summary:
Received complaint 4/13/23 as follows: Resident’s guardian said she’s dissatisfied with Millcreek of Arkansas’ services. Guardian reported that he has had on campus visits with the resident and each time she has witnessed poor hygiene: dirty clothes, dirty fingernails, toenails, and bruises. The guardian also reported the resident always says he’s hungry during phone calls and appears to be starving whenever she sees him. Guardian also mentioned that when she calls the facility, she hardly ever gets someone to answer the phone and that they have only been giving the resident antibiotics and medication to help with bowel movements. Guardian said she spoke with the CEO once, and he was nice, but did mention that they normally don’t take in individuals that wear pull ups, who aren’t potty trained, and the resident is old enough to go to the restroom on his own. Guardian said the CEO was really nice aside from that statement. Guardian said there are no changes in the resident’s medications and that she was under the impression that Millcreek would be helping the resident, but instead his behaviors have worsened.
Licensing Specialist: Clayton DeBoer.
Regulations out of compliance: 908.8 – The administering of all medications, including over the counter, shall be logged at the time the medication is given, by the person administering the medication.

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and medication to help with bowel movements. Guardian said she spoke with the CEO
once and he was nice but did mention that they normally don't take in individuals that
wears pull ups, who aren't potty trained ,and that the member is old enough to go to the
restroom on his own. Guardian said the CEO was really nice aside from that statement.
Guardian said there are no changes in member's medications and that she was under the
impression that Millcreek would be helping the member, but instead his behaviors have
worsened. Member is refusing to attend school and complete assignments at the facility per
guardian. Guardian said the facility should to notify her before making decisions because
the member is her son. A lot of the member's clothes, underwear, and socks has be stolen
per guardian. Guardian reports spending a lot of money on new items for the member.
Guardian also stated the member has had two home visits and that the member refuses to
bathe. Guardian reported she will likely remove member from Millcreek?s program, pending
other availability from other providers. Licensing Specialist Clayton DeBoer phoned
on 4/13/23. stated she can take phone calls regarding
this issue between 3PM-4PM and anytime after 4:30PM. Ms. Sawrie stated that during visits
on Saturdays with her son Tayton Sawrie, she and her boyfriend have to clean feces off of
him. To clarify, stated it was ?s feces she had to clean off of him.
stated that is not potty trained ?he knows how to use the bathroom he just
doesn?t?. She stated that she spoke with Chris Butler about a month ago and that is the only
staff at Millcreek who has spoken with her over the phone about these concerns. She stated
that Chris Butler said if Millcreek had known about the bathroom issue they would not have
accepted him ( . She stated that has had two home visits while at Millcreek.
She stated that eats like a ?barbarian? and refuses to bathe. She stated that she was
successful in bathing but she had to force him. She stated that bathing has always
been an issue with stated that during home visits says he has
watched ?R rated movies? and ?talks about cutting people up?. She stated that talks
about ?bed bugs? and that she has seen bites on him. stated that Tayton school
grades are ?slipping? and that he is on a 1st to 2nd grade level. She stated that when Tayton
was attending Lake Hamilton School, he made straight A?s. stated that
Millcreek ?gave him antibiotics and didn?t even tell me?. stated that she has had
to buy clothes for while at Millcreek because his clothes go missing, specifically
socks and a coat. stated that ?s therapist is and his case
manager is . She stated she has called Millcreek several times to speak with
these individuals to no avail. stated that when she calls Millcreek to speak with
, Millcreek staff tell her either doesn?t want to talk on the phone or is not
available. Ms. Tayton stated that Tayton resides at Rock Hill at Millcreek. stated
that Tayton still resides at Millcreek ?as of right now? and that she has had Tayton on a
waiting list for a UAMS program for 2 years. ?s boyfriend briefly spoke on the
phone adding ?we had to clean feces out of his shoes?. Facility visited 4/17/23 in response
to complaint regarding client . interviewed. was fully clothed with shoes, socks.
shorts and a Sonic the Hedgehog shirt. appeared clean and had no noticeable odor. TS
was briefly escorted from school to Rock Hill. was asked to show what clothes other than
what he was wearing he had. dumped a plastic bin which contained an additional pair of
shoes and several socks, underwear, and when asked stated "10" shirts. was asked if

he was missing any clothes "last time I went on home pass half went missing". When asked
stated that he does get bug bites. When asked if the bites have been worse or better
"kind of better". pointed to what appeared to be a few bites on his knee. also had a
bruise on his knee that he stated he didn't know where it came from. When asked, TS stated
that he lives at home with his mom, dad, brother sister and two dogs. stated that he
misses being at home and plays with his brother and sister for fun. 's MAR reviewed for
March and April. April 2nd the AM meds are not initialed. Nursing confirmed that
medications were given but not initialed. DON Amanda Williams consulted regarding
complaint of receiving antibiotics without parent's consent. Ms. Williams stated that an
attempt was made to contact parent/guardian but no answer and no way to leave voice
mail. Ms. Williams stated protocol for administering an antibiotic for an infection is to begin
giving per Dr.'s orders as long as an attempt has been made to notify guarding. Chris Butler
states this is not in a written policy but following protocol set in place by unit physician.
s attendance record reviewed to be perfect attendance. grade's reviewed which are
one A, 5 B's and one C. Rid-a-Pest records reviewed for pest extermination. Rid-a-Pest
record for 11/14/22 and 1/18/23 did note bedbugs for Rock Hill and that bedbug treatment
was performed. Chris Butler added that on 3/14/23 Rid-a-Pest had completed a Rock Hill
wide bedbug treatment. Invoice could not be located today but will send to licensing in the
future. Millcreek Policy for movies is that no R rated movies be shown to client and that
age-appropriate guidelines be followed. Facility cited 908.8 for medication not being
initialed for on 4/2/23. Follow up phone call was made to 4/17/23.
was explained that her concerns had been addressed today by Licensing and to feel
free to call if needed. Ms. Sawrie was explained that follow up visits regarding any
additional concerns can be addressed. stated that Millcreek Therapist Samara
White had called her boyfriend Eric and that Eric was able to speak with
stated that Ms. White stated would call this evening, 4/17/23, for a more extensive
phone call. Received notification 6/6/23 that maltreatment complaint was unfounded.


state: AR

facility_name: Millcreek Behavioral Health / Habilitation Center, Inc.

summary: A resident was sent to Dallas County Medical Center for an x-ray after falling while playing kickball.

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: 4/4/2023
Date Received by DCCECE: 4/5/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , State Custody, DOB: ) engaged
in a game of recreational kickball. She slipped and fell while kicking the ball. She reported
pain in her right wrist and lower arm. Slight swelling noted. Sent to Dallas County Medical
Center for outpatient x-ray. X-ray report indicated no fracture. She was released to return to
the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client engaged in a game of recreational kickball. She
slipped and fell while kicking the ball. She reported pain in her right wrist and lower arm.
Slight swelling noted. Sent to Dallas County Medical Center for outpatient x-ray. X-ray
report indicated no fracture. She was released to return to the facility. Client remains at
facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary:
A resident was sent to Dallas County Medical Center for assessment following a physical altercation. The facility was cited:
 907.2. Staff responsible for supervising residents involved made minimal effort to mitigate the situation.
109.1.g. Staff bear hugs resident causing him to fall to the floor.

