summary: Multiple deficiencies were cited during the Inspection of Care review conducted on 10/17/2023. A Corrective Action Plan was submitted and approved.

raw_content:
October 23, 2023
REVISED: November 30, 2023
Woodridge Of Forrest City, Llc
603 Kittel Rd
Forrest City, AR 72335-7728
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
Woodridge Of Forrest City, Llc
Provider Medicaid ID:
Onsite Inspection Date: October 17, 2023
Onsite Inspection Time: 11:25 AM
A summary of the inspection and any deficiencies noted are outlined below.
The provider must submit a Corrective Action Plan (CAP) designed to correct any deficiency noted in the
written report of the IOC. Accordingly, you must complete and submit to AFMC a Corrective Action Plan for
each deficiency noted. The Corrective Action Plan must state with specificity the:
(a) Corrective action to be taken.
(b) Person(s) responsible for implementing and maintaining the corrective action; and
(c) Completion date or anticipated completion date for each corrective action.
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report. Please
follow the link provided in the email notice to submit either a Reconsideration or CAP for the inspection, all via
AccessPoint.
The contractor (AFMC) will:
(a) Review the Corrective Action Plan.
(b) Determine whether the Corrective Action Plan is sufficient to credibly assure future compliance; and
(c) Provide the Corrective Action Plan to the Division of Provider Services and Quality Assurance (DPSQA).
Please see § 160 of the Medicaid Manual for an explanation of your rights to administrative reconsideration and
appeal. Additionally, the imposition of this Corrective Action Plan does not prevent the Department of Human
Services from prescribing additional remedial actions as may be necessary.

Inspection of Care Summary
Facility Tour:
Upon arrival to facility, AFMC staff was promptly greeted at the entrance by a Woodridge of Forrest City, LLC
staff member where a COVID-19 screening was conducted and AFMC staff were issued paper masks to wear.
AFMC was immediately taken to a conference room where they were met by the Chief Executive Officer.
A tour of the facility was completed with the Program Director. The facility environment was clean, well-
organized, and in good repair. Staff were able to answer all questions regarding the facility. The following is a
list of environmental observations per unit that was noted by AFMC staff during the facility tour:
• Masks are currently required to be worn by all staff in the facility due to the rise in COVID
cases. AFMC staff noted that about half of the staff weren’t wearing a mask or were wearing
mask so that it didn’t appropriately cover their nose and mouth.
• Four client units were toured. Each unit was being cleaned or had been recently cleaned by
housekeeping. AFMC staff noted each unit smelled so strongly of bleach that it was burning
their eyes and nose.
• A group of 12 clients were noted outside playing basketball as a recreational activity. One staff
member was noted on their phone while supervising the clients.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, the following deficiencies were
noted:
Regulation Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: The facility does not have a program in Safety Intervention policy provided does not
221.804; 42 CFR place offering training on the facility's identify the frequency and delivery of the
482.130, 483.376 Restraint and Seclusion policy, and/or training on the facility's Restraint and
training on the appropriate procedures to Seclusion. This policy was updated September
be used in Restraint and Seclusion. 01, 2023.
The policy states, "All direct care staff are
trained in SAMA and will follow the
procedures outlined in their manual and
training. Staff who is not currently certified
shall not be allowed to participate in the
restraint procedures."
Personnel Records – Licenses, Certifications, Training:
There was a total of 18 personnel records reviewed, seven (27%) professional and 11 (25%) paraprofessional.
During the review of the personnel records, there were no deficiencies noted.
Observations:
AFMC staff reviewed the final document request form with the Chief Executive Officer and the Program Director
at the completion of the on-site Inspection of Care and the provider signed the acknowledgement of manual
requirements that were not made available in the provider’s policy and procedures.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
Woodridge Of Forrest City, Llc – Forrest City, AR – IOC Report 2 | P ag e

No active FFS Medicaid clients were currently admitted at the time of IOC. Therefore, no client interviews were
conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in group activities and in the classroom setting. Staff
were calmly interacting with clients and providing a therapeutic environment that was conducive for learning
and treatment therapies. Clients were noted to be engaged in the classroom setting. Staff to client ratio was
adequate and followed the facility’s staffing ratio requirements policy.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being complaint with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies.
Facility nurse was able to verbalize the step-by-step process of medication delivery including the demonstration
of the five rights of medication administration, documentation of medication delivery, verification of client
taking medication including mouth/cheek checks, and how clients are educated about each medication. Facility
nurse also verbalized the process utilized when a client refuses medications. Tour of medication room completed
no discrepancies with medication storage, cleanliness of medication room, and knowledge of medication
dispensing found.
Clinical Record Review Deficiencies:
No active FFS Medicaid clients were currently admitted at the time of IOC. Therefore, no clinical records
reviewed.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge Of Forrest City, Llc – Forrest City, AR – IOC Report 3 | P ag e

October 23, 2023
Woodridge Of Forrest City, Llc
603 Kittel Rd
Forrest City, AR 72335-7728
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
Woodridge Of Forrest City, Llc
Provider Medicaid ID:
Onsite Inspection Date: October 17, 2023
Onsite Inspection Time: 11:25 AM
A summary of the inspection and any deficiencies noted are outlined below.
The provider must submit a Corrective Action Plan (CAP) designed to correct any deficiency noted in the
written report of the IOC. Accordingly, you must complete and submit to AFMC a Corrective Action Plan for
each deficiency noted. The Corrective Action Plan must state with specificity the:
(a) Corrective action to be taken.
(b) Person(s) responsible for implementing and maintaining the corrective action; and
(c) Completion date or anticipated completion date for each corrective action.
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report. Please
follow the link provided in the email notice to submit either a Reconsideration or CAP for the inspection, all via
AccessPoint.
The contractor (AFMC) will:
(a) Review the Corrective Action Plan.
(b) Determine whether the Corrective Action Plan is sufficient to credibly assure future compliance; and
(c) Provide the Corrective Action Plan to the Division of Provider Services and Quality Assurance (DPSQA).
Please see § 160 of the Medicaid Manual for an explanation of your rights to administrative reconsideration and
appeal. Additionally, the imposition of this Corrective Action Plan does not prevent the Department of Human
Services from prescribing additional remedial actions as may be necessary.

Inspection of Care Summary
Facility Tour:
Upon arrival to facility, AFMC staff was promptly greeted at the entrance by a Woodridge of Forrest City, LLC
staff member where a COVID-19 screening was conducted and AFMC staff were issued paper masks to wear.
AFMC was immediately taken to a conference room where they were met by the Chief Executive Officer.
A tour of the facility was completed with the Program Director. The facility environment was clean, well-
organized, and in good repair. Staff were able to answer all questions regarding the facility. The following is a
list of environmental observations per unit that was noted by AFMC staff during the facility tour:
• Masks are currently required to be worn by all staff in the facility due to the rise in COVID
cases. AFMC staff noted that about half of the staff weren’t wearing a mask or were wearing
mask so that it didn’t appropriately cover their nose and mouth.
• Four client units were toured. Each unit was being cleaned or had been recently cleaned by
housekeeping. AFMC staff noted each unit smelled so strongly of bleach that it was burning
their eyes and nose.
• A group of 12 clients were noted outside playing basketball as a recreational activity. One staff
member was noted on their phone while supervising the clients.
Facility Review – Policies and Procedures:
Upon review of the site’s policies, procedures, and certification requirements, the following deficiencies were
noted:
Regulation Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: The facility does not have a program in Safety Intervention policy provided does not
221.804; 42 CFR place offering training on the facility's identify the frequency and delivery of the
482.130, 483.376 Restraint and Seclusion policy, and/or training on the facility's Restraint and
training on the appropriate procedures to Seclusion. This policy was updated September
be used in Restraint and Seclusion. 01, 2023.
The policy states, "All direct care staff are
trained in SAMA and will follow the
procedures outlined in their manual and
training. Staff who is not currently certified
shall not be allowed to participate in the
restraint procedures."
Medicaid IP Sec. 2: There is no documentation that all direct The provider lacked evidence that all direct
215.220, 218.000 42 care personnel hold current licenses, as care personnel hold current licenses, as
CFR: 441.156 required by their position and profession required by their position and profession and/or
and/or licensing authority. licensing authority.
Personnel Records – Licenses, Certifications, Training:
There was a total of 18 personnel records reviewed, seven (27%) professional and 11 (25%) paraprofessional.
During the review of the personnel records, the following deficiencies were noted:
Rule Found Credential Validated Personnel Record Reviewer Notes
Deficient Number
214.100B Federal Background SR015210 The provider lacked evidence of a federal
Check-IP Acute background check from the Arkansas
Department of Public Safety.
215.220, Professional License SR015213 No file received
218.000 or Certificate - IP SR015215
Acute
Woodridge Of Forrest City, Llc – Forrest City, AR – IOC Report 2 | P ag e

