a Video Rcr ierv l-og.
Seclusron. Aggressrveness to Staff and Peers.
lnjury to Staff, Threat to Safety, and Property When arrl thing is noted that is either questionahlc
Oestruction " Also described Resident berng or inapprrrpriatc. thc ('hiefClinical olllcer is
rude, hid in closet. refused medications ffipped notilicd. .\(tion taLcn cith*r Icad. h) rclraining
over furnrture personal restraint, placed in
lbr lhc lranr rnenrhc'r(sl inrolrcd. a hotline call.
seclusion. broke peers cup, exposed sharp
and,or disciplina[, itction up lo and including
plastic edges, spiting, scratching statf, atter
banging her head on walls and front window of tcrm ination.
seclusron room RN (Registered Nurse) In thc casc ol'lhis incidcnt. thc teanr nlenrbcr
assessment noled after the incident Resident inrrrlvcd in the inappropriate hold rcceir cd
reported small abrasron on her palm srde next to
disciplinary acliLrn ol'disnlissal. All olhcr tcirn
her thumb from the restraint, petechiae around
mrnrbcrs \rho \!crc pan ol tht'incidcnl reccivcd
her eyes and cheeks that were not observed on
1012512023 A hot|ne reporl was made The retraining lionr lheir t nil \'lanagcr. {nlhor)
resident was ordered for turther evaluation at ER \\ hitc. rcgarding tpproprialc holds in ( risis
(Emergency Room) on 10/26/2023 for petechia Prc!ention lnslilutc lraining on l0'16rll. 'lhe)
rash, on her fac€ and headache, knee parn with a
also rcceired disciplinary aclion in th('li)nlr
dragnosrs of concussion Resrdent was placed on
achvity limit for three (3) days ofa uriltcn personncl action. Ihc incident uas
reponcd to rhe ('hild .Abuse llollinc on lhe
b An interview with Chief Clinical Offrcer on dat('ol rc!ieu.
1112712023 a|130 PM stated that OBHP On l(l :5 l.i. lhc d tc ()l'lhc incidcnt lbr
(Oualifed Behavioral Health Provider) #1 had
been let go because. "Vrdeo footage showed Rcsidcnt ,; l. shc rras assesscd ht nursc
IOBHP #11 had rnitiated a one-person restrarnt,
ierking patient and had shoved her into seclusion
Wthout ensunng that the room was free of
hazards or other occupants "
FORM CMs 256i(02-99) Pr6v'ous V6rs'ons Obsol6rs EEnr lD BssL l1 ll conlrnualDn shoei Page 2 ol9

PRtNTEO. 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
c NT R F R MEDICARE & MEDICAID SERVICES oMB NO 0938-0391
STATEMENI OF DEFICIENCIES (X1 ) PROVIDER,SUPP!IEFl/CTIA (X2) MUTTIPTE CONSTRUCTION (X3) OATE SURVEY
ANO PLAI OF CORRECTION IOENTIf ICATION NIJMEER A AUILOING COMPTEIEO
c
04L107 ltt2at2023
NAME OF PROVIDER OR SUPPLIER SIREETAODRESS CITY SIATE ZIP CODE
2O,aO0 COLOIEI GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
1X4)rD SUMMARY STATEMENl OF DEFICIENCIES ID - PROVIOERS PL!\r{ OF CORRECTTON
IEACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIV€ ACTION SHOULD BE
TAG REGULATORY OR LSC IOENTIFYING INFORMATION) TAG CROSS.REFERENCEO IO THE APPROPRIATE
OEFICIENCYI
N 132 Contrnued From page 2 N 132 Ebonl Galnrorc. R.N. al 8:28 p.m . as part of
her face-lo-tbcc assessmcnl after lhe incidenl.
c Physician Orders dated 10/25/2023, at 8:06 \l'e consider thal an) olhcr residenl ofour
PM. read in part. ".. Place in locked seclusion for ,'acilir) has thc polential lo bc afl'ected b) the
up to 60 minutes until calm and cooperative and
findings: tht'refore. on the dale ofthe incidenl.
no longer a threat to safety "
that included .19 olher residenls. \\'e rtill
d. On 1112712023. at 1 35 PM. a telephone conlinue lo n)onilor each incident ofseclusion'
intervrew was conducted with RN #1 She stated. restraint thal occurs in our facilitl. The
"The resrdent refused her medrcatron. by nronitoring is completed by video review of
slamming her door, and had stepped away for
all incidents b1 the Unit Manager assigned kr
three minutes Upon returning, she heard resident
screaming and being escorted to the seclusion the area lhe incident occurs in wilh docunren-
room by IOBHP #1] " ln response to the questron. tation ol dclail:' r ia a Video Re\ ie$ Log.
"What did you observe?" RN #1 stated. "Resident The Chief Clinical Ofticcr reviews on a *eekl)
had prcked up a water botlle left by another
basis aDd rcpons results from the log at each
resident and was banging it on the glass
banging her head on the floor There were three. Perfornrance I ntpror'cnrenl
IOBHP #11. IOBHP #2] and [OBHP #3] holdrng ( ommiltec nreeling on a quanerh basis. Nlembers
her on the floor lgot a pillow for her head and ofthat conrmiltcc includc our Chief i\'ledical
then she agreed to stop and went to the comfort ol'ficer- all rhe l:\eculi\e Team. Director of
room refused treatment The resident went to the
Nursing. all othcr departDrcnls \r ilhin the l'acilit)'.
hospital the next day "
e Dunng a lap top video revrew on 1112712023 al
'1r50 PM wrth the Unit Manager #1 . he stated that ln addition. beginning January l. 202.1 Youth
Client #1 on 1012512023 at8 05PM. had walked
lJonre is enrbarking on a concened effort 1o
into the day room, and knocked over t\,/vo chairs
"[OHBP f1] aggressively took the resident to the decrcast'our nunrbcr ol restraints and seclusions.
seclusron room. locked the door as IOHBP #21 Wc rvill begin using a checklist to assist with
escorted another resident out of the open predicting violenl bchavior rthich has been efl'ective
seclusion room leaving the plastic empty water in orher scrtitrgs sirrilar lo ours. lt is a checklist
bottle Then from 8 06 PM to 8 10 PM. the
lhal is conrplelcd on cach patient lbr each shift
resrdent contrnued to loudly scream and break
the plashc bottle into small pEces, hrttrng rt on the lhal helps predict lheir le\el oiescalation. ll
walls. camera. and the front wndow of the room is conrnrunicalcd lo each shili corrring on to
I
as well as bangrng her head on walls At 10 PM help thcnr bc prepared lo sorl bt'sl u ith each
IOHBP #llwith two other employees came rnto patienl. 1he nunrbcr ofseclusitrns and restraints
the room. subdued the resident by holding arms
and legs. IRN #1]began to remove shards of the prior to beginning the lool will be corrpared
Evenl lD HSSL 11 lfcontnualron sheel PaOe 3ol9