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: 4/2/2023
Date Received by DCCECE: 4/3/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , Parent Custody, DOB: ) was sent to Dallas
County Medical Center for assessment following a physical altercation. He reported
dizziness during his on-site nursing assessment. ER report indicates no loss of
consciousness, no vision changes, no neurologic deficits. Mild headache reported. DCMC
provided Tylenol and ordered neuro checks every 4 hours for next 24-hours as a
precautionary measure. He was released to return to Millcreek.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client was sent to Dallas County Medical Center for
assessment following a physical altercation. He reported dizziness during his on-site
nursing assessment. ER report indicates no loss of consciousness, no vision changes, no
neurologic deficits. Mild headache reported. DCMC provided Tylenol and ordered neuro
checks every 4 hours for next 24-hours as a precautionary measure. He was released to
return to Millcreek. Email sent to facility 4/4/23 to inquire if there is video footage of this
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

incident. Email received 4/4/23 stating that there was camera footage of this incident and
that a report was made to the . The report was not
accepted for investigation. The report provided by Millcreek states that
"it was seen that was taunted, punched, and kicked by peers over a period of 15
minutes" and " and were the employees assigned to Magnolia
Hall. The camera review revealed that both employees made minimal effort to mitigate the
situation". Facility cited 907.2 on 4/5/23. Facility visited 4/6/23 and video reviewed.
Citation from 4/5/23 stands. Staff do not intervene as client is attacked by peers.
Additionally, at the beginning of this incident, staff is seen bear hugging client in
an aggressive manner after client takes a drink from staff . Client falls to the
floor. Facility cited 109.1g on 4/6/23.


summary: A resident was sent to Dallas County Medical Center for assessment following a physical altercation with a peer. The facility was cited 907.2. Staff did nothing to intervene nor assist resident in 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: 4/1/2023
Date Received by DCCECE: 4/3/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: Custody, DOB: was
sent to Dallas County Medical Center following a physical confrontation. He reported pain
in his nose during the on-site nursing assessment. He was sent for outpatient x-ray. X-ray
report indicates "
CT imaging would best define if needed clinically."
Tylenol was provided for pain. He was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client was sent to Dallas County Medical Center
following a physical confrontation. He reported pain in his nose during the on-site nursing
assessment. He was sent for outpatient x-ray. X-ray report indicates "
. CT
imaging would best define if needed clinically." Tylenol was provided for pain. He was
released to return to the facility. Email sent to facility 4/4/23 to inquire of video footage of
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

this incident. Received email from facility 4/4/23 that there was camera footage of this
incident. Per phone call 4/5/23 with Chris Butler, Risk Mgmt. Millcreek, Chris Butler
reviewed this video and stated that was punched in the nose by a peer. When this
happened staff was outside of the unit and staff was inside of the
unit but did nothing to intervene. Chris Butler stated that both staff and r were
terminated due to this incident. Facility visited 4/6/23 and video reviewed of this incident.
Staff is seen sitting down. A client in a red shirt is seen punching client in
the face. The aggressor is seen throwing a second punch towards The aggressor returns
to a hallway area and client leaves camera view as to go outside. Client reported to
facility that he was taken to the nurse's office by staff (other staff at Magnolia Hall)
subsequent this incident. According to video, it seems that staff directly witnessed
this incident. At no time during this incident did staff s leave his seat to intervene nor
assist client Facility cited 907.2.


summary: After review of the facility’s mandated reporter policy, Licensing determined that it does not comply with A.C.A 12-18-402 nor the Minimum Licensing Standards. Technical assistance was provided regarding A.C.A 12-18-402, R102.3.h and R110.9.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 3/31/2023
Home Visit Date: 3/31/2023
Purpose of Visit: Technical Assistance Request Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 1. 102. 3 .h
Regulation Description: The following policies of the agency shall be current and available to all employees of
the agency and the Licensing Specialist:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 110. 9
Regulation Description: Any owner/operator, employee, foster parent, or volunteer in a child welfare agency
shall immediately notify the Child Abuse Hotline if he or she has reasonable cause to suspect that a child has
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

been subjected to child maltreatment, died as a result of child maltreatment or if they observe a child being
subjected to conditions or circumstances that would reasonably result in child maltreatment.
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
After review of your agency’s current mandated reporter policy, it has been determined that it does not
comply with A.C.A. 12-18-402 nor the Minimum Licensing Standards.
Technical assistance was provided to the agency regarding A.C.A. 12-18-402, R102.3.h, and R110.9.
Please ensure that your current policy is updated to reflect the need of all staff to report directly to the child
abuse hotline without delay to come into compliance with A.C.A. 12-18-402, R102.3.h, and 110.9. All reports
will be screened by the Child Abuse Hotline to determine if they meet criteria for investigation. The updated
policy shall be submitted to the Licensing Unit by4/14/23and all applicable staff should be retrained on the
updated policywithin two weeksof the enactment of the updated policy at the agency.
Provider Comments:
CCL Staff Signature : Date: 3/31/2023
Provider Signature : Date: 3/31/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: Licensing documented employment status of persons not eligible to be employed by a child welfare facility. Offer was rescinded for 3 individuals, 3 individuals were never hired, 1 individual was terminated on 01/23/23, and 1 individual who was on leave since 03/23/23 is scheduled to be terminated on 03/28/23.

raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
=a! SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Millcreek of Arkansas PRTF

Facility Number: 233

Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742

Licensing Specialist: Clayton DeBoer
Person In Charge: Chris Butler
Record Visit Date: 3/28/2023

Home Visit Date: 3/28/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

The following persons are not eligible to be employed by a child welfare facility. This is to document the
following persons employment status.

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

WB -Offer rescinded

Wl -Offer rescinded

W- Offer rescinded

Mi -Never hired

B-Never hired

H-0n leave since 3/23/23. Scheduled to be terminated 3/28/23.
Wi -Terminated 1/23/23

Bi-Never hired

Provider Comments:

CCL Staff Signature : Date: 3/28/2023

Provider Signature : Date: 3/28/2023

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


summary: A resident was sent to Dallas County Medical Center for x-rays after punching a closed door multiple times.

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: 3/26/2023
Date Received by DCCECE: 3/27/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , ( Custody, DOB: )
was sent to Dallas Co Medical Center for outpatient x-rays. Following his punching a
closed-door multiple times, he reported pain in his right hand during a nursing assessment.
ER Discharge report indicated . The finger
was reset, and he was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client was sent to Dallas Co Medical Center for
outpatient x-rays. Following his punching a closed-door multiple times, he reported pain in
his right hand during a nursing assessment. ER Discharge report indicated
. The finger was reset, and he was released to return to the
facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officer was dispatched for a runaway juvenile from the facility. The officer located and returned the juvenile to the facility.

raw_content:
JUN/27/2023/TUE 01:12 PM Fordyce Police Dept PAX No, 870-352-8187 P. 002

Incident # 23-00251 Fordyce Police Department Report Date 03/20/23 __
Page 4 of 4 Incident Report Report Time 5:41 AM

Status ORI/Agency
AROZ00100

Exception Glearance Data
Not Applicable

Reporting Officar

306 Ellis, Charles
Entered By =| Approving Officer
cellis

Active

Assigned Officer
Ellis, Charles
Assisting Officers

Complainant Le ie CH ee m
Name Contact Name
Milcreek
Business Address Business Phone
204 Cadiz ST,Fordyce, AR 71742
Incident Location Zone