Observations:
AFMC staff reviewed the final document request form with the Chief Executive Officer and the Program Director
at the completion of the on-site Inspection of Care and the provider signed the acknowledgement of manual
requirements that were not made available in the provider’s policy and procedures.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
No active FFS Medicaid clients were currently admitted at the time of IOC. Therefore, no client interviews were
conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in group activities and in the classroom setting. Staff
were calmly interacting with clients and providing a therapeutic environment that was conducive for learning
and treatment therapies. Clients were noted to be engaged in the classroom setting. Staff to client ratio was
adequate and followed the facility’s staffing ratio requirements policy.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was onsite.
Due to the observation of non-Medicaid clients not being complaint with the HIPAA minimal necessary rule, no
medication pass was observed. AFMC RN visited with the facility medication nurse who was able to show
AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies.
Facility nurse was able to verbalize the step-by-step process of medication delivery including the demonstration
of the five rights of medication administration, documentation of medication delivery, verification of client
taking medication including mouth/cheek checks, and how clients are educated about each medication. Facility
nurse also verbalized the process utilized when a client refuses medications. Tour of medication room completed
no discrepancies with medication storage, cleanliness of medication room, and knowledge of medication
dispensing found.
Clinical Record Review Deficiencies:
No active FFS Medicaid clients were currently admitted at the time of IOC. Therefore, no clinical records
reviewed.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Woodridge Of Forrest City, Llc – Forrest City, AR – IOC Report 3 | P ag e

Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge Of Forrest City, Llc – Forrest City, AR – IOC Report 4 | P ag e

doc_type: IOC Report


state: AR

facility_name: Perimeter Behavioral of Forrest City

summary: Licensing visited the facility to perform a buildings and grounds walkthrough and to review children’s records and personnel files. No deficiencies cited.

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

Perimeter Behavioral of Forrest City Kendra Rice
603 KITTLE ROAD Donaghey Plaza
FORREST CITY AR 72335 P.O. Box 1437

Little Rock, AR. 72203
Facility Visit Compliance Notice

Facility#: 142

Date of Visit: 10/17/2023

Visit Type(s): Subsequent Building and Grounds
Time: 10:30 AM - 1:51 PM

Visit Comment :
Time of visit: 10:30 am to 12:45 pm

Census: 55

Licensing Specialist completed buildings and grounds. The following areas were observed: grounds, dining
room, administration building, nurse’s station, bedrooms, bathrooms, parking lot, and courtyard.

Licensing Specialist was escorted by Mr. | | a. Program Director. A fire inspection was being
completed during the buildings and grounds walkthrough. Licensing Specialist participated in a fire drill due
to a test being conducted.

Walking to the building, Licensing Specialist observed parked cars on the parking lot, some flower bushes
near the building, nicely cut grass in front of the parking lot, and two flowerpots on each side of the
entrance/exit doors. In the lobby area, Licensing Specialist noticed new furniture. Mr. |) informed
Licensing Specialist that the floors on the stations have been stripped and waxed. The only floors left to be
stripped and waxed are the dayrooms on the stations.

Page 1 of 2

Mr. | informed Licensing Specialist the water fountains on the stations have been removed and the
residents utilize water coolers/dispensers for drinking water. The shower areas in the bathroom have bathroom
mats and the residents have been provided with shower shoes.

On the SRU Hall, Licensing Specialist observed bedrooms and the bathroom. Some bedrooms had three (3)
residents to a room and one (1) resident to a room. Licensing Specialist observed Halloween decorations on
the hallways leading to the station. Licensing Specialist noticed the four-square lines have been repainted on
the courtyard.

Licensing Specialist observed the classrooms on the educational hall. Classroom 1, ratio 2:11; Classroom 2,
3:14; Classroom 3, 3:13; and Classroom 4, 3:13. Licensing Specialist observed staff and residents being
escorted to different areas (bathroom and nurse's station).

Licensing Specialist reviewed the MAR’s on the residents listed below:

All initialed and up to date.

Licensing Specialist received a copy of the fire inspection.

CCL Staff Signature : Date: 10/17/2023
mol rR

| / J if

Provider Signature : Date: 10/17/2023

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

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

Page 2 of 2

Perimeter Behavioral of Forrest City
603 KITTLE ROAD
FORREST CITY AR 72335

ARKANSAS
DEPARTMENT OF

Ay) <7 HUMAN
= °.f SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Kendra Rice
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 142

Date of Visit: 10/17/2023

Visit Type(s): Child Record Review Visit
Time: 12:45 AM - 1:53 PM

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

Census: 55

Licensing Specialist reviewed four (4) children files:

All children’s files reviewed complied with the minimum licensing standards.

Page 1 of 2

CCL Staff Signature : Date: 10/17/2023

Provider Signature : Date: 10/17/2023

i) 4
|

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

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

Page 2 of 2

Perimeter Behavioral of Forrest City
603 KITTLE ROAD
FORREST CITY AR 72335

ARKANSAS

I rey FET OF

WARS) <>; HUMAN
all »-¢ services

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

Kendra Rice
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 142

Date of Visit: 10/17/2023

Visit Type(s): Personnel Records
Time: 1:15 PM - 1:55 PM

Visit Comment :
Time of Visit: 1:15 pm to 1:30 pm

Census: 55

Licensing Specialists reviewed three (3) personnel files:

i ER (9/11/2023) Mental Health Technician
| | (10/9/2023) Mental Health Technician
i «(9/1 1/2023) Mental Health Technician

Personnel files reviewed complied with the minimum licensing standards.

Licensing Specialist received documentation of staff member [jj I suspension.

Page 1 of 2

CCL Staff Signature : Date: 10/17/2023

hy N
Illa |.
mallihie) A)
WVAKY

Provider Signature : Date: 10/17/2023

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

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

Page 2 of 2

doc_type: Compliance Report


summary: Officers were dispatched to the facility in response to a report that a resident was attacking staff members.

raw_content:
CFS - Command Log Printed on November 1, 2023
hw NOV ET LEV CO

CFS # CFS2343855
Call Taker TALECIA CHAMBER
Location 603 KITTLE RD

Location Details
Primary Incident Code ASSAULT : Assault/Battery

Mod Emergency Fire/Medical

Priority 1

Use Caution No

Primary Disposition Handled By Officer / Deputy

Beat

Zone Forrest City Police Department

Call Time 10/12/23 21:08:21

Completed Time 10/12/23 21:41:04
Reporters

KIMBERLY MCCOY (Initial Reporter)

Sex

DOB

Address

Report Time = 10/12/23 21:08:21
How Reported

From Phone

Contact Phone (870) 530-5907
Comments

Other Names

Vehicles

Responders
540 540 - THOMAS, MICHAEL —_FCPD (Primary)
543 (Primary) 543 - MITLEFF, DALTON FCPD (Primary)
545 545 - ALBERT, TANESHA — FCPD (Primary)

Response Times

Assigned 10/12/23 21:15:37
Enroute 10/12/23 21:15:46
Arrived 10/12/23 21:18:26
Leaving

Arrived At

Completed 10/12/23 21:41:04

_IR/ External Agency Numbers
FCPD202310922

Officer Addenda

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown
10/12/23 21:08:21 | CHAMBER, TALECIA | New CFS
oo eSeSeSeSSSSSSSSSSSSSSSSSSSSeSee
Page 1 of 2

10/12/23 21:10:46 | CHAMBER, TALECIA | CALLER ADVISE MALE RESIDENT ATTACKING STAFF MEMBERS
10/12/23 21:13:45 | CHAMBER, TALECIA | THE STAFF THEN ADVISE TO HOLD OFF ON SENDING AN OFFICER
THEY HAD TO NOTIFY SOMEONE ELSE BEFORE CALLING THE POLICE