PRTNTED 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO O
SIATEMENl OF OEFICIENCIES (xl I PROVIDER/SIJPPLIER/CI|A (X2I MULTIPTE CONSTRUCTION IX3) DAIE SURVEY
AND PLAN OF CORRECTION IDENlIFICA-IION NUMBER A AUILDING COMPLEIEO
C
04L107 11t28t2023
NAME OF PROVIDER OR SUPPLIER STREE'I ADDRESS CIIY STATE ZIP COOE
2O'OO COLONEL GLENN ROAO
YOUTH HOME INC
LITTLE ROCK, AR 722I0
(x4)tD SUMMARY STATEMENT OF DEFICIENCIES to PROVIDER'S PLAN OF CORRECTION
IEACIi OETICIENCY MUST AE PRECEDEO BY FUt L (EACII CORRECIIVE ACTION SHOU!D B€
IAG REGULATORY OR LSC IDENIIFYING INTORMATION) TAG CROSS,REFERENCEO IO THE APPROPRIATE
DEFICIENCY}
N 132 Continued From page 3 N 132 lo lhe nunrhcr alicr heginning ust each rronllr
\i ilh lhcsr rcsulls rc[x)ncd t() lhc [)erlbrrr]ancs
plastrc water bottle." ln response to the questron
"Vvhal was wrong with the restraints?" Unit lnrpro\cmcnl ( (nnnrillcc h) thc ( hic,-( linical
Manager #1 stated "He snatched her up. not the Olliccr on a qunncrll hasis.
CPI lcrisis Prevention lnstitutel hold we use.
grabbed her and spun her around "
t On t1t27 t2O23 at2.30 PM. OBHP #2 stated. "l
entered the dayroom after Client #1 had been
taken rnto the seclusion room by IOFIBP #1] " ln
response to the question, 'What did you
observe?" QBHP #2 stated, "She was banging a
plastic bottle on the window door I stayed at the
door. untilthey came back to subdue her
Another resident had been rn the open seclusron
room sleeprng and I had moved her out " ln
response to the questron. "Did you see her
bangrng her head?" OBHP #2 replred, "l drd not "
s On 11t27 t2O23 at2 45 PM OBHP#3 stated
that Clent #1 had not been complrant ln
response to the questron. '1 ,lhy was lclient #1]
not complrant?" OBHP #3 stated. "She was
yelfing screamrng. and throwng chairs My
partner. IOBHP #1]. grabbed her ldidnotgetup
as lwas eatrng drnner IOBHP#lltookherlothe
seclusion room and called me to take hrs place
IClienl #11 was kicking, screaming, scratching,
drew biood from my hand from scratches. and
bangrng her head [RN #1]brought a pillow She
deescalated to a calm state V1b released her to a
calm state she was assessed by the nurse " ln
response to lhe question. drd you see a broken
water bottle?" OHBP #3 drd not recall the water
bottle
h Al11l27t2O23 al3 '15 PM. Client #1 a(rved
accompanted by her counselor. ln response to
the questron. 'Can you tellme what happened
before gorng to the hospital on '10/26/2023?"
FORM CMS:561(O? 99) P.ev'tus Vor6'ons Obsol€16 Evenl lD HSSL l1 ll co.lrnuatron sheet Paoe 4 ol9

PRTNTED 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES oMB NO 0938-0391
STATEMENI OF OEFICIENCIES (X1) PROVIOER,/SUPPLIERrcLIA (X2) MULTIPIE CONS]RUCTION (X3) OATE SURVEY
ANO PLAN OF CORRECTION IDENTIFICATION NUMEER A BUITDNG COMPLETED
04L107 B IMNG 11t2812023
NAME OT PROMOER OR SUPPIIER SIREETADORESS CITY STATE ZIP COOE
2oatrc coLoNEL GLEXiT ROAO
YOUTH HOME ITC
LITTLE ROCK, AR 72210
SUMi/iqRY STATEMENT OF DEFICIENCIES ID PROVIOERS PT-AN OF CORRECIION
IEACH OEFICIENCY MUST BE PRECEO€O BY FUTL PR€FIX {EACH CORREC]IVE ACIION SHOULD BE
REGULAIORY OR LSC IDENTIFYING INFORMATION' CROSSREFERENCEO IO IHE APPROPRIAIE
DEFICIENCY)
N 132 Contrnued From page 4 N 132
Client #1 stated "l had left the comfort room
\1012512023)-. after having had locked myself in
my room closel so I could breathe I went to the
Dayroom and started knocking down chairs
IOHBP #11 grabbed me by my hoodie and took
me to seclusion I pinched him because he was
hurting me lcut my right hand Another girlwas
sleeprng, and I got her water bottle Rather not be
in seclusion so I banged my head and got a
concussion Banged my head on the walls and
floor. The concussion feels like bolts tightening
I
went to the hospital the next day " ln response to
the question. "VVhy drd you go to the hospital the
next day?" Chent #1 stated. "Needed docto/s
approval before I could go "
r Durrng a second laptop viewng of the incident
on 10i25/2023 at 8 07 PM. on 11/28/2023 with
Unrt Manager #2 He stated "The video of the
seclusion began at 8.06 PM, shows IOHBP #1],
taking lclient *1] rnto the locked secluspn room.
and the previous resident is moved out by IOHBP
#21. leavrng the water bonle on the floor The
residenl is banging the water bottle on the glass.
camera. and the wall as well as her banging her
head They should have held her, moved lhe
broken plastic out of the seclusion room They
usually talk them down before they lock the
resident in. making sure other residents were not
rn the room and free of plastrc bottles and debris."
ln addition, he sard, "[QHBP #1], took her to the
ground, CPI does not take residents to the floor lt
is not a prop6r technrque."
N 172 MONITORING DURING AND AFTER N 172
SECLUSION
CFR{s): 483 3&(bX2)
[A room used for seclusron mustl Be free of
ll contnuaton sheer Page 5 ol9