1410 W Fourth ST Fardyce, AR 71742
Earliest Possible Date Time Latest Possible Date Time

03/20/2023 05:41 © 03/20/2023 05:41

# [Statute(Code Cates
1 | ~~sit_ [Cals tor Service Nise [Completed 25[ 83 [38] |
lO

M Method Of Entry # Prems
na 0
Location Typas 13 Hway/Read/Alley = 37 Abandoned/Condemned 48 Industrial Sits Bias Motivation Codes . .
14 Hotel/Motal Structure 49 Military [nsta ‘lation 43 Lesbian, Gey, Bisexual,
01 Alr/Bueslrain Terminal 15 Jail/Prigon 38 Amusement Park 50 Park/Playground ANTI- 23 Protestant of Transgender, Mixed
02 Bank/S&L 16 Lake/Waterway 39 Arena/Stadium/Fair 51 Rest Area 11 White 24 Islamic (Muslim) Group (LGBT)
03 Bar/Night Club 17 Liquor Stora graunds/Coliseurn 52 School - 12 Black or african 25 Other Religion 44 Heteroaexuel
04 Chureh/Synag/Tomple 18 Parking LovGarage 40 ATM Separate from Bank College/Liniversity American 25 Multieligiaus group 45 Bisexual
0S CommerctavOtt Bldg 19 Rental Storage 41 Auto Dealership §3 Schaot - 13 American Indianor 27 Athelst/Agnastic 51 Phys Disability
06 Construction Site “acllity New/Used Elamentary/Secondary Alaska Native 31 Arab 52 Mental Disability
07 Convenience Stora 20 Residence/Home = 42 Camp/Campground 54 Shelter - 14 Aalan 32 Hispanic or Latino 81 Male
0B DeptiDiscount Store 21 Restaurant ___ 4d Daycare Pacility Mission/Homeless 15 Multi-races, Group 33 Not Higpanie or 62 Female
09 Drug Str/Dr OWHasp 24 Service/Gas Station 45 Dock/WharfiFreight’ §5 Shopping Mall 16 Native Hawaiian or Latino 71 Transgeader |
10 Fleld'Wooda 24 Specialty Store Modal Terminal 56 Tribal Lands Other Pacific Islander 41 Gay (male) 72 Gender Non-Conforming
11 GovtPublic Bldg 25 Unknown/Other = 46 Farmti Facility §7 Community Center 21 Jewish 42 Lesbien 8a None
12 Grocery/Supermarket 47 Gambling 58 Cyberspace 272 Cathallc 99 Unknown
Facitity’CasIno/Race Track
Suspsctad Of Using Criminal Activity Types Waapon Type(s) 20 Knife/Cutting Instr 65 Fire/Incendiary Davice
None B Buying/Receiving C Cultivating/Manuf/Publishing 11 Firearm (Auto) ae Blunt Object 70 Rrugs/Nare./Sleaping Pills
P Pogsessing/Concealing O Operating/Promoting/Assisting 42 Handgun (Auto) 35 Motor Vehicle a5 Asphyxiation
O Distributing/Selling T Transport/Import/Trangmit 13 Rifle (Auto) 40 Personal Weapons 90 Other
E Explotting Children U Using/Gonsuming 14 Shatgun (Auto) 50 Poison $5 Unknown
15 Other Firearm 60 Explosives 99 None
A Simple/Gross Neglect | Intentional Abuse & Torment
F Organized Abuse S Sexual Animal Abuge

“Nerralive& Statements. (4

Narrative - Ellis, Charles - 3/20/2023 5:50:06 AM (initial)

On Sunday March 20, 2023 at approximately 1300 hours. | Officer Charles Ellis
was dispatched to Darryl’s for a runaway Juvenile From Millcreek. Dispatch advise
it was 6’2 Hispanic male. He was wearing a white t-shirt and black jacket. On
arrival | saw the individual who fit the description of the information | had. | got out
and spoke with. He stated that he trying to go to McDonalds. | called Millcreek to
speak with someone about the runaway Juvenile and | stated that | will be in route
with the juvenile for return.

Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 6/27/2023 2:47:40 PM

doc_type: Police Report


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. The facility was cited 901.3 and 911.6 for issues identified during the review.

raw_content:
ARKANSAS
DEPARTMENT OF

> HUMAN
=a! SERVICES

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

521 Visit Compliance Report

Licensee: Millcreek of Arkansas PRTF

Facility Number: 233

Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742

Licensing Specialist: Clayton DeBoer
Person In Charge: Chris Butler
Record Visit Date: 3/17/2023

Home Visit Date: 3/17/2023

Purpose of Visit: Monitor Visit

Regulations Out of Compliance:

Regulation Number: 9. 901. 3

Regulation Description: The agency shall establish and post a written list of children’s rights.
Findings Description: No client rights posted in Deerfield.

Action Due Date:

Action Due Description:

Comply Date:

Sub Regulation Description:

Regulation Number: 9. 911.6

Regulation Description: All buildings and furnishings shall be safe, clean, and in good repair.

Findings Description: Repair issues including flooring, baseboards, shower nozzle and paint in Rock Hill and
Pebble Creek.

Action Due Date:
Action Due Description:
Comply Date:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Sub Regulation Description:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:
Buildings & Grounds conducted from 10:30AM-12:00PM. Census: 166
Pebble Creek, Rock Hill, Deerfield and Store observed today. Store for faculty use only at this time.

Pebble Creek had no clients present at this time. Clients in school. 1 bathroom shower nozzle was broken
leaving 3 additional functioning bathrooms with functioning sinks, showers and toilets. 1 bathroom had
scattered spots on the ceiling, the other three bathrooms did not. Sleeping quarters furnished, clean and in
good repair.

Rock Hill observed. Bedroom 1 had chipped paint on the walls. Bedroom 2 had flooring that was not laid
adjacent to the door hinge, leaving an open area that had collected dirt. Bedroom 4 had a missing baseboard.
Bedroom 5 had graffiti on the second shelf of a closet. Bathroom 2 missing shower rings. Flooring in common
area had holes throughout.

Deerfield observed. No patient rights could be found posted in Deerfield. Baseboards in bedroom | tattered
and not connecting. All bedrooms and sleeping quarters observed.

Facility consulted regarding issues found today. Floors in Rock Hill will be contracted out. All other issues to
be addressed by facility maintenance. Facility maintenance issues will be prioritized and ready for review on
or before 4/3/23. Rock Hill floor repair will depend on contracting schedules. Status of Rock Hill flooring will
be reviewed on or before 4/3/23 as well.

MAR checked for:

www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

ss
All initialed and up to date.

Facility cited 901.3 for no posted client rights in Deerfield and 911.6 for multiple repair issues in Rock Hill
and Deerfield.

Provider Comments:

CCL Staff Signature : Date: 3/17/2023

Provider Signature : Date: 3/17/2023

www.arkansas.gov/dhs

Serving more than one million Arkansans each year Page 3 of 3


summary:
Maltreatment
During a therapy session, client reported that a staff member had threatened to “cut his vocal cords” because he wouldn’t stop humming, made him get under a table and pushed a chair against him, made him “stand up in a corner when it was time to go to bed”, and “poked him with a pen” behind his ear and the side of his head. Nurse noted a healed abrasion with scab behind ear. Child Abuse Hotline was called and accepted. Staff member was placed on administrative leave pending the investigation.
Licensing follow-up: Video reviewed on 03/13/23 showed client being directed to stand in the corner from 7:15pm until 9:40pm with brief breaks (on 03/09/23). The office door was open during the entire time reviewed, and a staff member was on her cellphone during most of the video. During further review, a staff member was seen bumping client with her stomach area to direct client back to the corner (Child Abuse Hotline was called separately for this incident) and a client is seen transporting a cleaning agent unsupervised (later determined to be soap).
Unfounded: At no time is alleged staff member seen pushing a chair against client or poking him with a pen.
Founded: Client was observed being directed by 2 staff members to stay in corner area until 9:40pm. On 03/17/23, facility indicated staff 1 remains on administrative leave pending certain termination and staff 2 will be retrained on TCI which encompasses appropriate staff/client interaction.
CACD investigation was unsubstantiated as of 05/03/23. Staff 1 was terminated on 03/23/23. Staff 2 was retrained and has since been terminated as of 05/22/23.
Regs out of compliance –
905.3 – Child stood in the corner from 7:15pm – 9:40pm.
905.4.f – Child stood in the corner from 7:15pm – 9:40pm.
907.2 – Door to the office in video reviewed was open with no staff inside the office for duration of the video. A client is seen transporting what appears to be a cleaning agent unsupervised.
905.4.g – Staff member bumped client with her stomach to direct him back to a corner he had been standing in for an extended period of time.