10/12/23 21:15:33 | CHAMBER, TALECIA | MOMENTS LATER THEY CALLED BACK NEEDING AN OFFICER EN
ROUTE

10/12/23 21:15:37 | CHAMBER, TALECIA | 543 | Assign

10/12/23 21:15:46 | CHAMBER, TALECIA | 543, 545 | Enroute

10/12/23 21:18:26 | CHAMBER, TALECIA | 540, 543, 545 | On Scene

10/12/23 21:23:39 | CHAMBER, TALECIA | 540 | Clear Alarms

10/12/23 21:23:43 | CHAMBER, TALECIA | 543 | Clear Alarms

10/12/23 21:23:46 | CHAMBER, TALECIA | 545 | Clear Alarms

10/12/23 21:41:04 | CHAMBER, TALECIA | 540, 543, 545 | Complete

10/12/23 22:41:00 | CHAMBER, TALECIA | EVENT#: 2310120018

10/12/23 22:41:04 | CHAMBER, TALECIA | Complete

CLQ

Requested At
Sent To

Status
Received At
Location (
Accuracy

eee

Page 2 of 2

CES - Unit Response Times Printed on November 1, 2023
—_— te 0 November 1, 2023

CFS # CFS2343855
Call Taker TALECIA CHAMBER
Location 603 KITTLE RD

Location Details
Primary Incident Code ASSAULT : Assault/Battery

Mod Emergency Fire/Medical
Priority 1
Use Caution No
Primary Disposition Handled By Officer / Deputy
Beat
Zone Forrest City Police Department
Call Time 10/12/23 21:08:21
Completed Time 10/12/23 21:41:04
Reporters |
KIMBERLY MCCOY (Initial Reporter)
Sex
DOB
Address
Report Time 10/12/23 21:08:21
How Reported
From Phone
Contact Phone (870) 530-5907
Comments

Other Names

Vehicles

Responders
540 540 - THOMAS, MICHAEL FCPD (Primary)
543 (Primary) 543 - MITLEFF, DALTON FCPD (Primary)
545 545 - ALBERT, TANESHA — FCPD (Primary)

Response Times

Assigned 10/12/23 21:15:37
Enroute = 10/12/23 21:15:46
Arrived 10/12/23 21:18:26
Leaving

Arrived At

Completed 10/12/23 21:41:04

IR / External Agency Numbers
FCPD202310922 —

Officer Addenda

| Unit Response Times

Non Unit Specific Times
90

Page 1 of 2

10/12/23 21:08:21 | New CFS

10/12/23 21:10:46 | CALLER ADVISE MALE RESIDENT ATTACKING STAFF MEMBERS

10/12/23 21:13:45 | THE STAFF THEN ADVISE TO HOLD OFF ON SENDING AN OFFICER, THEY HAD TO NOTIFY
SOMEONE ELSE BEFORE CALLING THE POLICE

10/12/23 21:15:33 | MOMENTS LATER THEY CALLED BACK NEEDING AN OFFICER EN ROUTE

10/12/23 22:41:00 | EVENT#: 2310120018

10/12/23 22:41:04 | Complete

540
10/12/23 21:23:39 | Clear Alarms

540, 543, 545

10/12/23 21:18:26 | On Scene

10/12/23 21:41:04 | Complete

543
10/12/23 21:15:37 | Assign —

10/12/23 21:23:43 | Clear Alarms

543, 545
10/12/23 21:15:46 | Enroute

545

10/12/23 21:23:46 | Clear Alarms

eee

Page 2 of 2

FORREST CITY
POLICE DEPARTMENT Detail Page

225 N. ROSSER ST

Address

City FO

CAD EVENT

Call

Description

Disposition

A

Comments

Unit ID Unit Stat

FORREST CITY, AR.

Type 56

is Status Time

Location KITTLE RD
RREST CITY

CAD Event

Event # Print Date
2310120018 01/05/2024

County ST FRA State AR

CALL ACTIVE

REPORTING PARTY INFORMATION

CALL DETAILS
PATROL ACTIVITIES

Comment / Location Officer #1/2 Vehicle!D Dispatch ID

560 D 10/12/2023 22:27:45 461
KITTLE RD
560 A 10/12/2023 22:27:51 461
KITTLE RD
Printed By/On: 412 / 01/05/2024 11:27:03

CrimeStar® Computer Aided Di:

ich System

Licensed to: FORREST CITY AR|POLICE DEPARTMENT

FORREST GITY rx 14 Incident
POLICE DEPARTMENT

Incident #

2310120018
Type Seq

Atternpt
10/12/2023 | 22:27

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

Crime / Incident (Prima
5-13-203 BATTERY

Rpt Dist
1

1

, Secondary, Tertiary)
BRD DEGREE

Ou

1012/2023 |__|
CL] 10/12/2023 T

Day
Thu
Thu

hu

Location of Incident 1521 ALBERT, FORREST CITY, AR

LE RD

Cross Street K/

"RP" = Reporting Party “W" = Witness "S$" = Suspect “O" = Other
Last, First, Middle [Firm if Business) [sex T Age THT [wr | Hair | Eyes _| Home Phone

City, State, Zip Code SSN Local ID # State # FBI # Cell Phone
FORREST CITY CITY AR 72335 Pe
Last, First, Middie|(Firm if Business) Race Sex Age HT WT Hair Eyes Home Phone
16 (870)
Address DOB DL Number State | Work Phone
a AR | (870)
City, State, Zip Code SSN Local ID # State # FBI# Cell Phone
FORREST CITY AR 72335 0
Address DOB DL Number Work Phone
City, State, Zip Code SSN Local ID # FBI # Cell Phone

Synopsis

Address

5

bes)

5

Continuation PropertyList
Attached L | attached  [_]| ProvertyDamage$ $0.00
Press Domestic Violence
Gang Related N Victim Senior Citizen |
Force Used [| Child Abuse [__]
Solvabili : sal
Report Complete/Ready for Review CADICFS Event # 2310120018

Assigned To Date

oO Reviewed By Approved Date
ficerID ALBERY, TANESHA 560 Lt. Michael Thomas 10/13/2023

<H-r-w><r OH

222222222222

Printed By/On: 412 / 01/01/2024 09;05:;39
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page 2 Incident cont'd
POLICE DEPARTMENT Narrative

Crime / Incident (Primary Attempt | Type Seq
5-13-203 BATTERY 3RD DEGREE C 1

On October 12), 2023, Officer Albert was dispatched to 1521 Albert Street (a
behavioral Facility) in reference to one of the residents assaulting a staff
member. Upon jarrival I made contact with the 16-year-old child
who advised that he was advised that he had to be moved to another hallway and
he wasn't moving as fast as the staff member wanted so the staff member
started to throw his things and he got upset. He advised that the

grabbed him, and he defended himself. He says he complied with all of
his staff's drders and the staff was aggressive with him.

I also made contact with the staff member who was assaulted (xD
who advised He told 16-year-old that he had to move to another hall
when he brushed them off by moving slowly. He says he walked into other
residents' rdom waking them up shaking their hands and moving at his own pace.
He says he wasn't compliant and became aggressive and he attempted to put

in a restraint, and he assaulted him.

HS had red marks on his nose and a scratch on his throat area on the left

side. eS b=: a red mark on his nose, a scratch on the left side of his
head and multiple scratches on the left side of his neck. The facility was

advised of the affidavit process.

Reviewed By Approved Date
Officer 1D ALBERT, TANESHA Lt. Michael Thomas 10/13/2023
Printed By/On: 412 / 01/01/2024 09:05:39

CrimeStar® Law Enforcement Records Management System
Licensed to; FORREST CITY AR POLICE DEPARTMENT

|

WM

doc_type: Police Report


summary: A resident was sent to Forrest City Medical Center for evaluation after a desk fell on his foot.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Texas Date/Time of incident: 10/11/23/09:15
Please give a description of the incident: In the classroom a desk fell on resident?s right foot
causing injury. Corrective Actions Taken: Resident was assessed and checked by nurse who
pain and swelling of the foot Nurse consulted with APRN who advised that resident be sent
to the Forrest City Medical Center for evaluation. After the medical exam there were that
resident had on X-Ray resident sent back to the
facility for continuance of care. Additional Information: None currently. Guardian Notified:
Kymberlie Malatek, CPS Worker
Interim Action Narrative: Resident was assessed by the nurse and referred to FCMC for an
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was sent to Forrest City Medical Center for evaluation after receiving a laceration to the eye while playing with a peer.