PRTNTED 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
R tll AR M ID ERVICES N
SlAIEMENI OF OEFICI€NCIES IX1) PROVIOEF'SUPPLIER/CTIA IXz) MULIIP!E CONSIRUClION (I3)OAIE SURVEY
ANO PLAN OF CORRECTION IOENTIFICATION NUMEER A BUILOING COMPLETED
c
041107 B W1NG 1',t t28t2023
NAME OF PROVIDER OR SUPPIIER SIRE€TADORESS CIIY S'IATE ZIP COOE
20aoo corot{EL GLEt{t{ Roao
YOUTH HOME II{C
LITTLE ROCK, AR 722,10
(xai rD SUMMARY STATEMENT OF OEfICIENCIES to PROVIOERS PTAN OT CORRECIION
PREFIX IEACH O€FICIENCY MUSI BE PRECEOEO 8Y TULT I€ACH CORRECTIVE ACTION STIOULO BE
TAG REGUL.AIORY OR lSC ID€N-IIFYING INTORMATION} TAG CROSSREFERENCEO TO THE APPROPRIATE
oEFroErlcY)
l] ]8 t.r
N 172 Continued From page 5 N 172 Retraining on thc propcr usc ol scclusron was
potentially hazardous condilrons such as pror ided b1 lhc ( ni( Nlanagcr. Anlhon)
unprotected light fixtures and electrical outlets \\'hite- r)n l0 l(r ll lirrall stallinvolvcd in
thc incidcnt quickll alicr revir$ ol thc vidco.
lhis rctraining inclrrdcd l rcnrindcr tlircus:.ion
This ELEMENT rs not met as evidenced by:
Based on observatron, intervrew and record ol thc nccd t,, inlcn(rrc uhcrr arr irrnppropriatc
review, the facility failed to ensure a resrdent was inleraction is ohservcd.
protected from physical harm while being placed ,\lldircet carc \lflll \\rrc assir.lllcd il lrainins
in a locked seclusron room (Clrent #1)
rttodrrlc on scclu\inrl in (,rrr r}nlir)e lcilrtrirtg
The findrngs are syslcrn on l: ?'li k) bc conrplclcd h} l1 l.lr13
Al lhc tinre ol'rcpo(. alllcarn nrcmhc'rs crccpt
1 Client #1, had diagnoses of "Reaclive I 8 had conrplctcd lhis lraining. .\n1 rr ho halc
Attachmenl Disorder and Disruptrve Mood *ill
ool conrpl('tcd the lrairrirrg nrrrdulc hc
Dysregulation Dasorder
rrqui[crJ t0 ct'rrrpletc il prior trr bcing in rutir,
a An lncrdent Repon, provrded by the Record on thcir nc\l schcdulcd shiti. I'itilurc to tlo so
Complance Offrcer on 10/2512023 hsted the uill rcsull in disciplinrn action.
complaint as "Personal Restraints. Locked
Seclusron. Aggressiveness to Staff and Peers. Youth I lonrc rr ill nron ilor cach incidcnt ol'
lniury to Staff. Threal to Safety, and Property scclusion that occur-s irl our ldcilil). I hc
Oestruction " Also descnbed Resident being nronilorin,r is contplclcd h) r idco rcr ierr ol
rude hd in closet refused medrcations. flipped all incidcnts h\ lhc l ril \lanagcr assigncd
over furnfure. personal restrarnt placed in
kr the arcn rrherc thc incirlcrrt occurs rrith
seclusron. broke peers cup. exposed sharp
plastrc edges, spiting, scralchrng statf after docunrcnlation ol tlctlils r ia a \,itlco Rcr icrr
banging her head on walls and front wndow of l-og. Ihc ( hicl ( lirricirl Oll'iccr rcrierrs trn a
seclusion room RN (Registered Nurse) $ccl,11 hasis and rcporls rc\ulls Irorn thc krg
assessment noted after the rncrdent Resdent al cir!h lt(rlirrnrir !( lrrnn)\crncnl (',rl|rrillcc
reported small abrasion on her palm side next to
her thumb from the restraint, petechiae around nreclinq on a quancrll basis.
her eyes and cheeks that were not observed on
1012512023 A hotline report was made. The
resrdent was ordered for lurther evaluation at ER
(Emergency Room) on '10i26l2023 for petechia
rash, on her face and headache, knee pain with a
dragnosis of concussion Resident was placed on
activity limit for three (3) days
Ecnr lD HSSLII ll contrnuatron sheel Paoe 6 ol9

PRTNTEO r2106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
NT R F MEDICARE & MEDICAID SERVICES oMB NO. 0938-0391
STATEMEN] OF OEFICIENCIES IX1) PROVIOEFVSUPPLIER/CTIA (X?I MULIIPLE CONSTRUCTION {X3) OATE SURVEY
AND PI AN OF CORRECIION IOENTIFICATION NUMEER A BUILDING COMPLEIEO
C
041107 B WNG 11t28t2023
NAME OF PROVIDER OR SUPPLIER STREEI AODRESS ClTY STATE, ZIP CODE
20400 coLoNEL GLEi{I ROAO
YOUTH HOI{E II{C
LITTLE ROCK, AR 72210
(xa) ro SUMMARY SIAIEMENI OF OEFICIENCIES ID PROVIOCR'S PLAN OF CORRECIION
IEACH DEFICIENCY MUST B€ PRECEOEO SY FULL PREFIX IEACH CORR€CTIVE ACIION SHOULD BE
TAG REGULAIORY OR ISC IOENIIFYING INFORMATION) TAG CROS$REFERENCED IO IHE APPROPRIATE
OEFICIENCY)
N 172 Continued From page 6 N 172
b. An interview with Chief Clinical Officer on
11127 t2O23 at l:30 PM. stated that QBHP
(Oualified Behavioral Health Provider)#'l had
been let go because, "Mdeo footage showed
IQBHP #'1] had in[ialed a one-person restrainl.
jerking patient and had shoved her into seclusaon
Wthout ensunng that the room was free of
hazards or other occupants "
c On 11t2712023 at 1 35 PM. On 1112712023. al
1 35 PM, a telephone interview was conducted
wrth RN #1. She stated. "The resident refused her
medication, by slamming her door, and had
stepped away for three mrnutes Upon retuming.
she heard resident screamrng and berng escorted
to the seclusion room by IOBHP #1] " ln response
to the questron "Vvhat did you observe?" RN #1
stated. "Resident had prcked up a water bottle.
left by another resrdent and was banging it on the
glass, banging her head on the floor There were
three, IQBHP #1], [OBHP #2] andIQBHP#3]
holding her on the floor. I got a pillow for her head
and then she agreed to stop and went to the
comfort room. refused treatment The resdent
went to the hosprtal the next day "
d During a lap top vrdeo review on 1112712023 al
1:50 PM wath the Unit Manager *1. he stated that
Client #1 on 10/2512023 at 8:05 PM. had walked
into the day room, and knocked over two chairs
"[QHBP #1] aggressrvely took the resident to the
seclusion room locked the door as IQHBP #21
escorted another resident out of the open
seclusion room leaving the plastic empty water
bottle Then from I06 PM to 8:10 PM. the
resident continued to loudly scream and break
the plastic bottle into small pleces. hatting ( on the
walls. camera. and the front window of lhe room
as wellas banging her hoad on walls. At 8 10 PM
Evenl lO HSSLIl ll conlrnualon sheel Page 7 of I

PRTNTED 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
SIAI€MENI OF OEFICIENCIES (X I ) PROVTOEFVSUPPLIER/CLIA (X?) MULTIPLE CONSTRUCTION (X3) DAIE SURVEY
ANO PLAN OF CORRECIION IO€NTIFICATION NUMBER A BUTtOTNG_ COMPLETED
c
041't07 B !\/lNG 1112at2023
NAME OF PROVIDER OR SUPPLIER STREEIADORESS. CITY STATE ZIP CODE
2I}4OO COLONEL GLENN ROAO
YOUTH HOME INC
- LITTLE ROCK. AR 722I0
(xa)ro SUMMARY STATEMENT OF DEFICIENCIES to PROVIOER'S PLAN OF CORRECTION
(EACH OEFICIENCY MUST BE PRECEOEO BY FULL IEACH CORRECTIVE ACIION SHOULD BE
IAG REGUIAIORY OR ISC IOENIIFYING INFORMATIONI CROS$RETERENCED IO THE APPROPRIAIE
OEFICIENCY)
N 172 Continued From page 7 N 172
(OHBP #llwith two other employees came into
the room, subdued the resrdent by holding arms
and legs IRN #1]began to remove shards ofthe
plastac water bottle " ln response to the question
"\Mat was wrong wath the restraints?" Unrt
Manager #1 stated "He snatched her up. not the
CPI lcrisrs Preventron lnsl ute] hold we use.
grabbed her and spun her around "
e On 1112712023 al2 30 PM. OBHP#2 stated. "l
entered the dayroom after Client #1 had been
taken rnto the seclusion room by IOHBP #11 " ln
response to the question. "yvhat drd you
observe?" OBHP #2 stated. "She was banging a
plastic bottle on the window door I stayed at the
door. until they came back to subdue her
Another resident had been rn the open seclusion
room sleeprng and I had moved her out " ln
response to the question "Did you see her
banging her head?" OBHP #2 replied. "l did not "
t. Al 1112712023 at 3 1 5 PM. Clrent#1 arrived
accompanied by her counselor ln response to
the question. "Can you tell me what happ€ned
before going to the hosprtal on 10/26/2023?"
Clent #1 stated. "l had lett the comfort room
\1012512023) after haung had locked myself rn
my room closet so I could breathe lwent to the
Dayroom and started knocking do\,yn charrs
[QHBP #1]grabbed me by my hoodie and took
me to seclusion I prnched hlm because he was
hurting me. I cut my right hand. Another girlwas
sleeping, and I got her water bottle. Rather not be
in seclusion so I banged my head and got a
concussion Banged my head on the walls and
floor The concussron feels lrke bolts tightening I
went to the hosp al the next day " ln response to
the question 'Wtry drd you go to the hospital the
next day?" Cl€nt #1 stated. "Needed doctor's
Evenr lO HssL11 ll contnual,on she€l Pag€ I ol9