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: 3/10/2023
Date Received by DCCECE: 3/10/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type:
Incident Type: Dual
Report Description: A report to the was performed. No return
correspondence has been received at the time of this report. Allegation: During a family
session, (Arkansas, Adoptive parent custody, DOB: ) reported to
his therapist and adoptive mother that staff member threatened to
"cut his vocal cords" because he wouldn't stop humming. stated that
made him get under a table and pushed a chair against him. reported that
made him "stand up in a corner when it was time to go to bed". He stated that
"poked him with a pen" behind his right ear and on the right side of his head. Nursing
Assessment: Healed abrasion. Scab noted behind right ear. Estimated to be one week old.
No injury noted in the indicated area on the right side of head. Risk Interview:
was unable to state a day or exact time. He felt this event occurred one or two nights ago on
2nd Shift. (Video review places event on 3.9.23 beginning at 1915). was
interviewed, and he denied s claims. stated that did stand
against the wall, but it was voluntary. stated that it was allowed because
was provoking other patients, and this was to keep him separated and safe. Preliminary
camera review was able to confirm that he did stand against the wall. At the time of this
report, we are unable to substantiate any of the other claims made by . The internal
investigation is ongoing. has been placed on administrative leave,
pending the results of the investigation.
Interim Action Narrative: Staff placed on administrative leave pending investigation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative: call accepted . Info faxed to
3/10/23. AV is . AO is , staff person
at Millcreek. AV reported that AO threatened to "cut his vocal cords" because he wouldn't
stop humming. AO made AV get under a table and pushed a chair against him. He made
him stand in a corner and poked him with a pen behind his right ear. was
interviewed and denied claims. AO placed on administrative leave. Email 5/3/23 stating
that maltreatment was unsubstantiated.
Licensing Narrative: A report to the was performed. No return
correspondence has been received at the time of this report 3/10/23. Email 3/13/23 stated
that for this incident was accepted . Allegation: During a
family session, client reported to his therapist and adoptive mother that
staff member threatened to "cut his vocal cords" because he wouldn't
stop humming. stated that made him get under a table and pushed a
chair against him. reported that made him "stand up in a corner when it
was time to go to bed". He stated that "poked him with a pen" behind his right ear
and on the right side of his head. Nursing Assessment: Healed abrasion. Scab noted behind
right ear. Estimated to be one week old. No injury noted in the indicated area on the right
side of head. Risk Interview: was unable to state a day or exact time. He felt this
event occurred one or two nights ago on 2nd Shift. (Video review places event on 3.9.23
beginning at 1915). was interviewed, and he denied s claims.
stated that did stand against the wall, but it was voluntary.
stated that it was allowed because was provoking other patients, and this was to
keep him separated and safe. Preliminary camera review was able to confirm that he did
stand against the wall. At the time of this report, we are unable to substantiate any of the
other claims made by . The internal investigation is ongoing.
has been placed on administrative leave, pending the results of the investigation. Facility
visited 3/13/23 and video reviewed from 3/9/23 which showed client being directed to
stand in the corner from 7:15PM until 9:40PM with brief breaks. Facility requested to send a
download of video of this complaint. The facility was unable to provide the video today due
to the large amount of video but will mail it to licensing after it is downloaded onto a flash
drive. Video footage also showed office door open during entire time reviewed. Video
showed staff on her cell phone during most of the video reviewed.
Facility cited 905.3, 905.4f and 907.2. Licensing is not prepared to make a finding on this
allegation yet as to further review video. As to document sub-regulation f: The following
disciplinary actions shall not be used: Restriction to a dark room or area. 3/14/23 flash drive
of entire video provided by facility to Licensing. Video was viewed in real time in its entirety
on 3/16/23. Staff is seen bumping client with her stomach area to
direct back to the corner. The was called separately for this
incident involving and . A client is seen transporting what

appears to be a cleaning agent unsupervised. Client goes into the unlocked office, retrieves
a cleaning agent and presents it to staff sitting at table. The staff then pour some of the
cleaning agent on a rag and give rag to client. Client then transports the cleaning agent
back to the unlocked office unsupervised. Facility has already been cited 907.2 for this case.
907.2 revisited and noted for visit to facility 3/17/23. Facility cited 905.4g for incident
involving staff and client Staff will be retrained on
interacting with clients without exhibiting threat of bodily harm. Email 5/3/23 stating that
maltreatment was unsubstantiated. was terminated from employment
from Millcreek 3/23/23. was retrained and has since been terminated
from employment from Millcreek 5/22/23.


summary: A resident was sent to Dallas County Medical Center for an x-ray after he was punched in the nose 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: 3/9/2023
Date Received by DCCECE: 3/10/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , (AR, Guardian Custody, DOB: ) was sent
for outpatient x-ray at Dallas County Medical Center. He engaged in physical confrontation
with a peer and was punched in the nose. Nurse assessment noted slight swelling to the
bridge of the nose. He was referred for x-ray by the medical director. X-ray report reflects
that no fracture was present. He was released and returned to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:On 3/9/23 client was sent for outpatient x-ray at
Dallas County Medical Center. He engaged in physical confrontation with a peer and was
punched in the nose. Nurse assessment noted slight swelling to the bridge of the nose. He
was referred for x-ray by the medical director. X-ray report reflects that no fracture was
present. He was released and returned to the facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for x-rays after reporting pain and bruising to his hand from punching 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: 3/8/2023
Date Received by DCCECE: 3/9/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , (Kentucky, DCBS Custody, DOB: 1 ) was sent
for outpatient x-rays at Dallas County Medical Center. He punched a peer on 3.7.2023. The
initial nurse assessment indicated that no pain was verbalized, and no injury was observed.
On 3.8.2023 he reported pain and bruising in his hand/wrist area. X-ray report indicated
that there was no fracture. He was released back to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Client was sent for outpatient x-rays at Dallas County
Medical Center. He punched a peer on 3.7.2023. The initial nurse assessment indicated that
no pain was verbalized, and no injury was observed. On 3.8.2023 he reported pain and
bruising in his hand/wrist area. X-ray report indicated that there was no fracture. He was
released back to the facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility for a report of an escapee. A staff member advised that a resident ran away through the woods towards Johnson’s Furniture. The resident was later located by Millcreek staff.

raw_content:
MAR/21/2023/TUE 11:36 AM Fordyce Police Dept PAX No, 870-352-8187 P. 002

Incident # _23-00210 Fordyce Police Department Report Date __ 02/07/23
Page 4 of 2 Incident Report . Report Time 9:14 AM
Status Exeaptior Claarance Date Reporting Officer ORWVAgency
Closed Not Applicable 101 Hubanks, Chief Chad ARO200100
Assigned Officer Entered By =| Approving Officer
Hubanks, Chief Chad chubanks | Vaughan, Chief Jimmy

Assisting Officers

Contact Name

Mill Creek Of Arkansas
Business Address
1810 Industrial DR,Fordyce, AR 71742
Offenses ;