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: 10/10/2023
Date Received by DCCECE: 10/11/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/10/23-14:00
Please give a description of the incident: Resident received laceration to the eye during an
accident that took place while playing with a peer during recreation time. Corrective Actions
Taken: Resident was assessed and checked by nurse who observed the skin above the eye
broken that injury had taken place. Nurse consulted with APRN who advised that be
sent to the Forrest City Medical Center for evaluation. After the medical exam there were no
other . Resident sent back to the
facility for continuance of care. Additional Information: None currently. Guardian Notified:
Tessa Mann, DHS Caseworker
Interim Action Narrative: Resident was assessed by the nurse and referred to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of redness and swelling to his hand.

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: 10/6/2023
Date Received by DCCECE: 10/9/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Ohio Date/Time of incident: 10/6/23/14:00 Please
give a description of the incident: Resident came to Nurse station with redness and swelling
to his right hand and did not disclose origin on injury he just said his hand hurt. Corrective
Actions Taken: Resident was assessed and checked by nurse. The nurse consulted with
APRN who recommended that resident be sent to Forrest City Medical Center for
assessment and X-Ray. Results of X-Ray and assessment are not findings or significant
injury sent back to the facility for continuance of care. Additional Information: Guardian
Notified: Mother
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
10/10/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after hitting a wall while angry.

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: 10/6/2023
Date Received by DCCECE: 10/9/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Texas Date/Time of incident:
10/6/23/16:05 Please give a description of the incident: Resident came to Nurse station
after hitting the wall with his right hand when angry and in conflict with another peer.
Corrective Actions Taken: Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that resident be sent to Forrest City Medical
Center for assessment and X-Ray. Results of X-Ray and
Additional Information: Guardian Notified: Daniela Hernandez CPS
Worker
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
10/10/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaints of pain and swelling to the knee.

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: 10/4/2023
Date Received by DCCECE: 10/5/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Florida Date/Time of incident: 10/4/23/09:20
Please give a description of the incident: Resident came to Nurse station with complaints of
left knee swelling and pain. The origin of the injury was not specified by resident. Corrective
Actions Taken: Resident was assessed and checked by nurse. The nurse consulted with
APRN who recommended that resident be sent to Forrest City Medical Center for
assessment and X-Ray. Results of X-Ray and assessment are left leg swelling, no acute
findings or dislocation, mild prepatellar tissue swelling. Sent back to facility for continuance
of care. Additional Information: Guardian Notified: Mother
Interim Action Narrative: Resident was assessed by the nurse and sent to FCMC for an
assessment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after hitting a wall while angry.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/3/2023
Date Received by DCCECE: 10/4/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/3/23-
16:14 Please give a description of the incident: Resident reported pain in his right hand after
hitting the wall because he was angry. Corrective Actions Taken: Resident was assessed and
checked by nurse. The nurse consulted with APRN who recommended that resident be sent
to Forrest City Medical Center for further medical assessment and X-Ray. Findings were:
. Additional Information: None currently. Guardian
Notified: Father Guardian
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after injuring his thumb while playing outside.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/3/2023
Date Received by DCCECE: 10/4/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/3/23-13:05
Please give a description of the incident: Resident injured his left thumb when they were
outside playing during recreation time with another resident. Pain and swelling was noted
by Nurse when resident was brought to the nursing station after injury. Corrective Actions
Taken: Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that resident be sent to Forrest City Medical Center for further medical
assessment and X-Ray. Findings were:
. Referred out to see Dr.
Busby for ortho. Appt on 10-4-23 @ 13:30 and sent back to the facility for continuance of
care. Additional Information: None currently. Guardian Notified: LaShama Lee DHS
Worker
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
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 will follow-up with facility on resident's appointment with
Ortho. 10/9/2023, Licensing Specialist followed-up with the facility on resident's follow-up
appointment.


summary: A resident was sent to Forrest City Medical Center for assessment after injuring his great toe while outside playing.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/3/2023
Date Received by DCCECE: 10/4/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/3/23-14:30
Please give a description of the incident: Resident reported pain in his great right toe after
injuring it while outside playing during recreation time. Corrective Actions Taken: Resident
was assessed and checked by nurse. The nurse consulted with APRN who recommended
that resident be sent to Forrest City Medical Center for further medical assessment and X-
Ray. Findings: ; no acute findings or injury Additional
Information: None currently. Guardian Notified: Mother Guardian
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after injuring his back while horseplaying with a peer.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/3/2023
Date Received by DCCECE: 10/4/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/3/23-13:07
Please give a description of the incident: Resident reported pain and injury to back after
horseplaying with another peer outside during recreation time and was taken to the Nurses
Station. Corrective Actions Taken: Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that resident be sent to Forrest City Medical
Center for further medical assessment and X-Ray. Findings were:
. Additional Information: None currently. Guardian
Notified: Guardian
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident of licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after injuring his shoulder while playing dodgeball.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/3/2023
Date Received by DCCECE: 10/4/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/3/23-
16:14 Please give a description of the incident: Resident reported pain and swelling in his
great right shoulder after playing a game of dodgeball. Corrective Actions Taken: Resident
was assessed and checked by nurse. The nurse consulted with APRN who recommended
that resident be sent to Forrest City Medical Center for further medical assessment and X-
Ray. Findings: .
Additional Information: None currently. Guardian Notified: Mother
Guardian
Interim Action Narrative: Resident was assessed by the nurse, referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center after he took a splint off his wrist and threw it away.

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: 10/2/2023
Date Received by DCCECE: 10/3/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 10/2/23-13:27
Please give a description of the incident: Resident took off splint and threw it away.
Corrective Actions Taken: Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that resident be sent to Forrest City Medical
Center for another assessment and Forrest City Medical Center referred resident to Le
Bonheur Hospital for cast reevaluation hard cast to be put on it to reset fracture and
immobilize it so the wrist can heal properly. Resident sent back to the facility outpatient for
continuance of care after procedure was completed. Additional Information: None
currently. Guardian Notified: CPS Worker
Interim Action Narrative: Resident was assessed by nursing, assessed at FCMC, and
referred to LeBonheur Hospital for treatment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
10/4/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment due to dizziness and increased heart rate.

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: 10/2/2023
Date Received by DCCECE: 10/3/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 10/2/23-13:00
Please give a description of the incident: Resident was sent out for chest X-Ray from
previous orders due to dizziness and increased heart rate for follow up. Corrective Actions
Taken: Resident was assessed and checked by nurse. The Resident was sent to Forrest City
Medical Center for follow up Chest X-Ray. The procedure was XR Chest 2 View. Diagnosis
was: . The lungs are clear.
The osseous structures are intact; no acute cardiopulmonary abnormality. Additional
Information: Guardian Notified: Father
Interim Action Narrative: Resident was assessed by nursing and sent to FCMC for follow-up
and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
10/4/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility for a battery report.

raw_content:
FORREST CITY Pse 1 Incident
POLICE DEPARTMENT ay

225 N. ROSSER ST.

2310010001
Criminal Report

FORREST CITY, AR. 72335 RptDst] Type

Crime / Incident (Primary, Secondary, Tertiary)
5-13-203 BATTERY 3RD DEGREE

2

Attempt! Occurred

Time

00

oO
a
<

0/01/2023
0/01/2023
0/01/2023

=
©

=

Location of Incident 1521 ALBERT ST, FORREST CITY, AR

Cross Street 1601 NEWCASTLE
Dispo "V" = Victim "RP" = Reporting Party "W" = Witness “S" = Suspect

Address 0oB ber State Work Phone
1521 ALBERT ST | AR | (870)
City, State, Zip Code Local ID # State # FBI # Cell Phone
FORREST CITY AR 72335 0
Last, First, Middle (Firm if Business) Race Sex Age HT WT Hair Eyes | Home Phone
M || (870) 633-3200
Address DOB DOL Number State | Work Phone
1521 ALBERT ST | AR |0
City, State, Zip Code Local ID # State # FBI # Cell Phone
FORREST CITY AR 72335 0
Last, First, Middle (Firm if Business) Sex Home Phone
Last, First, Middle (Firm if Business) Race ye | WT Le | Home Phone

Continuation PropertyList
Attached L_] | attached _L_]| ProperyDamages $0.00

Domestic beer o

Victim Senior Citizen CL]

| Pursuit [_] | Force Used [—] Child Abuse [|

PF Connecting Case #

CADICFS Event # 2310010001

Assigned To

OfficerID RICE, JAMES 567

County
ST FRA

Other

Home Phone

(870) 633-3200

9°
Ls)

222222222222

Date

Reviewed By Approved Date
Lt. Virginia Edwards 10/01/2023

Printed By/On: 412 / 10/02/2023 08:17:03
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page 2 Incident conta
POLICE DEPARTMENT Narrative ineent# 2310010001
Crime / Incident (Primary) Attempt | Type Seq

On October 1, 2023, at approximately 12:19 A.M., I Officer Rice was dispatched
to Forrest City Medical Center for a Battery 3rd report. Upon arrival I made
contact with Mr. (complaint/victim). 9MJis doing the
report on Mr. (suspect).