PRTNTED 12106/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORI\,I APPROVED
c R F R MEDI RE MEDI ID SERVICES oM8 NO 0938-0391
STATEMENI OF OEFICIENCIES (x1) PROVTOEfVSUPPUEFUCLIA (X2) MUIIIPLE CONSTRUCTION (X3)OAIE SURVEY
ANO PLAN OF CORRECTION I.IENTIf ICATION NUMBER A BUiLDING COMPLETED
04L107 11t24t2023
NAME OF PROVIOER OR SUPPLIER STREEI AOORESS CITY STATE ZIP CODE
2O'OO COLOT{EL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(xa) lo SUMMAFY STAIEMEN.' OF OETICIENCIES to PROVIOER'S PtAN OF CORRECTION
(EACH O€FICIENCY MUST BE PRECEOED AY FULL 1EACH CORRECTIVE ACTION SHOULO BE
TAG RECULAIORY OR LSC IOENTIFYING INFORMATION' CROS}REFERENCED TO THE APPROPRIATE
OEFICIENCY)
N 172 Continued From page 8 N 172
approval before I could go "
g. Ouring a second lap top viewing of the incident
on 10125t2O23 al 8 07 PM . on 11 128t2O23 wilh
Unit Manager #2 He stated "The video of the
seclusion began at 8.06 PM. shows IOHBP #1).
lakrng lChenl #'11 rnto the locked seclusron room
and the previous resident is moved out by IOHBP
#21, leavrng the water bottle on the Roor The
resident is bangrng the water bottle on the glass
camera, and the wall as well as her banging her
head They should have held her. moved the
broken plastic out of the seclusron room They
usually talk them down before they lock the
resident in. making sure other residents were not
in the room and free of plastrc bottles and debris '
ln addrtron. he sard. "IQHBP #11. took her to the
ground, CPI does nol take resrdents to the floor lt
is not a proper technique "
h The Policy 'Use of Seclusron-lntensrve
Residenlral" (Revre\.yed 0712412023). read in part,
"
Seclusion is utlized to protect the patient from
tnjuflng self or others lt is not used as
punrshment or for the convenrence of team
members Seclusron is used only for emergency
situations when less restriclrve rntervenlrons have
not b€en successful Vlll Seclusion rs not used
in a manner that causes undue physical
discomfort. harm or pain to the patrent '
FORM CMS 2567t02 99r P,6vesVdr'ds Obsor€re E€tr1lO HssLll ll conlrnualon she€l PaOe I of 9

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
March 4, 2024
David Napier, Administrator
Youth Home Inc
20400 Colonel Glenn Road
Little Rock, AR 72210-5323
Dear Mr. Napier:
During the Revisit survey conducted on February 21, 2024, your facility was found to be in compliance
with program requirements. Please email the signed CMS 2567 Theresa.Forrest@dhs.arkansas.gov.
If you have any questions, please contact your reviewer: Theresa Forrest at 501-320-6235 or email
to: Theresa.Forrest@dhs.arkansas.gov.
Sincerely,
DPSQA/Office of Long Term Care
Survey and Certification Section
tf

PRINTED: 03/04/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
R-C
04L107 B. WING _____________________________ 02/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
20400 COLONEL GLENN ROAD
YOUTH HOME INC
LITTLE ROCK, AR 72210
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{N 000} Initial Comments {N 000}
Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.
A revisit was conducted on February 21, 2024, for
all deficiencies cited on November 28, 2023. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.
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:HSSL12 Facility ID: 3006 If continuation sheet Page 1 of 1

doc_type: Complaint Survey


state: AR

facility_name: Youth Home

summary: A resident was transported for acute care after an incident in which she slammed her head and body against walls and ignored redirection.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/7/2023
Date Received by DCCECE:11/8/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report 1 for DOB: Private
placement client in our PRTF program and resides in Mabee House. Incident Report
date/time: 11/07/23 1:16pm Location of Incident: Mabee House Incident Description:
Threat to Safety Staff Involved: Anthony White, Joseph Davis, Jacqueline Wheeler Events
Leading: Client escalated for no apparent reason, or reasons she can't or won't express.
Client observed in the seclusion area, on her on volition, slamming her head into the walls
of the seclusion room with varying force. Staff present offering support. After a short time,
client exited this area, and ran down the hall. There client was observed to slam her wrists
and arms, and fists into the wall around her. Client ignored support given by staff. After
prompting from several staff, client continued these behaviors. 1:16pm Personal Restraint:
Client restrained for safety. Client physically resisted against restraint. Client observed to
attempt to slam her head into the wall behind her, prompting staff to attempt to buffer with
their arms. Client vehemently protested against this. Client aggressively grabbed at staff's
clothing, and spit on staff's arms. Client given verbal support and remind that as she's able
to relax, staff will be able to relax the hold on her as she's being safe. This cycle continued
for several minutes. 1:20pm: Personal Restraint End: Client began relaxing her posture and
staff was able to relax the hold on her. Restraint ended at this time. Patient Debriefing
date/time: 11/07/23 1:30pm: Client given support and asked to reach out in the future and
to be safe. Nursing Assessment date/time: 11/07/23 2:10pm: Client upset due to family
session. Client admits that she feels as though there "is too much on my plate". Upon my
arrival, client was banging on the walls of front seclusion room. Client banged head on the
unlocked seclusion room door. Client required personal restraint due to threat to safety.
Client was encouraged to calm down and do the next right thing multiple times. Client
began to show signs of calming and was released. Client went down hallway and required
personal restraint to prevent injury. Here is where client again hit hand on wall. Client
complains of right hand pain, given icepack and ibuprofen x 2. Client has full/active ROM
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