Incident Location

1810 Industrial DR Fordyce, AR 71742

Earliest Possibla Date Latest Possible Date Time
03/06/2023 03/06/2023 12:10

Business Phone
8703528203

Time
12:00

# |Stat om ok AtvComp jLoc |Bias
§-54-112 3RD DEGREE ESCAPE / ESCAPES FROM CUSTODY Completed} 5
Mo Method Of Entry # Prems
Wa ie)
Location Types 13 Hway/Road/Allay 47 Abandonad/Condermned 42 Industrial Site Bias Motivetion Codes
14 Hotel/Mate} Structura 49 Military Installation 43 Lesbian, Gay, Bisexual,
01 Air/Bus/Train Terminal 15 Jall/Prison 38 Amusement Park 50 Park/Playground ANTI- 23 Protestant or Transgender, Mixed
02 BankW/S&L, 16 Lake/Waterway 39 Arena/Stadium/Fair 51 Rest Aree 11 White 24 Islamic (Musilm) Group (LGET}
03 Bar/Night Club 17 Liquor Store grounds/Catizeum 52 School - 12 Black or African 25 Other Religion 44 Heterosexual
04 Church/Synag/Temple 18 Parking LovGarage 40 ATM Separate from Bank Callege/University American 26 Multi-religious group 45 Bleexusl
05 Commercial/Off Bldg 19 Rental Storage 41 Auto Dealership 53 School - 13 American Indian or 27 Athelst/Agnostic 51 Phys Qisability
08 Canstruction Site Faclllty New/Used Elementa-y/Secondary Alaska Native 31 Arab 52 Mental Disability
07 Convenience Store 20 Residenca/Home = 42. Camp/Campground 54 Shelter - 14 Asian 32 Hispanic ov Latino @1 Male
08 DepyOiscount Store 271 Restaurant 44 Daycare Facility Mission/Homeless 15 Multtaces, Group «39 Not Hispanic or 62 Female
09 Drug Str/Or Of/Hosp 24 Service/Gas Station 45 Dock/WhartiFreight’ 55 Shapping Mall 18 Nativa Hawallan or Letina 71 Transgender
10 Field/Woods 2¢ Specielty Store Modal Terminal Sé Tribal Lands Other Pacificlslander 41 Gay (ale) 72 Gender Non-Conforming
14 Gave Public Bldg 25 Unknown/Other 46 Farm Facility 57 Community Center 24 Jewish 42 Leablan 88 None
12 Grocery/Supermarket 47 Gambling 58 Cyberspace 22 Cathalic -, 99 Uriknawn
Faallty/Cagina/Pace Track
Suspected Of Using Criminal Activity Types Weapon Type(s) 20 Knife/Cutting Instr 65 Fire/iceendiary Davie
None B Buying/Recelving ¢ Cuttivating/Manut/Publishing 11 Firearm (Auta) 30 Blunt Object 70 Druge/Nare./Sleeping Pills
P Passessing/Concealing © Operating/Promoting/Assisting 12 Handgun (Au‘o) 35 Motor Vehicle 85 Asphyxlaton
D Dietributing/Sel'ing T Transpot/lmpor/Transmit 13 Rifle (Auto) 40 Personal Weapang 90 Other
E Explolting Children U Using/Gansuming 14 Shatgun (Auto) 50 Polaon 95 Unknown
15 Other Firearer 60 Explosives 99 None
A Simple/Gross Neglect | Intentional Abuse & Tarment
F Organized Abuse § Sexual Animal Abuse

Mietin: #1. [ils Complainant |. Event és Related Ex
Name Contact Name
Mill Creek Of Arkansas

Business Address Business Phone
1810 Industrial DR,Fordyce, AR 71742 8703528203

Victim Type Injury Type Aggravated Assault/Homicide Circumstances Relationship Te Suspect
Business None, None #1 NIA

Justifiable Hornicide Circumstances Taken to: (Hospital Name)
None

Injury Description

Copyright Relativity inc.@ - RPS(Relativity Public Safety)
Printed : 3/21/2023 10:29:07 AM

MAR/21/2023/TUE 11:36 AM Fordyce Police Dept PAX No, 870-352-8187 P. 003
Incident #__23-00210 Fordyce Police Department Report Date __ 05/07/28
Page 2 of 2 Incident Report Report Time 9:14 AM

SSNAD/TIN

Sex |Resident Status
M Unknown

Race White Ethnicity DL (#, ST)

Not Hispanic/Latino

Home Phone

US Citizan
Yes

Nationality

| Home Address
© 1810 Industrial DR,Fordyce, AR 71742

Work Address

Employer

Height

Narrative & Statements

Narrative - Hubanks, Chief Ghad - 3/6/2023 12:10:24 PM (Initial)

On March 6, 2023 at approximately 1210 hours, | was dispatched to Mill Creek for

a report of an escapee. Upon arrival | spoke with Jerry Harrison and he stated that
a White male had ran a way through the woods towards Johnson’s

Furniture. Mr. Harrison gave me the face sheet on i that had his
information, AAA as located by Mill Creek staff at approximately 1800

hours. |

Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed ; 3/21/2023 10:29:07 AM


summary: A resident was sent to Dallas County Medical Center for an x-ray of his hand after punching a cinderblock wall.

raw_content:
applied and released to return to the facility. Will schedule a follow up with Arkansas
Children's Orthopedic in one week. 3/6/23 email sent to facility to inform licensing of
results of follow up appointment.


summary: A resident was sent to Dallas County Medical Center for an x-ray after he slipped in the mud and then complained of right shoulder 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: 3/4/2023
Date Received by DCCECE: 3/6/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , (Nevada, parent custody, DOB: ) was returning
to his living unit from an outdoor activity and slipped in the mud. He complained of pain to
his right shoulder. Nursing assessment noted redness and slight bulging to the right
shoulder. He was referred to Dallas County Medical Center for outpatient x-ray. X-ray
report revealed no fractures or dislocations.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Client was returning to his living unit from an outdoor
activity and slipped in the mud. He complained of pain to his right shoulder. Nursing
assessment noted redness and slight bulging to the right shoulder. He was referred to
Dallas County Medical Center for outpatient x-ray. X-ray report revealed no fractures or
dislocations. Client remains at facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/10/2023
Date Received by DCCECE: 2/13/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: Client , DOB , IA Foster Care, was sent for x-ray
on Friday, Feb. 10th. He was punched in the nose by a peer. Medical director examined him
and referred for outpatient x-ray at Dallas County Medical Center. The diagnostic report
indicated that there were no fractures found.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client , DOB IA Foster Care, was sent for x-ray
on Friday, Feb. 10th. He was punched in the nose by a peer. Medical director examined him
and referred for outpatient x-ray at Dallas County Medical Center. The diagnostic report
indicated that there were no fractures found. Client remains at facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray after falling and hurting his right forearm and wrist while playing basketball.

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: 2/5/2023
Date Received by DCCECE: 2/6/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (Washington D.C., Parent Custody, DOB: )
reported continued pain from a recreational injury he incurred on 2.2.23. He stated that he
had fallen during an outdoor basketball game, hurting his right forearm and wrist. Staff
reported the injury to the nursing department and supervisor. Nursing assessment: Swelling
noted to right forearm. PO given. Complaint of pain 3/10. Referred for
outpatient x-ray at Dallas County Medical Center. Diagnostic report found no fractures.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: reported continued pain from a recreational injury
he incurred on 2.2.23. He stated that he had fallen during an outdoor basketball game,
hurting his right forearm and wrist. Staff reported the injury to the nursing department and
supervisor. Nursing assessment: Swelling noted to right forearm. PO given.
Complaint of pain 3/10. Referred for outpatient x-ray at Dallas County Medical Center.
Diagnostic report found no fractures. Client remains at facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray after he was punched in the face 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: 2/5/2023
Date Received by DCCECE: 2/6/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (Nevada, Parent Custody, DOB: ) engaged in a
physical confrontation, where he was punched in the face by a peer. The patients were
separated and assessed by nursing. Nursing assessment: Pain reported at 7/10. Bruising
noted to both lower eye areas with swelling and bruising to nose. Sent for outpatient x-ray at
Dallas County Medical Center. Diagnostic report indicated that no fractures were found.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: engaged in a physical confrontation, where he was
punched in the face by a peer. The patients were separated and assessed by nursing.
Nursing assessment: Pain reported at 7/10. Bruising noted to both lower eye areas with
swelling and bruising to nose. Sent for outpatient x-ray at Dallas County Medical Center.
Diagnostic report indicated that no fractures were found. Client remains at facility. Email
sent 2/6/23 to inquire of video footage of the incident. Received email from facility 2/6/23
that the incident occurred in a client bedroom. No video footage available. Facility visited
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