Mr. F | explained that he was lying in bed at Woodridge Juvenile facility
when he was attacked by Mr. . Mr. QMexplained that Mr. BEM got out
of his bed and walked over to his bed and hit him in the eye with a closed fist.

Mr. P| was then escorted to Forrest City Medical Center for examination of
his eye because it was swelled closed. Forrest City Medical Center explained
that Mr. 9M has a fractured left lamina papyracea.

Mr. QM explained that there was no past issue other then Mr. P| just
being a bully. Mr. JJ explained that he did try to defend himself but he
couldn't because of Mr. IMJ size advantage.

I Officer Rice made contact with Woodridge facility nurses to make contact with
a Supervisor to get information in regards to someone Signing an affidavit for

Mr. MM. The facility explained that they will make contact with Mr. rs
mother to sign an affidavit to press charges.

Onassis Reviewed By Approved Date
icer RICE, JAMES 567 Lt. Virginia Edwards YES 10/01/2023
Printed By/On: 412 / 10/02/2023 08:17:03
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT


summary: A resident was sent to Forrest City Medical Center for an x-ray after the resident was attacked by a peer.

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: 9/30/2023
Date Received by DCCECE: 10/5/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 9/30/23-20:30
Please give a description of the incident: Resident was attacked(punched) and kneed in the
nose by another resident in the face by another resident and this caused injury to his left eye
where swelling was noted, resident was bleeding from his nose, and pain reported by
resident. Corrective Actions Taken: Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that resident be sent to Forrest City Medical
Center for assessment and X-Ray. Results of X-Ray and assessment are:
Forrest City Medical
Center recommended follow up with APRN within 2-3days, continuance of care and follow
up with ophthalmology in 2 weeks. Prescribed . Additional
Information: Guardian Notified: Mother
Interim Action Narrative: Resident was assessed by the nurse, sent to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist was informed of this provider reported incident
via email and informed no camera footage was available. 10/5/2023, Licensing Specialist
informed facility that provider reported incident was not in ELS. 10/6/2023, Licensing
Specialist reviewed provider reported incident for licensing concerns. Licensing Specialist
will request nursing notes, if residents involved were placed on any precautions, and follow-
up in two weeks on the outcome of resident's appointment with the ophthalmology.
10/16/2023, Licensing Specialist followed-up on requested additional information.
Licensing Specialist informed that resident discharged from the program and his guardian
took over treatment. Peer who attacked resident was placed on unit restrictions and later
discharged from the program for assaulting the resident.


summary: Officers were dispatched to the facility for an assault report.

raw_content:
CFS - Command Log Printed on November 1, 2023
———— eee US

CFS # CFS2341791
Call Taker KATHERINE WILSON
Location 1601 NEWCASTLE RD, FORREST CITY (FORREST CITY MEDICAL CENTER)

Location Details
Primary Incident Code ASREPORT : Assault Report No Weapon

Mod

Priority 4

Use Caution No

Primary Disposition Handled By Officer / Deputy

Beat

Zone Forrest City Police Department

Call Time 09/30/23 22:50:29

Completed Time 09/30/23 23:51:36
Reporters

KATELYN DILLIER (Initial Reporter)

Sex

DOB

Address

Report Time 09/30/23 22:50:29
How Reported Phone

From Phone = (870) 816-6332
Contact Phone

Comments

Other Names
Vehicles

Responders
535 (Primary) 535 - RICE, JAMES FCPD (Primary)

Response Times

Assigned 09/30/23 22:50:55 *
Enroute 09/30/23 22:50:55
Arrived 09/30/23 23:11:08
Leaving

Arrived At

Completed 09/30/23 23:51:36

| IR/ External Agency Numbers
Officer Addenda

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown

09/30/23 22:50:29 | WILSON, KATHERINE | New CFS
09/30/23 22:50:55 | WILSON, KATHERINE | 535 | Enroute
09/30/23 23:11:08 | LANOS, JASMINE | 535 | On Scene
09/30/23 23:51:36 | LANOS, JASMINE | 535 | Complete

Se
Page 1 of 2

10/01/23 00:16:14 | WILSON, KATHERINE | EVENT#2310010001

CLQ

Requested At
Sent To

Status
Received At
Location ;
Accuracy

nee eee
Page 2 of 2


summary: A staff member was overheard cursing residents. The staff member resigned. The facility was cited 905.4.c as a result of this incident.

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: 9/28/2023
Date Received by DCCECE:9/29/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 9/28/23-12:40pm Please give a description of the incident:
Employee was heard cursing out residents in particular Resident in the
dining hall by other employees. Corrective Actions Taken: Program Director met with HR
Director with suspected employee. Employee admitted to cursing at children and resigned
on the spot. Resignation was accepted and former employee will not be eligible for re-hire.
The Program Director made a hotline report immediately after resignation was accepted. It
was not accepted because it did not meet criteria set forth in Child Maltreatment Laws or
Neglect; here is additional information about the report below: Referral Number:
Child: Additional Information: None currently. Guardian Notified: N/A
Interim Action Narrative: Staff member resigned, resignation was accepted, and staff
member is not eligible for re-hire.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
10/2/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about resident's guardianship, staff member's name, and
facility wide meetings on use of foul language with or towards residents. 10/3/2023, facility
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

informed Licensing Specialist professional conduct will be reviewed with all staff within 30
days. 10/5/2023, Licensing Specialist consulted with Program Coordinator. Facility will be
cited for R905.4.c. Licensing Specialist will follow-up with facility in 30 days regarding staff
being informed on professional conduct.


summary: A resident was sent to Forrest City Medical Center for an x-ray after injuring his hand while playing sports.

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: 9/27/2023
Date Received by DCCECE:9/28/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Texas Date/Time of incident: 9/27/23-08:00
Please give a description of the incident: Resident states that he hurt his hand while playing
sports/ physical activity and went to the nursing station because of pain in his left hand.
Swelling was observed in his left hand with range of motion. Corrective Actions Taken:
Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that be sent to Forrest City Medical Center for assessment and X-Ray.
Results of X-Ray are: Dorsal offset of the epiphysis of the radius with suspected
metaphyseal corner fracture of the posterior radios is likely a Salter two fracture, Diagnosis-
Left wrist, and hand trauma/contusion per Physician at Forrest City Medical Center.
Additional Information: None currently. Guardian Notified: Kymberlie Malatek CPS Worker
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after punching a wall while angry.

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: 9/27/2023
Date Received by DCCECE:9/28/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Texas Date/Time of incident: 9/27/23-16:00
Please give a description of the incident: Resident punched a wall when angry in the quiet
room while trying to regulate himself. Resident complained of pain to right hand and went
to the nurse?s station. The nurse observed swelling of right hand. Corrective Actions Taken:
Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that be sent to Forrest City Medical Center for assessment and X-Ray.
Results of X-Ray are: None, Diagnosis-Right hand pain, contusion per Physician at Forrest
City Medical Center. Additional Information: None currently. Guardian Notified: Brenda
Zeiters CPS Worker
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after complaining of hand pain from 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: 9/25/2023
Date Received by DCCECE:9/26/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Florida Date/Time of incident: 9/25/23-08:50
Please give a description of the incident: Resident punched a wall when angry. Resident
complained of pain to right hand and went to the nurse?s station. The nurse observed
swelling of right hand. Corrective Actions Taken: Resident was assessed and checked by
nurse. The nurse consulted with APRN who recommended that be sent to Forrest
City Medical Center for assessment and X-Ray. Results of X-Ray and physician assessment
are pending. Additional Information: None currently. Guardian Notified:
Mother
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: 9/27/2023- Program Coordinator emailed the facility to request a copy
of the Xray results. X-ray findings received, no acute fracture or dislocation per
documentation received from FCMC.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing provided technical assistance for 110.17.

raw_content:
Perimeter Behavioral of Forrest City
603 KITTLE ROAD
FORREST CITY AR 72335

pao ARKANSAS
DEPARTMENT OF

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

Kendra Rice
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 142

Date of Visit: 9/21/2023

Visit Type(s): Technical Assistance Request Visit
Time: 8:15 AM - 8:39 AM

Regulation# 1.110. 17
Result : T/A Provided
Action Due Date : Date Corrected:

Action Due :

Comment : Facility failed to notify Licensing by the next business day of serious occurrences that required medical

attention.