with pain 9/10, capillary refill <3 seconds, area reddened, no other discoloration noted.
Encouraged client to rest, ice, ibuprofen and elevate it. Client denies numbness/tingling,
PERRLA, no swelling noted to head, no hematoma detected. No other needs identified
now, will continue to monitor. Guardian was notified by nurse on 11/07/23 at 2:39pm
Injuries to staff or client: Client complains of right hand pain Follow-up to injuries: given
icepack and ibuprofen x 2. Actions to prevent injuries: Client refraining from punching
things. Additional comments: Client is becoming a concern for this Unit Manager. She
requires so much attention and resources to the extent that the other clients in the house are
excluded from various things at any given time. It is this Manager's thoughts that this client
is not appropriate for this setting as it stands, and other services should be considered.
Incident Report 2 Date/time: 11/07/23 1:57pm Location of incident: Mabee House Incident
Description: Self Injury (Not Suicidal), Threat to Safety Staff Involved: Anthony White,
Joseph Davis, Anthony Mask, Melissa Rhude Events Leading: Following previous incident,
client sat in seclusion area attempting to calm. Client began slamming her head into the
wall of the seclusion room with varying force. Attempts to redirect client were unsuccessful.
As staff attempted to place their hands between the wall and her head, client became
combative. 1:57pm: Personal Restraint: Client placed in restraint. Nurse restricted her arms
as she attempted to strike staff attempting to prevent client from hurting herself. 1:58pm:
Personal Restraint End: Client broke free from restraint. Staff attempting de-escalation and
redirection for behaviors. Attempts unsuccessful. 1:59pm: Other/None: Staff attempting to
attend to client's need. Client unable to voice them; insists on harming self slamming head
on door. 2:00pm: Personal Restraint: Client restrained. Client combative with staff and
resisting against restraint. staff continue de-escalation and redirection. 2:01pm: Personal
Restraint End: Client broke free as staff continue de-escalation and redirection. Client
resumes head slamming. 2:02pm: Personal Restraint: Client restrained. Client combative
with staff and resisting against restraint. staff continue de-escalation and redirection.
2:03pm: Personal Restraint End: Client broke free as staff continue de-escalation and
redirection. Client resumes head slamming. 2:04pm: Other/None: Client sitting in seclusion
area as staff continue verbal de-escalation. Client resumes head banging and ignores
redirection from staff. 2:05pm: Personal Restraint: Client restrained. She physically resisted
and attempted to thrash and slam her body about. Staff offered verbal support. Client
offered medication by mouth to help her calm. Client declined. Client continued to thrash
about and become tearful as staff offered verbal support. 2:12pm: Personal Restraint End:
Client began to calm and was no long combative. She sat quietly as staff talked with her.
Restraint ended at this time. Client slapped the walls of the seclusion room door and began
slamming her head into the wall again. Client ignored prompting and redirection to stop.
2:13pm: Personal Restraint: Client restrained. Client thrashed her body and screamed
throughout. Client offered verbal support. Nursing approached with IM medication. 2:15pm
Chemical Restraint: Nursing administered shot to client at this time. 2:16pm: Personal
Restraint End: Client tearful and no longer resisting against restraint. Restraint ended at
this time. Patient Debriefing date/time: 11/07/23 2:25pm: Time spent talking with client
about how she could have handled the situation differently. Nursing Assessment date/time:
11/07/23 2:25pm: Client upset due to family session. Client admits that she feels as though
there "is too much on my plate". Upon my arrival, client was banging on the walls of front

seclusion room. Client banged head on the unlocked seclusion room door. Client required
personal restraint due to threat to safety. Client was encouraged to calm down and do the
next right thing multiple times. Client began to show signs of calming and was released.
Client went down hallway and required personal restraint to prevent injury. Here is where
client again hit hand on wall. Client complains of right hand pain, given icepack and
ibuprofen x 2. Client has full/active ROM with pain 9/10, capillary refill <3 seconds, area
reddened, no other discoloration noted. Encouraged client to rest, ice, ibuprofen and elevate
it. Client denies numbness/tingling, PERRLA, no swelling noted to head, no hematoma
detected. No other needs identified now, will continue to monitor. Chemical restraint
administered per nursing. Client showing signs of calming. Client in good spirits around
6pm, client had positive sounding telephone conversation with guardian. Awaiting transport
to acute placement. Guardian notified on 11/07/23 at 2:39pm was transported to
Rivendell for an acute stay on 11/07/23 during the evening shift. She remains at Rivendell at
this time.
Interim Action Narrative: Resident was restrained for safety, assessed by the nurse, and
place in acute care.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire if resident will be returning to the facility and
documentation for chemical restraint. Licensing Specialist informed that it is unknown at
this time if resident will be returning to the facility.

doc_type: Notice of Incident


summary: A resident displayed self-harming behaviors, such as hitting and kicking doors and scratching herself during an incident at the facility.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/6/2023
Date Received by DCCECE:11/7/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report for DOB: is a private
placement client in our PRTF program and resides in Mabee House. Incident Report
date/time: 11/06/23 2:05pm Location of Incident: Siebert School Incident Description: Self
Injury(Not Suicidal), Suicidal, Aggressive to Adults, Attempted Runaway, Threat to Safety
Staff Involved: Christian Spratt, Rodney Ellis, Charles Hoof, Elizabeth Larson Events
Leading: The patient was putting a snake like fidget toy around her neck. A peer stated that
she could get in trouble for playing around in that manner. She stated that she did not care
as she was already on consequence. Staff informed her that unsafe behaviors would land her
on other consequences. She was not pleased to hear this and threw he things down and ran
out the door fleeing. 2:05pm: Personal Restraint: The patient fled the area of supervision
and was restrained to prevent elopement. She began kicking the walls and kicked a door
into staff as she being escorted towards seclusion. She ignored staff as they tried to speak
with her to calm her down. 2:06pm: Personal Restraint End: The patient was asked could
she remain calm and she nodded her head in agreeance and was released from the restraint.
2:07pm: Other/None: The patient voluntarily entered the seclusion area to have a moment
to herself and began kicking and punching the wall. Staff asked that she take a seat or stand
quietly in order to collect her thoughts rather than self harm. 2:11pm: Personal Restraint: She
ignored this and continued to punch the wall. She was restrained as a result and she began
kicking staff in the legs and stomping on their feet. 2:15pm: Personal Restraint End:
Additional staff arrived that she appeared to have rapport with and she agreed to be calm
and compliant and process with them. After talking with them for a few minutes she showed
calm behavior and she was released. 2:17pm Personal Restraint: The patient became
annoyed that she was still at the school and not on her way to the house and she began
digging her nails into her left arm leaving marks. Staff restrained her to further prevent this.
She voiced that she felt she had nothing to live for and no longer felt like being good.
2:19pm: Personal Restraint End: Staff continuously processed with her to keep her in good
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

spirits and keep her calm. Once again contracting for safety she was released and staff
helped her gather her things to return to the house. Patient Debriefing date/time:
11/06/2023 2:55pm: The patient did not want to speak on the incident so staff briefly asked
her to try to communicate her feelings in the future before doing something brash. She
nodded her head in agreeance. Pt was placed on Freeze, eyeball and FOH. Upon returning
to the house, pt continued to test limits and struggled to remain safe. Nursing Assessment
date/time: 11/06/23 2:21pm: Pt was seen my this nurse. Assessed at this time. Pt states that
she has nothing to live for and isn't going to continue to participate and doesn't want to be
here anyone. Pt states that she doesn't care about anything. Pt denies pain or injury at this
time. Pt is noted to have fingernail marks to left forearm where she dug her nails into arm to
attempt to self harm, Did not break the skin, superficial indentions noted to skin. Pt states I
do not care upon nurising examining arms. Guardian was contacted on 11/06/23 at 3:14pm
and 3:20pm: 0314pm mom did not answer, left voicemail to call charge nurse phone,
information passed on to Meredith Reddin RN- Liz Larson RN 1520 - Mother called charge
phone. Information given to guardian. No further needs at this time. - Meredith R., BSN
RN. UM Debriefing date/time: 11/06/23 4:00pm: Injuries to staff and client: Staff was hit by
a door. No injuries to pt from intervention. Pt did claw self. Follow-up to injuries: Staff
stated they called Medcore and will self care as directed. Pt seen by nurse, placed on eyeball
and FOH. What actions might prevent the injuries: If pt had displayed safe behavior, staff
would not have been injured. If pt had utilized her coping skills, injury would not have
occurred. Staff quickly intervened to prevent any serious injury from her self-harm attempts.
Additional Comments for this incident: Pt continues to struggle to remain safe and needs to
continue developing coping skills.
Interim Action Narrative: Resident was placed in restraints for safety. Resident was placed
on freeze, eyeball, and FOH. Resident was assessed by the nurse.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. 11/9/2023, Licensing Specialist will inquire about FOH. Licensing Specialist
informed that FOH stands for "front of house."