2/9/23. interviewed. stated that he and were
"horseplaying", then it got "serious". stated it took "about one or two minutes" before
staff broke up the fight. stated that he feels safe at this facility. stated that he feels
comfortable telling staff if he is ever threatened or harmed. interviewed.
stated that he and were "horseplaying" then he ( ) fought after about "two
minutes" of continued horseplay. stated that after about "5 minutes" another peer
present, , went to get staff. Staff immediately separated and .
stated that he felt safe at this facility. stated that he felt comfortable telling staff if he
were threatened or harmed. interviewed. stated that and fought for
about "3 minutes" before he ) went to get staff. stated that staff immediately
separated and . stated that he felt comfortable notifying staff he was threatened
or harmed. stated that he felt staff would keep him safe.


summary: A resident was sent to Dallas County Medical Center for an x-ray after injuring his hand by punching a tree.

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: 2/3/2023
Date Received by DCCECE: 2/3/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: On 2.2.2023, (AR, DHS Custody, DOB: )
reported to his therapist that several days earlier he had injured his hand. He was unable to
report an exact date and time for the injury. He stated that he had punched a tree after he
became upset with another patient. Upon observation, the therapist observed swelling and a
small laceration to a knuckle and reported the injury to the nursing department for
assessment. Nursing assessment: Swelling and laceration noted on right hand. Referred for
outpatient x-ray at Dallas County Medical Center. No diagnostic report has been received at
this time.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: On 2/2/23 client complained to staff of pain in his hand from
punching a tree. Client is scheduled for X-ray 2/3/23 with Dallas Co Medical Center.
Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary:
A complaint received states: My daughter was at Millcreek for treatment for 6 weeks. She was treated poorly by staff. They would yell at her. They were constantly yelling and cussing at the other children there. She wasn’t being given her medication properly.
The facility was cited 908.8 and 905.4.c as a result of this complaint.

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: 2/2/2023
Date Received by DCCECE: 3/9/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type:
Incident Type: Licensing
Report Description: My daughter was at Millcreek for treatment for 6 weeks.
She was treated poorly by staff. They would yell at her. They were constantly yelling and
cussing at the other children there. She wasn?t being given her medication properly.
Interim Action Narrative: The facility reports that they will complete their "Nurture Heart"
training with the staff listed on the complaint, supervisory training for the unit coordinator
and will conduct ongoing monitoring of the unit. Nurture Heart certificates of completion
for
Maltreatment Narrative:
Licensing Narrative: 3/10/23- Reporter was contacted via telephone by licensing supervisor
Chelsea Vardell. Information was gathered regarding the complaint and the case was
assigned to Specialist Clayton DeBoer. 3/13/23- Program Coordinator Chelsea Vardell and
Specialist Clayton DeBoer visited the facility to collect more information regarding this
complaint. Licensing received a complaint on 3/9/23 regarding an accusation that several
staff members had yelled and cussed at residents on the Zebra Hall. Additionally, when a
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

resident reported the concerns, the resident was retaliated against by the staff. The
complaint also listed concerns about a resident who did not receive her medication as
prescribed (a that is supposed to be taken one hour prior to eating and
not taken with any other medications). The complaint stated that the residents were not
being allowed to do things such as have recreation, phone calls with family, or go to school
if any of the residents were having "acting out" behaviors. Licensing spoke to Chris Butler
who provided the last names of the staff listed in the complaint. The facility was already
aware of the allegations and had performed in service training for several of the staff listed
on the complaint regarding cleanliness, recreational activities, supervision, and not
cancelling activities due to other residents' behaviors. Licensing spoke to the DON and a
unit nurse who stated that the should be given at 6am from the night
nurse, breakfast is at 7am, then all remaining morning medications should be given at 8am.
However, the MARs documentation for resident showed that her
and were being given at 8am by the morning nurse. Licensing discussed ensuring
that all medications required to be given at 6am before breakfast are documented as 6am on
the MARs and given to residents accordingly. The facility reports that they spoke to their
pharmacy consultant who reported that there is not contraindications between and
being administered at the same time. Licensing interviewed the following residents
, , , and . It was noted that staff do occasionally yell and use profanity on
the unit. The facility reports that they will complete their "Nurture Heart" training with the
staff listed on the complaint, supervisory training for the unit coordinator and will conduct
ongoing monitoring of the unit. Nurture Heart certificates of completion for Zebra Hall
staff involved in this complaint sent from facility 4/11/23. On 3/13/23 facility cited 905.4c
and 908.8. Phone call and email sent to facility 3/21/23 asking for MAR indicating
is given at 0600. is no longer at facility. MAR requested for other clients on
similar medication and that is is being distributed at 0600.


summary: A resident was sent to Dallas County Medical Center for an x-ray after slipping and 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: 1/31/2023
Date Received by DCCECE: 2/1/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (IL, DCFS Custody, DOB: ) left the cafeteria
after eating lunch. While exiting the cafeteria, she slipped on a wet floor tile and fell to the
floor. She reported ankle pain to her staff and was brought to the nursing station for
assessment. Nurse Evaluation: Reports left ankle pain of 4 out of 10. No swelling, bruising,
or abnormalities observed. Patient walking with a slight limp. No other injuries noted.
Medical director assessed her and referred her to Dallas County Medical Center for
outpatient x-rays. Diagnostic report indicated that there were no fractures.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client fell on the floor in the cafeteria and complained
of pain in her ankle. Client sent to Dallas Co Medical Center which yielded no fractures.
Client remains at facility. Continue to monitor.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray of her ankle after tripping and 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: 1/31/2023
Date Received by DCCECE: 2/2/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (MO, DSS Custody, DOB: was leaving the gym
to return back to her living unit. She started running, tripped and fell to the ground. She
reported left ankle pain and was assessed by the nurse. Nurse Assessment: Left ankle pain.
No swelling, bruising, or abnormalities. Noted to be walking with a slight limp. No other
injuries noted. On 2.1.22, she reported continued pain. She was assessed by the medical
director and sent for outpatient x-ray at Dallas County Medical Center. Diagnostic report
indicated that there were no fractures.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: On 2/1/23 client complained of pain in her ankle from
tripping. Client was sent to Dallas Co Medical Center 2/2/23 for X-ray. No fracture
detected. Client remains at facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray of his knee after slipping while playing basketball.