Visit Comment :

No in-person licensing visit completed on 9/21/2023.

Licensing Specialist is providing the facility with the following Technical Assistance (T/A):

R110.17; facility did not notify Licensing by the next business day of serious occurrences that required

medical treatment for ELS Cases: JIE. ES. EE. EE. 20

Moving forward, when the facility is unable to email or enter serious occurrences in ELS, the facility will

contact Licensing Specialist via telephone.

Page 1 of 2

CCL Staff Signature : Date: 9/21/2023

ii

Ny |

Provider Signature : Date: 9/21/2023

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

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

Page 2 of 2


summary: A resident reported that a staff member hurt him after the resident was guided out of a peer’s room.

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: 9/20/2023
Date Received by DCCECE:9/21/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: XAllegation of abuse/neglect related to a restraint Residents
Name/DOB: State: Florida Date/Time of incident: 9/20/23-7:30pm
Please give a description of the incident: Hotline report filed when resident alleged that staff
hurt him after he was guided out of a resident?s room that he had ran into. Resident along
with another resident stated that they were horseplaying and staff perceived resident and the
other resident running into another resident?s room to fight. The actions of these two
resident?s running into the resident?s room resulted in an ESI of another resident. was
observed hitting himself in the chest after another resident instructed him to make an old
bruise ?new again?. wrote an allegation. Hotline reported completed as part of
investigation. Hotline call was not accepted. Hotline reference number pending email.
Corrective Actions Taken: Safety team conducted an internal investigation. Safety team read
all staff and residents involved statements. Safety team talked with resident and
three other residents involved. Clinical Director completed Hotline Call. Allegation was not
accepted. was moved to another hall immediately after allegations were made by
to not work directly with staff he alleged hurt him. Additional Information: None currently.
Guardian Notified: Madison Lee Case Manager Please see cut and paste from Hotline
below: Jessica Romero <Jessica.Romero@asp.arkansas.gov> Antoine Jackson Referral
Number: Child: The referral was not accepted for investigation and was
documented only due to; Does not meet criteria set forth in Child Maltreatment Laws for
Child Abuse or Neglect. For questions, please contact a Hotline Supervisor at 501-618-8900.
Please do NOT reply to this email. This email has been scanned for spam and viruses by
Proofpoint Essentials. Click here to report this email as spam.
Interim Action Narrative: AR hotline called but not accepted. Resident was moved to
another hall and staff member will not work directly with resident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. 9/22/2023, Licensing Specialist inquired about camera footage, witness
statements, nursing notes, and allegation. Licensing Specialist was informed that staff
member was guiding resident out of the bedroom that he ran out of. Resident alleged that
staff member grabbed him by the neck and hurt his chest. 9/25/2023, Licensing Specialist
informed there is no camera footage. Licensing Specialist will review witness statements
and nursing note. 10/9/2023, Licensing Specialist reviewed witness statements and nursing
note. 10/12/2023, Licensing Specialist staffed with Program Coordinator. 10/16/2023,
Licensing Specialist inquired if staff member was working with resident. Licensing
Specialist informed that resident has been discharged from the program.


summary: A resident was sent to Forrest City Medical Center for assessment after complaining of lower back pain with shooting pains to right leg.

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: 9/20/2023
Date Received by DCCECE:9/21/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Serious injury requiring outside medical attention Residents
Name/DOB: State: Texas Date/Time of incident: 9/20/23-13:45
Please give a description of the incident: Resident complained of lower back pain with
shooting pains to right leg, bruise to left ear, and swelling of right ring finger. Resident
expressed that he had experienced pain for the past three days and would not disclose the
origin of his injuries even after staff prompts and requests. Corrective Actions Taken:
Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that be sent to Forrest City Medical Center for assessment and X-Ray.
The physician did not confirm any further injuries or conditions. No discharge instructions
and Tylenol as needed. X-Ray completed on finger and no findings present. Additional
Information: None currently. Guardian Notified: Jessi Sternat CPS Case Manager
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for an
assessment and x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. 9/22/2023, Licensing Specialist inquired about resident's date of birth.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

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

Perimeter Behavioral of Forrest City Kendra Rice
603 KITTLE ROAD Donaghey Plaza
FORREST CITY AR 72335 P.O. Box 1437

Little Rock, AR. 72203
Facility Visit Compliance Notice

Facility#: 142

Date of Visit: 9/19/2023

Visit Type(s): Subsequent Building and Grounds
Time: 6:15 PM - 7:09 PM

Visit Comment :
Time of visit: 6:15 pm to 7:00 pm
Census: 56

Licensing Specialist completed buildings and grounds. The following areas were observed: bedrooms,
bathrooms, cafeteria, nurse’s stations, quiet rooms, laundry rooms, classroom hall, administration building,
and gym.

Licensing Specialist was escorted by Mr. MM), Program Director and Mr.

Clinical Director.

Walking to the building, Licensing Specialist observed parked cars and flowerpots near the entrance entering
the building. Housekeeping was observed cleaning the administration building and the classroom hallway.

Licensing Specialist walked through the halls (100, 200, 300, 400). 100 Hall residents were completing
hygiene. 400 Hall, ratio 2:11, residents were in the dayroom getting ready to watch a movie. 300 Hall
residents were eating dinner in the cafeteria, ratio 3:14. 200 Hall SRU residents were completing hygiene,
playing games, and watching a movie.

Page 1 of 2

Bedrooms were organized and clean. The bathrooms were in use due to residents completing hygiene.
Licensing Specialist observed the activity schedules and emergency escape plan on the walls of each hall.
Client rights are posted on the walls in the cafeteria and classroom hallway. The grievance boxes for the
residents are kept by nurse’s station.

Licensing Specialist reviewed the MAR’s on the residents listed below:

All initialed and up to date.

CCL Staff Signature : Date: 9/19/2023
} |

MM AC

’ yur y

Provider Signature : Date: 9/19/2023
Wh

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

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

Page 2 of 2


summary: A resident was sent to Forrest City Medical Center for assessment after reporting worsening pain and flu-like symptoms.

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: 9/16/2023
Date Received by DCCECE:9/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
DatPlease give a description of the incident: Resident reported, and fever observed by nurse.
Resident also reported worsening feelings of pain and flu like symptoms. Corrective Actions
Taken: Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that be sent to Forrest City Medical Center for assessment.
Diagnosed with and given prescription for
. Sent back to facility for continued monitoring. Additional
Information: None currently. Guardian Notified: Mother e/Time of
incident: 9/16/23-16:00
Interim Action Narrative: Resident was assessed by nursing and sent to FCMC for an
assessment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident on
9/18/2023 via email. 9/19/2023, Licensing Specialist reviewed provider reported incident for
licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after he was attacked by a peer.

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: 9/16/2023
Date Received by DCCECE:9/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 9/16/23-14:00 Please give a description of the incident: Resident
was punched in the face and attacked by another peer causing injury to nose and causing
resident to hit head on the ground. Corrective Actions Taken: Resident was assessed and
checked by nurse. The nurse consulted with APRN who recommended that be sent
to Forrest City Medical Center for assessment. The physician confirmed head injury and
conducted medical screening exam. Resident sent back to facility for continued monitoring.
Additional Information: None currently. Guardian Notified: Mother
Interim Action Narrative: Resident was assessed by nursing and sent to FCMC for an
assessment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
9/19/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist informed resident involved himself in an altercation and was trying to
break up a fight, he was not fighting. All parties involved were placed on assault
precautions. 9/20/2023, Licensing Specialist reviewed camera footage.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 9/20/2023
Home Visit Date: 9/20/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 10:30 am to 11:30 am
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 56
Licensing Specialist spoke with Mr. Clifton Williams, Program Director, regarding ELS Case #016238. The
Provider Reported Incident happened on 9/16/2023 on the courtyard. Licensing Specialist reviewed camera
footage on 9/20/2023.
Licensing Specialist observed residents from the 300 Hall outside on the courtyard participating in different
activities. Licensing Specialist observed resident and a peer throwing a football back and forth. The ratio was
4:15.
The actual incident took place in the corner of the courtyard. Due to the angle of the camera and the darkness
of the area, Licensing Specialist was unable to observe the residents in a physical altercation. Licensing
Specialist observed staff members running to the area to intervene the physical altercation.
Residents were separated and were walked in two different directions of each other. Another staff member
was observed having the other residents line up near the building. Mr. Williams informed Licensing Specialist
that residents involved were placed on assault precautions. Resident was moved to the 100 Hall for
safety.
Provider Comments:
CCL Staff Signature : Date: 10/22/2023
Provider Signature : Date: 10/22/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