summary: A resident reported that she was restrained improperly and that a staff member dug his nails into her hand. She also stated that she was grabbed by the collar of her shirt and that it was tight on her neck, choking her. The facility was cited 109.1.g and 905.15 as a result of this incident. The complaint was FOUNDED by Licensing.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/25/2023
Date Received by DCCECE: 10/27/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Dual
Report Description: Incident Report for DOB: Private placement
client in our PRTF program and resides in Mabee House. Incident Report date/time:
10/25/23 8:04pm Location of Incident: Mabee House Incident Description: Aggressive to
Adults, Threat to Safety, Property Destruction, Injury to Staff/Authorized Visitor Staff
Involved:
Events Leading: Client was upset after receiving a
pause for being rude to staff. Client went into her room closet after med monitoring. Client
refused to take meds. Client then came out of her room and started flipping over furniture.
Client was then in PR 8:04pm Personal Restraint: Client is in PR and being taken to
seclusion. Client is upset and and still yelling at staff. Staff is trying to clear out seclusion so
she could go in. 8:05pm Personal Restraint End: Client was placed in seclusion and let out
of restraint. 8:06pm Locked Seclusion: Client is in seclusion and is very upset. Client is still
refusing to calm. Staff is observing client and trying to get her to calm. 8:08pm Locked
Seclusion End: Client has broken a peers cup and has exposed sharp plastic edges around
the cup that could be used to self harm with. Staff opens seclusion door to remove the item
from 8:09pm Personal Restraint: Client threw bottle at staff when staff came in to get
item from her. Client was then placed in another PR. Client was upset and kicking and
scratching staff. Client was trying to bang her head on the floor and spit on staff as well.
Staff is trying to calm client down and get her out of the personal restraint. 8:24pm Personal
Restraint End: Client has calmed and has agreed to talk with nurse once staff let's her out of
restraint. Patient Debriefing date/time: 10/25/23 9:00pm: Client has calmed down
significantly and is processing with the nurse. Client has agreed to restore with staff about
her freeze. Nursing Assessment date/time: 10/25/23 8:28pm: When the nurse got back to
Mabee, she heard furniture shifting before she ever went inside. After entering at Mabee
House, staff members locked the patient in seclusion. The patient was shouting at staff
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

members and pounding the window with another patient's water bottle while in lock
seclusion. While in lock seclusion, the patient began hitting the camera with a water bottle
until it broke. Because the patient had broken a water bottle and there were shards of plastic
all around the seclusion room, staff had to go inside because that area was now unsafe for
patient. The patient was physically restrained because she was too unstable for the staff to
release her from seclusion. It was observed that the patient was trying to spit on the staff
members and was scratching and kicking while under physical restraint. The patient was
repeatedly instructed to cease kicking and scratching, but she refused to comply. After
being warned multiple times not to do so, the patient was seen digging her nails into the
staff member's hand. The left hand of the staff had blood on it. The patient was hitting her
head on the ground as well. The nurse put a pillow under the patient's head and tried again
to calm her down so she could be let go. Finally, the patient was able to relax and was
released from personal restraint. Patient vitals were T-99.2, HR 122, R 23 and BP 114/67 at
the time of nurse examination. The patient was able to respond appropriately and spoke in a
clear and understandable manner. PERRLA equal and reactive to light. No vomiting or
nausea were mentioned. No reports of visual impairment or dizziness. There are no
symptoms of sore throat, hoarseness, coughing, drooling, respiratory distress, or difficulty
swallowing. There are no visible markings on the neck. Petechia noted around the cheeks,
nose, and eyeballs. According to the patient the petechia was caused by her using face wash
last week. No sensitivity to noise or light reported by patient. The patient reported that her
head was pulsating. The patient stated that the pulsating was merely on the right side,
toward the end of her right eyebrow, and not a headache. Two scratches are visible on the
patient's right thumb towards the bottom. That happened while the personal restraint. The
patient refused the medication that the nurse offered. Patient said she could clean scratches
on her own, even though the nurse offered to help. In front of the nurse, she was handed
alcohol wipes to clean off her scratches. The nurse advised the patient to notify staff if her
condition worsens so that she can be examined. The patient was tearful and apologetic
during assessment. The patient was able to recall events leading to incident. Patient injuries
and incident were reported to the on-call MD. MD ordered freeze, lock isolation, unlock
seclusion, and personal restraint. Both the patient's mother and the on-call UM were
informed of the occurrence. The nurse gave the patient her nightly medications and
escorted her back to her room. Steady gait now with no issues with balance or coordination.
The patient did not note or report any other symptoms or concerns. In addition, the patient
complained of knee pain while in physical restraint. She stated that she hurt her knee earlier
today while outside. Upon evaluation following the patient's release from restraint, a tiny
red mark on the right knee was observed; edema was absent. Patient's gait was steady and
range of motion was good. When the nurse asked if the patient needed anything to help
with her pain, the patient said no. Guardian was notified on 10/25/23 at 8:45pm, 8:47pm,
8:53pm Incident Report on 10/26/23 at 8:48am Location of Incident: Siebert School
Incident Description: Staff Involved: Elizabeth Larson, Richelle Kumiyama,
Cody Horn Events Leading: Today while in med checks being seen by the provider for
weekly evaluation. stated that she was placed in a restraint last night and was
placed in seclusion. Pt states that she was restrained improperly and that they were not
holding her properly and she knew this by the way she was able to still pinch and

he was digging his nails into her hand(stating that a small abrasion on palm side next to
thumb was from this.) She also reported that she was grabbed by the collar of her shirt and
that it was tight on her neck and it was "choking her." Pt states that she tried to tell them
that she was being choked but they wouldn't listen. Pt had no marks on her neck/throat but
is noted to have some petechiae around her eyes and cheeks that wasn't there yesterday. A
hotline report was made due to the statements and findings on patient Incident Report on
10/26/23 at 3:30pm: Location of Incident: Siebert School Incident Description: Medical
Emergency (Trip to ER/Urgent Care) Staff Involved: Valerie Alvarez, Elizabeth Larson
Events Leading: EL, RN reported the following and inquired what to do: "While doing med
checks today and seeing she stated that she was placed in a restraint last night
and was placed in seclusion. Pt states that she was restrained improperly and that they were
not holding her properly and she knew this by the way she was able to still pinch
and he was digging his nails into her hand(stating that a small abrasion on palm side next
to thumb was from this.) She also reported that she was grabbed by the collar of her shirt
and that it was tight on her neck and it was "choking her." Pt states that she tried to tell
them that she was being choked but they wouldn't listen. Pt had no marks on her
neck/throat but is noted to have some petechiae around her eyes and cheeks that wasn't
there yesterday. This could be from numerous things and I don't want to assume its from
the collar of her clothing since no marks were present on her throat/neck." She was
instructed to pass this on to the UMs for further instructions. Attending APRN/DON/MD
notified with order to send out to ACH ER for further evaluation of petechiae rash
on face and headache that has not responded to PRN treatment. was transported to
ACH ER in Youth Home Van with a team member and left campus around 1730. Nursing
Assessment date/time: 10/26/23 9:40pm: MR, RN notified the treatment team via email the
following: " . returned from ACH at about 7:45pm tonight. She was diagnosed with
. Medications ordered are as follows: mg tablet Directions
Take 3 (three) tablet by mouth three times a day as needed for headache for 7 days. She has
also been placed on activity limit x 3 days then reevaluate d/t potential for post-concussion
syndrome. Please watch for irretractable vomiting. She may have sensitivity to light and
screens. Straining while reading or focusing may lead to a headache." Guardian was
notified on 10/26/23 at 5:40pm: A. Mother was called and notified of attending APRN
sending out to ACH ER for further evaluation of petechiae rash on face and
headache that has not responded to PRN treatment. This nurse inquired if CT has been in
contact with her today. She reported if CT attempted to reach out to her, she missed it.
Discussed with CT will be in contact with her regarding incident that happened
the evening prior and notification of child abuse hotline call. inquired if another
hotline call was made against them again. Instructed guardian the allegations reported were
regarding the incident the evening prior and CT will be contact with her. Guardian reported
she would attempt to get into contact with CT.
Interim Action Narrative: Resident was assessed by the nurse and sent to ACH for further
evaluation. Resident placed on activity restrictions. AR Hotline was called.