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: 1/30/2023
Date Received by DCCECE: 1/31/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (IA, parent custody, DOB: ) was engaged in a
recreational game of basketball. He was trying to go after the basketball and slipped,
bending his left leg back and hitting his knee on the floor. He presented to the nurse with
left lateral knee pain. He was referred to Dallas County Medical Center for an outpatient x-
ray. Diagnostic report indicated that there was no fracture. He will receive a follow-up
assessment with PCP on 1.31.23.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client was engaged in a recreational game of basketball.
He was trying to go after the basketball and slipped, bending his left leg back and hitting
his knee on the floor. He presented to the nurse with left lateral knee pain. He was referred
to Dallas County Medical Center for an outpatient x-ray. Diagnostic report indicated that
there was no fracture. He will receive a follow-up assessment with PCP on 1.31.23. Client
remains at facility.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for x-rays after he was punched in the face 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: 1/30/2023
Date Received by DCCECE: 1/31/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (AR, DHS Custody, DOB: ) engaged in a
verbal confrontation with peers. The peers became upset and approached him aggressively.
Staff stood between the patients but a peer punched in the face. Two other peers
joined in the confrontation, displaying physical aggression towards . Staff were able to
separate and de-escalate the patients. Nurse assessment indicates bruising and swelling to
left eye. Tylenol and icepack provided. Referred to DCMC for outpatient x-rays. Diagnostic
report indicates a . He received a referral to Arkansas
Children's Hospital for follow-up treatment. This appointment will be scheduled by ACH.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: On 1/30/23 client was involved in an altercation with a
peer and was punched in the face. X-ray from Dallas Co Medical Center indicated a
to the . Follow up appointment to be scheduled with ACH. Client remains
at facility. Facility visited 2/3/23. Video reviewed from 1/30/23. Staff/client ratio seen in
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

the incident 3:7. Staff used bodies as barriers to intervene between clients in altercation.
Male staff member observed grabbing clients by their shoulders to move them away from
altercation. 2 female staff seen using bodies as barriers between clients in altercation. No
inappropriate holds observed. Staff appeared to be attempting to provide supervision and
care to each child during the incident. Safety Plan and Witness Statements of staff involved
attached to investigation for this case.

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: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Chelsea Vardell
Person In Charge: Chris Butler
Record Visit Date: 3/3/2023
Home Visit Date: 3/3/2023
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulation Number: 1. 109. 1 .g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Staff aggressively pushed residents several times during the course of an incident that
occurred at Pebble Creek on 1/30/23.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 9. 907. 2
Regulation Description: Child caring staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s
age, individual differences and abilities, surrounding circumstances, hazards and risks.
Findings Description: Three staff failed to ensure the safety and well-being of a resident who was attacked on
the unit by multiple residents.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
On 1/30/23 an incident involving multiple altercations between residents and the serious injury of a resident occurred in the Pebble
Creek Cottage at the facility. Review of the video showed 3 staff members involved. Staff and can be seen slowly
engaging with clients in attempts break up fights involving client and other residents. Once a big fight breaks out, Staff .
can be seen with his hands in his pockets in the middle of the fight and pushing multiple clients. Staff is slow to respond but
does attempt keep clients separate. Staff can be seen using her body as a shield in some instances to try and protect clients. At
no time during the incident did staff attempt to call for help. After further review by licensing, it has been determined that staff
failed to provide adequate supervision to ensure the safety and well-being of the residents and one staff engaged in unprofessional
conduct when he aggressively pushed several residents' multiple times during the incident.
The facility will be cited for 907.2 and 109.1.g.
During the 3/3/23 visit, Millcreek's TCI (Therapeutic Crisis Intervention) instructors were present to view the video. Training for
staff involved in this incident will include Protective Interventions, Proximity, and the use of codes when in a crisis
situation. Discussion occurred around the programming during that time of day during transition. During the discussion, I was
informed that staff are sitting outside the view of the camera at the table working on case notes because it is shift change during the
video. Staff should not all be sitting at the table together; they should be engaging with the residents. If staff need to complete
paperwork, they should be mixed around the common area. Or staff may take turns sitting at the table completing end of the shift
paperwork. If staff realize clients are overly stimulated, they should be actively engaging using the skills learned in training.
Please ensure that all three involved staff are retrained on appropriate interventions when handling an acting out resident prior to
returning to work with any resident at the facility. Documentation of the retraining shall be submitted to the Licensing Unit for
review. This training should include facility protocol regarding de-escalation techniques, to include but not limited to, removing
other residents out of the area of an acting out resident. Training shall be completed as soon as possible. Documentation of the
retraining shall be submitted to the Licensing Unit for review.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

Provider Comments:
CCL Staff Signature : Date: 3/3/2023
Provider Signature : Date: 3/3/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: Licensing visited the facility to review children’s records. 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
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge: Chris Butler
Record Visit Date: 1/27/2023
Home Visit Date: 1/27/2023
Purpose of Visit: Child Record Review Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
Clients Records reviewed for:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

All items per Minimum Licensing Standards accounted for.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


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
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge: Chris Butler
Record Visit Date: 1/24/2023
Home Visit Date: 1/24/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
Buildings & Grounds conducted from 10:30AM-11:30AM. Census: 162
Magnolia and Eagle Hall observed to be furnished, clean, safe and in good repair. Shower areas/bathrooms
observed to be clean and sanitary with functioning sinks, showers and toilets.
Staff/client ratio in Magnolia Hall: 2:12. Eagle Hall clients were in school during this visit.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

MAR checked for:
All initialed and up to date.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for an x-ray of his arm after slipping while getting out of the shower.

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: 1/20/2023
Date Received by DCCECE: 1/23/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: , (Maryland, DHR Custody, DOB: ) reported
that he slipped while getting out of the shower. He fell on his right arm. Nursing report
indicated pain while rotating right arm, palms were bluish in color, and light swelling noted.
He reported having broken that arm 3 or 4 times before. He was sent for x-ray assessment at
Dallas County Medical Center ER and diagnosed with a of
the He was provided a wrist brace and sling and was released to return to the
facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Client reported slipping while getting out of the
shower. Client sent to Dallas Co. Medical Center and diagnosed with a
. He was provided a wrist brace and sling and was
released back to facility. Email sent to facility 1/23/23 as to follow up with possible slipping
hazard in the shower area. Received email from facility 1/23/23 that Risk Mgmt. Chris
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Butler observed the area and did not see anything that would increase the potential for
slipping. Facility visited 1/24/23 for Buildings & Grounds. Shower area observed to have
slip resistant tile with no water build up.


summary: A resident was sent to Dallas County Medical Center for an x-ray after punching a door with his fist while upset that a peer had punched him in the back.

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: 1/16/2023
Date Received by DCCECE: 1/17/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: 1?16/23 @ (Texas, DFPS Custody, DOB:
became upset when a peer punched him in the back as they returned to the living unit after
eating lunch. No physical confrontation occurred, but staff separated the patients. After
entering the living unit, punched the bedroom door with his fist. Staff provided
counseling, encouraging alternative choices for coping strategies. Nurse assessment noted
slight bruising to left hand 5th digit. He complained of 4/10 pain and received . On
1.17.2023 he continued to complain of pain. He was sent to Dallas County Medical Center
ER for x-ray. No diagnosis or report has been received at the time of this report.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: On 1/16/23 client became dysregulated and punch
a wall. complained of pain on 1/17/23 and was sent to Dallas Co. Medical ER for X-ray.
Email sent to facility 1/17/23 to inform licensing of the X-ray results. Received email from
facility 1/18/23: X-ray results indicated a . Joints are maintained. Impression was a
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

of the . He will be seen by our medical director today for a
decision on treatment.


summary: Licensing visited the facility to review children’s records. The facility was cited 902.3 for missing records.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge: Chris Butler
Record Visit Date: 1/13/2023
Home Visit Date: 1/13/2023
Purpose of Visit: Children’s Records
Regulations Out of Compliance:
Regulation Description: Each child shall have proof of current immunizations; a letter of exemption in
accordance with the Arkansas Department of Health or a scheduled appointment within one (1) week after
admission.
Sub Regulation Description:
Regulation Number: 9.902.3
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

Childrens Records reviewed:
Clients and did not have immunizations or proof of requesting immunizations. Facility cited
902.3.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


summary: A resident was sent to Dallas County Medical Center after swallowing Pine Sol cleaner. The facility was cited 910.1 and 907.2 for issues identified in this incident.