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

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: 9/14/2023
Date Received by DCCECE:9/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Wyoming
Date/Time of incident: 9/14/23-13:50 Please give a description of the incident: Resident
reported pain in his right thumb. When asked by the nurseresident could not specify cause
or source of pain. Corrective Actions Taken: Resident was assessed and checked by nurse.
The nurse consulted with APRN who recommended that be sent to Forrest City
Medical Center for assessment and X-Ray of thumb. No findings indicated by physician at
Forrest City Medical Center. Sent back to facility for continued monitoring. A follow-Up
appt. was not required for this procedure. Resident placed on activity restrictions until
cleared to resume activities by medical. Additional Information: None currently. Guardian
Notified: Guardian
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for an
assessment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
9/19/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
9/20/2023, Licensing Specialist informed that staff member was unable to log into his
computer from his residence.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after continued diarrhea and abdominal pain.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/14/2023
Date Received by DCCECE:9/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 9/14/23-12:32 Please give a description of the incident: Resident
reported to Nurse continued diarrhea and abdominal pain. Corrective Actions Taken:
Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that n be sent to Forrest City Medical Center for assessment and X-Ray
of his stomach. No findings indicated by physician at Forrest City Medical Center. Sent
back to facility for continued monitoring. Additional Information: None currently. Guardian
Notified: Mother
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for an
assessment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
9/19/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about late reporting. 9/20/2023, Licensing Specialist informed
that staff member was unable to log into his computer from his residence.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after injuring his hand by hitting 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: 9/14/2023
Date Received by DCCECE:9/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 9/14/23-15:40 Corrective Actions Taken: Resident was assessed and
checked by nurse. The nurse consulted with APRN who recommended that be sent
to Forrest City Medical Center for assessment and X-Ray of hand. No findings indicated by
physician at Forrest City Medical Center. Sent back to facility for continued monitoring. A
follow-Up appt. was not required for this procedure. Resident placed on activity restrictions
until cleared by medical. Additional Information: None currently. Guardian Notified:
Guardian
Interim Action Narrative: Resident assessed by nursing and referred to FCMC for an
assessment. Resident placed on activity restrictions.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident.
9/19/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about late reporting. 9/20/2023, Licensing Specialist informed
that staff member was unable to log into his computer from his residence. Licensing
Specialist informed that resident injured his hand by hitting a wall out of anger/frustration.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of pain from falling.

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: 9/14/2023
Date Received by DCCECE:9/18/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 9/14/23-12:32 Please give a description of the incident: Resident
reported that he had pain in his body after falling on 9-11-23. Resident was not able to
specify why he fell. Corrective Actions Taken: Resident was assessed and checked by nurse.
The nurse consulted with APRN who recommended that be sent to Forrest City
Medical Center for assessment and X-Ray of body. No findings indicated by physician at
Forrest City Medical Center. Sent back to facility for continued monitoring. A follow-Up
appt. was not required for this procedure. Additional Information: None currently. Guardian
Notified: Guardian
Interim Action Narrative: Resident was assessed by nursing and sent to FCMC for an
assessment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
9/19/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired on where resident fell at. 9/20/2023, Licensing Specialist
informed that staff member was unable to log into his computer from his residence.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Specialist informed that resident fell on the courtyard while playing catch with a
football.


summary: Officers were dispatched to the facility in response to a report from a parent that the facility would not release his son.

raw_content:
CFS - Command Log Printed on November 1, 2023
—[—S— Nove CT Le ES

CFS # CFS2338436
Call Taker KILEY HOWTON
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)

Location Details
Primary Incident Code INFO : Info

Mod Transfer Non Emergency

Priority 4

Use Caution No

Primary Disposition Handled By Officer / Deputy

Beat

Zone Forrest City Police Department

Call Time 09/10/23 17:14:02

Completed Time 09/10/23 17:55:26
Reporters

TONY PARRY (Initial Reporter)

Sex

DOB

Address

Report Time 09/10/23 17:14:02

How Reported

From Phone

Contact Phone (501) 409-5580

Comments

Other Names
Vehicles

Responders
545 (Primary) 545 - ALBERT, TANESHA —_FCPD (Primary)

Response Times

Assigned 09/10/23 17:16:23 *
Enroute 09/10/23 17:16:23
Arrived 09/10/23 17:21:07
Leaving

Arrived At

Completed 09/10/23 17:55:26

IR | External Agency Numbers
FCPD202309916

Officer Addenda

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown
09/10/23 17:14:02 | HOWTON, KILEY | New CFS
09/10/23 17:16:23 | HOWTON, KILEY | 545 | Enroute
09/10/23 17:21:07 | HOWTON, KILEY | 545 | On Scene
eee
Page 1 of 2

09/10/23 17:55:26 | MORGAN, SYDNEY | 545 | Available

09/10/23 18:03:14 | HOWTON, KILEY | CALLER ADVISED PERIMETER WOULD NOT LET HIM HAVE HIS SON
09/10/23 18:04:19 | HOWTON, KILEY | Complete

09/10/23 18:04:19 | HOWTON, KILEY | \

/CLQ

Requested At
Sent To

Status
Received At
Location ,
Accuracy

Se

Page 2 of 2


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of pain from someone stepping on his toes.

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: 9/8/2023
Date Received by DCCECE:9/11/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: DOB Date/Time of Incident: 9/8/23 @
1640 PM Staff reported that above named resident injured his right toes in the gyn as a result
of toes being accidently stepped on. He presented to nurses' station complaining of pain at
which time he was given an ice pack and Ibuprofen 200 mg. Upon examination of the
resident by APRN, n order was obtained from APRN Perry to send resident to FCMC ER
for x-ray of right foot. Results: No acute fracture or dislocation. The joint spaces are
preserved. Normal bone mineralization. No acute findings. Proper notifications were made.
Guardianship:
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to a report that a resident assaulted a staff member.

raw_content:
CFS - Comm

CFS #
Call Taker
Location
Location Detdi

and Log Printed on September 20, 2023

CFS2338092
SYDNEY MORGAN

1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)
ils

Primary Incident Code ASSAULT : Assault/Battery

Mod
Priority
Use Caution

Primary Disposition

Beat
Zone
Call Time
Completed Ti

me

Emergency Fire/Medical

1

No

Handled By Officer / Deputy

Forrest City Police Department
09/08/23 09:50:34
09/08/23 10:58:21

Reporters

SHERITA (Initial Reporter)

Sex
DOB
Address

Report Time

How Reported

From Phone

1521 ALBERT ST
FORREST CITY, AR 72335
09/08/23 09:50:34

Contact Phone (870) 633-3200

Comments

_ Other Names

Vehicles

| Responders|
a5 ‘se

545 (Primary)

Response Tjmes

Assigned 0
Enroute 0
Arrived 0
Leaving
Arrived At

Completed 0p/08/23 10:58:21

|

_IR/ External Agency Numbers

FCPD2023098.