Maltreatment Narrative: Resident reported she was placed in a restraint improperly hold
and staff member dug his fingernails in her hand. Resident also reported that she was
grabbed by her collar of her shirt and it was choking her.
Licensing Narrative: Licensing Specialist was informed of this complaint and provided
documentation. Licensing Specialist reviewed complaint for licensing concerns. Licensing
Specialist inquired about camera footage and requested for footage to be saved. 10/30/2023,
Licensing Specialist will inquire to see if complaint was accepted. Facility informed
Licensing Specialist that referral was accepted. Licensing Specialist requested the referral
number. Licensing Specialist inquired about the assigned investigator. 10/31/2023,
Licensing Specialist requested permission to contact the facility. Licensing Specialist
received permission to contact the facility. Licensing Specialist observed camera footage.
Licensing Specialist received the corrective action for staff member. 11/27/2023, Licensing
Specialist contacted investigator for an update. Licensing Specialist informed that case was
found unsubstantiated.


summary: A resident was transported for acute care after showing self-harming behaviors such as throwing her body against a wall, picking her skin, banging her head, and biting herself.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/14/2023
Date Received by DCCECE: 10/18/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report 1 for DOB: Private
placement client in our PRTF program and resides in Mabee House Incident Report
date/time: 10/14/23 5:00pm Location of incident: Mabee House Incident Description: Self
Injury (Not Suicidal), Suicidal, Aggressive to Adults, Threat to Safety Staff Involved: Khari
Williams, Kelton Johnson, Ebony Galmore Events Leading: went into the family
room without permission and refused to come out. When given the chance to process,
stated that everything was also stated that she was upset because one
of peers was able to do what they wanted without getting in trouble. Once left the
family room, she waked into the seclusion room. began to self harm by biting her
arm and throwing her body against the wall. 5:00pm Unlocked Seclusion: went into
seclusion on her own. stated that everything was wrong. stated that she has
told staff what was wrong and nothing was done about. appeared to be hopeless.
began to pick at the wall. also began to bang on the door. 5:10pm Unlocked
Seclusion End: began to throw her body against the wall. also started to bang
on the door with her fist. attempted to bang her head. Staff intervened by placing a
hand on the wall to support her head. also began to pick at her skin with her finger
nails. 5:11pm Locked Seclusion: s self harm began to escalate. was also non-
complaint with staff. Staff continued to ask to process instead of self harm.
continued to self harm. 5:15pm Locked Seclusion End: Locked seclusion ended due to
requiring a restraint. required a restraint because she continued to bang her
head and pick at her skin. attempted to break skin. 5:17pm Personal Restraint:
was placed in a personal restraint due to self-harm. was banging her head and
scratching her arms and legs. screamed at staff to let her go. 5:20pm Personal
Restraint End: was able to calm down by talking to staff. was no longer
kicking or screaming. agreed to stop self-harming. Patient Debriefing date/time:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

10/14/23 5:20pm Nursing Assessment date/time: 10/14/23 5:35pm: The patient was in the
seclusion room in a personal hold when the nurse got to the Mabee house. The patient
entered the seclusion room because she was unhappy and disobeyed staff directives,
according to the staff. After being observed hitting her head while in seclusion, the patient
was put in a personal restraint. The patient was eventually quiet enough to be taken out of
the personal restraint after ten minutes. Patient eventually displayed nurse self-harm scars
after initially refusing to allow nurse to examine injuries. The patient had three self-harm
marks: one bite mark just above the left wrist, one bite mark that penetrated the flesh on the
wrist, and a superficial scar on the left lower arm. Patient rejected all medical attention and
did not allow nurse to take vital signs. It was disclosed by the patient to the nurse that the
approaching anniversary of her grandfather's passing would make it a difficult month. On-
call physician ordered personal restraint, lock seclusion, unlock seclusion, freeze, FOH, and
eyeball. Mom and UM were informed at 630 p.m. At the table, the patient was playing cards
and finishing his dinner with the staff. There are no more issues to report. Guardian was
notified at 6:30pm on 10/14/23 Incident Report 2 for DOB:
Incident Report date/time: 10/14/23 7:30pm Location of Incident: Mabee House Incident
Description: Self-Injury(Not Suicidal) Staff Involved: Kelton Johnson, Khari Williams, Don
Rose Events Leading: Patient refusing to follow staff instructions including refusing
medications at medication pass. Patient being loud and disruptive. Patient agreed to go to
time out area to calm down. Nursing Assessment 1 date/time: 10/14/23 8:25pm: Patient
found in time out room being loud and repeating things about Satan. Patient shows no
signs of physical distress but refuses to answer any questions at all. Will continue to
monitor. Nursing Assessment 2 date/time: 10/15/23 12:40am: Patient received orders for
transfer to acute facility. Patient lying in the floor of the time out room on a mattress.
MEMS present and woke patient up for transport. Patient calm and cooperative and got on
the MEMS stretcher/transport device. Guardian was notified on 10/15/23 at 12:35am
Interim Action Narrative: Resident was placed in a restraint for safety, assessed by the
nurse, and transported to acute care by MEMS.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire about nursing notes. Licensing Specialist
informed that resident was still in acute care and a discharge date has not been decided.
10/24/2023, Licensing Specialist contacted the facility to see if resident has returned to the
facility. Licensing Specialist informed that resident returned to the facility on 10/23/2023.