~ 542 - HAWKINS,
NATHANIEL
545 - ALBERT, TANESHA

~~ FCPD (Primary)

FCPD (Primary)

108/23 09:50:34
108/23 09:53:25 *
108/23 09:53:25

35

Officer Addenda

Command Lpg Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown

-—-— OT SSS

Page 1 of 2

09/08/23 09:50:34 | MORGAN, SYDNEY | 542 | New CFS

09/08/23 09:52:33 | MORGAN, SYDNEY | NEEDS INCIDENT REPORT

09/08/23 09:53:25 | HENDERSON, CALANDRA | 545 | On Scene

09/08/23 09:54:28 | HENDERSON, CALANDRA | 542 | On Scene

09/08/23 09:54:55 | MORGAN, SYDNEY | PATIENT ASSAULTED STAFF MEMBER
09/08/23 10:09:16 | HENDERSON, CALANDRA | EVENT#2309080009

09/08/23 10:10:37 | HENDERSON, CALANDRA | 545 | Clear Alarms

09/08/23 10:19:40 | HENDERSON, CALANDRA | 542 | Clear Alarms

09/08/23 10:58:21 | HENDERSON, CALANDRA | 542, 545 | Complete

| CLQ

Requested At
Sent To
Status
Received At
Location ,
Accuracy

DSSS

Page 2 of 2

FORREST CITY
POLICE DEPARTMENT

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

Crime / Incident (Primaty, Secondary, Tertiary)
5-13-207 ASSAULT|3RD

Location of Incident 75)

Cross Street WOODRIDGE

Dispo "Vv" = Vict "RP" = Reporting Party

Last, First, Middie|(Firm if Business)
V | JONES, LUKE

Address

City, State, Zip Code

Last, First, Middle |(Firm if Business)

City, State, Zip Code
FORREST CITY AR 72335

sa Last, First, Middle|(Firm if Business)

City, State, Zip Code
FORREST CITY AR 72335

4 Last, First, Middlel(Firm if Business)

Synopsis

<H-r-wr<cron

Officer ID OFFICER NATHAN HAWKINS

Printed By/On: 412 / 09/21/2043 08:12:38
CrimeStar® Law Enforcement Records Management System
Licensed to; FORREST CITY AR POLICE DEPARTMENT

21 ALBERT ST, FORREST CITY, AR

Address DOB DL Number State
™
Address DO DL Number Sta ork Phone
1521 ALBERT ST re TX | (870)
0

City, State, Zip Code

Pse 1 |ncident

Incident #

2309080009

O
O
O

County
em |
(870)

Work Phone

Cell Phone
0

Home Phone

(870)
Work Phone
em |
Cell Phone
Ene

Home Phone
(870)

"W" = Witness "§" = Suspect "O" = Other

Sex Age HT Hair Eyes
M 17

5

wo

ean
~

—_ “ ey

Continuation PropertyList
attached L_] | attached  [_]| ProvertyDamages $0.00
Press Domestic Violence
at ee

Gang Related N Victim Senior Citizen |
cee
Solvability County i
Ss CT
Report Complete/Ready for Review CAD/CFS Event # 2309080009

Assigned To Date

Reviewed By Approved Date
550 Sgt. Adrian Todd 09/19/2023

ZZ2Z2ZZ222222222

TATA

FORREST CITY Page 2 Incident conta

POLICE DEPARTMENT Narrative necent# 2309080009
Crime / Incident (Prima Attempt | Type Seq
519207 ASSAULT 980 al ES ies

On 9/08/23 I] Ptl Hawkins was dispatched to 1521 Albert Street, Perimeter
Behavior Center, in reference to an assault. Upon my arrival I came in contact
with the victim Luke Jones ae . Mr Jones advised that he was assaulted by

two juveniles who attents the Behavior Center. Luke Jones stated that
and [EE 2 tacked him during
transitioning to the restroom. Mr Jones advised that he suffered injuries to his

right shoulder, back area, and hands. It is unknown why the juveniles attacked
Mr Jones.

>

Reviewed By aah Date
Officer ID OFFICER|INATHAN HAWKINS 550 Sgt. Adrian Todd YES 09/19/2023

ST

Printed By/On: 412 / 09/21/2023

; D8:12:38
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR|POLICE DEPARTMENT


summary: A resident was sent to Forrest City Medical Center for evaluation after a physical altercation with 4 of his peers.

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: 9/7/2023
Date Received by DCCECE:9/8/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Staff reported that above named resident was in a physical altercation
with 4 of his peers after leaving the gym. Staff reported that once back in the dayroom,
resident told his peers they were too loud and stood up and began to curse at the residents
and a physical altercation ensued. Staff were able to separate the residents. Actions taken:
upon examination resident was noted to have a knot under his left eye and a small knot on
his forehead. Order was obtained for APRN Perry and an order was obtained to send
resident to FCMC ER for further evaluation and treatment. Results: Assault by unspecified
means; contusion of other part of head. Proper notifications were made. Guardianship:
Interim Action Narrative: Resident injured was assessed by nursing and referred to FCMC
for evaluation and treatment. Residents placed on assaultive precautions.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire about camera footage and safety precautions for
residents involved. 9/11/2023, Licensing Specialist informed that residents involved were
placed on assaultive precautions. 9/12/2023, Licensing Specialist reviewed camera footage.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident complained of pain after a peer stepped on his ankle during a basketball game.

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: 9/3/2023
Date Received by DCCECE:9/5/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 9/3/23-18:30 Please give a description of the incident: Resident
reported to staff during basketball game that another peer stepped down on his ankle and
reported pain. The resident reported that he did not have pain and did not want to be
treated because he wanted to play more basketball. Resident was brought to nursing station
for assessment by Nurse. Corrective Actions Taken: Resident was assessed and checked by
nurse who observed swelling and explained to the importance both long and short
term of getting his ankle looked at. The nurse consulted with APRN who recommended
that ice pack be given to resident and X-Ray on 9-4-23 if further swelling and pain persists
and activity restriction. Additional Information: None currently. Guardian Notified: Tessa
Mann, DHS Caseworke
Interim Action Narrative: Resident was assessed by nursing, an ice pack was applied. and
placed on activity restriction.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after reporting hand pain from 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: 8/31/2023
Date Received by DCCECE:9/5/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Texas Date/Time
of incident: 8/31/23-12:10 Please give a description of the incident: Resident reported to
Nurse of pain in his right hand. He disclosed to the Nurse that he punched the wall in his
room and a pole outside today because he is angry. Corrective Actions Taken: Resident was
assessed and checked by nurse. The nurse consulted with APRN who recommended that
be sent to Forrest City Medical Center for assessment and X-Ray. Fracture was
indicated in hand. Resident sent back to facility for monitoring and pain medications PRN.
No other significant findings indicated.
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
9/5/2023, Licensing Specialist informed that resident has a follow-up appointment with
Jonesboro Ortho on 9/25/2023 at 11 am. 9/6/2023, Licensing Specialist reviewed provider
reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of chest pain.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/30/2023
Date Received by DCCECE:9/5/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Residents Name/DOB: State: Arkansas
Date/Time of incident: 8/30/23-16:20 Please give a description of the incident: Resident
reported to Nurse that he was having chest pains. The origins of chest pain were not
specified. Corrective Actions Taken: Resident was assessed and checked by nurse. The
nurse consulted with APRN who recommended that be sent to Forrest City Medical
Center. Resident was seen by Physician and given an X-Ray and medical assessments. The
lungs were clear and mediastinal silhouettes were in normal limits. Resident sent back to
the facility for continued monitoring as needed by Nurses. Additional Information: None
currently. Guardian Notified: Kaylen Edwards, DHS Caseworker
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after falling and hitting his head.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 8/28/2023
Date Received by DCCECE:8/29/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident reported to nurse that he was playing basketball and another
resident "kneed him" while playing. Resident was not fighting or in conflict with his peer.
Resident further stated that he fell to the gym floor and hit his head when he fell and
complained of left side to his head. Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that resident be sent to FCMC. Resident was seen
by physician and given a neurological flow sheet. Resident was diagnosed with head injury
and was also given a medical screening exam. Resident was sent back to the facility without
any further treatment or pain reported for monitoring by the nurse.
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
8/30/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after fainting and hitting his head on the wall.

raw_content:
AR KAN S A S&S
DEPARTMENT OF

+4 HUMAN
<a¥ SERVICES

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

Notice of Serious Incident

Date of Incident: 8/27/2023

Date Received by DCCECE: 8/28/2023

Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing

Report Description: x Serious injury requiring outside medical attention Resident
Name/DOB: Pe State: fF Date/Time of incident: 8/27/23-
5:53pm Please give a description of the incident: Resident reported to Nurse with
complaints of feeling lightheaded. The nurse sat the resident down to check him. When
resident got up, he fainted and hit his head on the wall at the Nurses station. Resident did
not disclose any activities or reason for feeling lightheaded prior to going to the Nurses
station. Corrective Actions Taken: Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that >< sent to Forrest City Medical
Center. Resident was diagnosed with a syncope and collapse-recurrent after assessment by
Physician at Forrest City Medical Center. Resident has been referred to see a cardiologist
specialist on 10-17-23 @9:30am Additional Information: None currently. Guardian Notified:

BEE Gr2ndmother

Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.

Maltreatment Narrative:

Licensing Narrative: Licensing Specialist informed of provider reported incident.
8/29/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.

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