summary: A resident was sent to urgent care after hitting her arm against a wall.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/14/2023
Date Received by DCCECE: 10/16/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report for DOB: 6 DHS placement
client from Clark County in our PRTF program and resides in Mabee House Incident
Report date/time: 10/14/2023 8:32am Incident Description: Medical Emergency(Trip to
ER/Urgent Care), Patient Injury Staff Involved: Don Rose, Gregory Nesdahl Events
Leading: Patient reported to nurse that two days ago she hit her arm against the wall and
bruised it. Patient was assessed initially yesterday and today it showed continued discomfort
and discoloration, orders received to be evaluated at urgent care. Awaiting staff transport.
Nursing Assessment 1 date/time: 10/14/23 9:10am: Patient presents in hallway and calm
and cooperative with nurse. Pt right medial aspect of hand noted to show signs of
discoloration and bruising. Pt reports difficulty and pain on movement of hand. Cap refill
less than 2 seconds. Orders received for urgent care evaluation. Nursing Assessment 2
date/time: 10/14/23 1:00pm: Patient return to Mabee house from ortho Arkansas. Nurse
examine patient upon return edema with bruising and discoloration noted to right wrist..
Patient complained about pain when moving the 4th and 5th digits. Patient refused
naproxen at that time. Ortho Arkansas had the following results: Per Amanda APRN at
ortharkansas patient right wrist is not fractured. Per Amanda patient have some swelling
noted to Ulnar side of right wrist. Recommendation include Tylenol, ibuprofen, and wrist
brace if one is available. ON call MD notified of ortho Arkansas recommendations patient
can not take Ibuprofen due to lithium interaction and patient have an allergy to Tylenol.
Patient may have naproxen 550mg twice a day as need. Patient have a follow up
appointment scheduled. Patient Caseworker notified of recommendations. Guardian was
notified on 10/14/23 at 10:48am
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative: Resident was assessed by the nurse and orders received for further
evaluation at urgent care.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. 10/17/2023, Licensing Specialist will follow-up with facility on scheduled follow-
up appointment. Licensing Specialist informed that resident has a scheduled appointment
at 2:20pm. 10/18/2023, Licensing Specialist informed there was no fracture but resident was
placed in a cast for two weeks due to bruising and swelling. Resident has a follow-up
appointment scheduled for 10/8/2023 at 3:40pm.


summary: A resident was sent to Arkansas Children’s Hospital for assessment due to a high blood sugar level.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/11/2023
Date Received by DCCECE: 10/12/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report for DOB: DHS
placement client from Pulaski County in our PRTF program and resides in Rose House
Incident Report date/time: 10/11/2023 7:00pm Location of Incident: Rose House Incident
Description: Medical Emergency (Trip to ER/Urgent Care) Staff Involved: Micah Craig,
Chastity Robinson, Brayjana Pettigrew, Meredith Reddin Events Leading: Client's blood
sugar was checked by the nurse. Client blood sugar was 540. Nurse informed the staff that
the client would need to be seen at the ER. Client was transported to the ER. 1st Nursing
Assessment date/time: 10/11/23 7:11pm: Pt taken to ACH ER d/t high BG levels. Pt was at
ACH OBGYN appt during snack BG check. When pt returned around 1630, this nurse did
dinner Accucheck. Pt told nurse she had eaten 'two rice krispies, original size' and 'two
packets of cheese peanut butter crackers'. Carb count was estimated at 86 carbs. Pt's BG
was 441. Pt was given 14 units Novolog (6 units per s/s 6 units per carb count, 2 units for
additional BG correction). Pt was told to wait to eat dinner until BG could be rechecked. Pt
refused and began to curse at this nurse and threaten to 'fuck things up'. Pt then grabbed
dinner and began eating it. BG rechecked a half hour after dinner was eaten. Pt told nurse
that she was feeling 'dizzy' and 'not well'. BG was 540. Ketones trace. Pt told nurse 'I need
to go to children's. If I don't go to Childrens I will fuck something up'. Nurse discussed w/
on call doctor. D/t pt's increasing BG and presenting symptoms the order was given for pt
to go to ACH ER. Pt apologized to nurse for curses/threats, told nurse 'I was afraid, and I
haven't had a good day today'. Reminded pt that threats were not the appropriate way to
have needs met and that we are here for pt's care and wellbeing. Pt receptive to information.
Staff escorted pt to ACH ER. 2nd Nursing Assessment date/time: 10/12/23 3:55am: This
writer was notified that client had returned from ER visit at approximately 0257. Upon my
arrival to the unit, client is awake and alert x3 to name, place, and time. Client is lying
quietly in bed. Client gives a thumbs up when asked about how she is feeling at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

No s/s of distress noted at this time. Attending LPN has recorded v/s and bs level upon
return. LPN also notified on-call physician and treatment team via phone call and text. will
follow physicians orders for continued plan of care. Guardian as notified on 10/11/23 at
7:15pm and 8:50pm.
Interim Action Narrative: Resident was assessed and monitored by the nurse. Resident was
sent to ACH ER for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Documentation was provided for the provider reported incident. Licensing
Specialist will inquire about discharge paperwork.


summary: A resident was sent to Arkansas Children’s Hospital for evaluation after twisting her ankle.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/8/2023
Date Received by DCCECE: 10/9/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report for DOB: Private placement
client in our PRTF program and resides in Rose House. Incident Report date/time:
10/08/2023 6:25pm Location of Incident: Rose House Incident Description: Medical
Emergency(Trip to ER/Urgent Care), Patient Injury Staff Involved: Gregory Nesdahl,
Amanda Skinner Events Leading: Patient was returning to house from outside activity and
twisted her right ankle. Orders received to transport to ACH for evaluation. Nursing
Assessment date/time: 10/08/2023 6:25pm: Patient presents outside entry door of Rose
house laying on concrete pad in pain. Pt reports she twisted her right ankle coming back to
house. Nurse assessed right ankle and cap refill at all digits purple bruising. Pt unable to to
stand and bear weight or perform active or passive range of motion. Pt noted to have
swelling beginning to from on right ankle. Pt noted grimacing often and pain level 10/10.
Orders received to transport to ACH for evaluation. Guardian was notified on 10/08/2023 at
7:15pm ER Discharge Paperwork was emailed to Kendra Rice on 10/09/2023.
Interim Action Narrative: Resident was assessed by the nursed and transported to ACH for
further evaluation.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist reviewed provided documentation for provider reported
incident.


summary: A resident was sent to urgent care for assessment after she injured her hand by punching a wall.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/8/2023
Date Received by DCCECE: 10/9/2023
Facility Name: Youth Home, Inc.
Facility Number: 128
Incident Type: Licensing
Report Description: Incident Report for DOB: Private
placement client in our PRTF program and resides in Rose House Incident Report
date/time: 10/08/2023 9:25am Incident Location: Rose House Incident Description:
Medical Emergency(Trip to ER/Urgent Care), Patient Injury Staff Involved: Gregory
Nesdahl, Matthew Chrysler, Michael Vasilj Events Leading: This nurse was reported to that
patient had punched the wall while she was agitated las night on 10/7/23. This nurse
assessed her right hand and noted swelling and purple discoloration at #5 proximal aspect
of digit, complaint of pain throughout digit. some abrasions noted on prone aspect of right
hand. Cap refill less than 2 seconds at distal #5 digit and proximal area of digit 5. Some
swelling of digit #5 noted. Patient is able to perform full range of motion to every finger
except digit #5 on right hand. Orders received to have her evaluated at urgent care. Nursing
Assessment date/time: 10/08/23 9:30am: This nurse was reported to that patient had
punched the wall while she was agitated last night on 10/7/23. This nurse assessed her right
hand and noted swelling and purple discoloration at #5 proximal aspect of digit, complaint
of pain throughout digit. some abrasions noted on prone aspect of right hand. Cap refill less
than 2 seconds at distal #5 digit and proximal area of digit 5. Some swelling of digit #5
noted. Patient is able to perform full range of motion to every finger except digit #5 on right
hand. Orders received to have her evaluated at urgent care. Guardian was notified on
10/08/2023 at 12:46pm. Nursing note from 10/07/23 and Urgent Care discharge paperwork
were emailed to Kendra Rice on 10/09/2023.
Interim Action Narrative: Resident was assessed by the nurse and referred to urgent care for
an evaluation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist reviewed and uploaded documentation provided via email.