raw_content:
County Medical Center ER for assessment and assessed/monitored for 6 hours. Otherwise,
no treatment was determined necessary. He was released into Millcreek care and placed on
1:1 supervision until 1.16.2023. Suicide assessment conducted on 1.16.2023 and 1:1 was
discontinued following the assessment. Follow up email sent to facility 1/17/23 to check on
status of client. Email received from facility that client has been incident free since Friday.
Client stated that he is remorseful for his actions and will not do that again. No site visit
conducted 1/17/23. Facility cited 907.2 and 910.1. Safety hazard was accessible to client.
Client was not supervised for a length of time long enough to ingest safety hazard.


summary: A resident was sent to Dallas County Medical Center for an x-ray following a physical altercation 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: 1/11/2023
Date Received by DCCECE: 1/13/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: On 1/11/2022, (Arizona, Parent Custody, DOB:
engaged in a physical altercation with a peer. Initial nursing assessment revealed no
swelling, bruising, or deformity of the right knee. He was given Tylenol and told to elevate
the leg. On 1/12/2022, he reported that he continued to have pain in the right knee. He was
sent to the Dallas County Medical Center ER for x-ray. X-ray report indicated that there was
no fracture.
Interim Action Narrative:
Maltreatment Narrative: Outcome:
Licensing Narrative: On 1/12/23 client was sent to Dallas Co. Medical Center
for an X-ray after complaining of pain in his knee from an altercation with a peer. No
fracture detected.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray of his right hand after a physical altercation 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: 1/11/2023
Date Received by DCCECE: 1/13/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: On 1/11/2022, ( , Parent Custody, DOB:
) engaged in a physical altercation with a peer. Initial nursing assessment revealed
no complaints or injuries involving the right hand. On 1/12/2022, he reported to the nurse
that he woke up with swelling and pain in the right hand and that he experienced difficulty
throwing a football during recreational therapy. He was sent to the Dallas County Medical
Center ER for x-ray. X-ray report indicated that there was no fracture.
Interim Action Narrative:
Maltreatment Narrative: Outcome:
Licensing Narrative: On 1/12/23 client was taken to Dallas Co. Medical
Center after complaining of pain in his right hand after an altercation with a peer. No
fracture detected.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the emergency room after swallowing batteries from a television remote.

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: 1/3/2023
Date Received by DCCECE: 1/4/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Facility Type: Residential
Incident Type: Licensing
Report Description: (West Virginia, DHHR Custody, DOB: )
reported to staff members that at 6:30pm, she had removed the batteries from a television
remote and swallowed them. Nurse assessment was conducted and no distress or breathing
difficulty was noted. She was sent to ER for evaluation and x-ray. X-ray report states a
metallic foreign body was present in the stomach. No obstructions were noted. Doctor
orders .
Interim Action Narrative:
Maltreatment Narrative: Outcome:
Licensing Narrative: Client reported to staff that she had swallowed the
batteries from a television remote. Client was taken to ER and X-ray performed yielding
. for
additional X-ray. Facility informed licensing 1/13/23 that on 1/5/23 and X-ray follow up
was performed .
. No follow up appointment needed.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


facility_name: Perimeter Behavioral of Forrest City

summary: A resident was sent to the ER for evaluation after injuring his hand when he physically assaulted a peer.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 032384
Date of Incident: 08/22/2025
Date Received: 08/25/2025
Facility Name: Woodridge Northwest LLC
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Under Review
DPSQA - Incident & Accident - OLTC
Report Description: Resident, , physically assaulted a peer while lining up
to transition to Hall. Resident right hand swollen and bleeding. Laceration noted between
his knuckles. Right hand wrapped in towel to control bleeding. Physician notified and
orders received to apply ice pack to right hand and send Reside to for further evaluation.
Resident left for at 2109 (9:09 pm).
Resident returned to the facility with transportation from
at approximately 0520 (5:20 am) with
Resident has Rx for q6 hours and for pain.
Guardian notified and reconciliation form completed. Resident denies pain at this time.
Camera footage reviewed and Resident interviewed by Safety team morning of 08/25/2025.
Resident assaults peer at 19:55:24. Staff swiftly intervened at 19:55:26. Resident and peer are
peer restricted. Resident and peer are peer restricted. Resident is on activity restriction until
further evaluation due to .
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the ER for treatment after he was physically assaulted by a peer.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 032385
Date of Incident: 08/22/2025
Date Received: 08/25/2025
Facility Name: Woodridge Northwest LLC
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Under Review
DPSQA - Incident & Accident - OLTC
Report Description: Resident, , physically assaulted by a peer while lining up to
transition to resulting in a superficial laceration to his right eye lid. Bleeding and
swelling noted. Physician notified and orders received for neuro checks for 48 hours, apply
ice pack and to send Resident to for further evaluation
Resident returned to the
facility with transportation from at approximately 0355 (3:55
am). Resident denies pain at this time.
Camera footage reviewed and Resident interviewed by Safety team morning of 08/25/2025.
Resident was assaulted at 19:55:24. Staff swiftly intervened at 19:55:26. Resident and peer are
peer restricted.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for an x-ray after injuring his hand by punching walls.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 032249
Date of Incident: 08/19/2025
Date Received: 08/20/2025
Facility Name: Woodridge Northwest LLC
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Under Review
DPSQA - Incident & Accident - OLTC
Report Description: Resident, , was in the quiet room and started
punching the walls which caused bruising and swelling to his Right hand. Physician
notified and orders received to send to Resident for X-ray. Resident oriented to person,
place, time, and situation. Breathes even and skin intact. Bruising noted to knuckle area.
Full movement noted to fingers and hand.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to a juvenile who was physically aggressive to staff members.

raw_content:
FORREST CITY rae 1 Incident

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FORREST CITY, AR. 72335

Crime / Incident (Primary, Secondary, Tertiary) as aera |__| ie | ae

5-13-203 BATTERY 3RD DEGREE | On or Fron] 07/20/2025 | 16:03 | Sun |
[eras [|S

[Reported [07/20/2025 | 16:03 | Sun_|

Location of Incident Kittle Road, Forrest City, AR Latitude / Longitude County
TFRA
Cross Street 1521 ALBERT ST 5

"RP" = Reporting Party "W" = Witness "S" = Suspect "O" = Other

Last, First, Middle (Firm if Business) Age Hair Home Phone
a ee |
Address DL Number State Work Phone

Pe ed Pant oll | ee

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FORRES TCITY AR 72335

Last, First, Middle (Firm if Business) Hair Eyes Home Phone
7 a ie
a fer |

AR_ | (870)

City, State, Zip Code Local ID # Cell Phone
Peyonmesromy an rans fff
pee eee

Address DL Number State | Work Phone

ml — = =— eye, | [ae [eee

Synopsis

Continuation PropertyList
Press Domestic Violence
UCR
cane
ili

Report Complete/Ready for Review [XJ CADICFS Event# 2507200012

222222222222

Assigned To Date 07/20/2025

Revie Approved Date
Offer iD _ DAVIS, JERIMIAH 585 DAVIS, CURTIS 07/20/2025

Printed By/On: 412 / 08/27/2025 14:16:20
CrimeStar® Law Enforcement Records Management System
Licensed to; FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page 2 Incident conta
POLICE DEPARTMENT Harvative inekient# 2507200012
aoe graans earrenvanooeorcee LET] SSSCid |

On July 20, 2025, I, Officer Davis, was dispatched to Perimeter Behavioral
Center in reference to an individual requesting to file a police report. Upon
arrival, I made contact with the complainant, identified as Mr. Davin Branch.
Mr. Branch advised that he wish report an incident involyj : nile
resident, identified as a According to Mr. eae
physically aggressive toward female staff members at the facility. In response,
Mr. Branch intervened and initiated a Physical Restraint Technique (PRT) in
accordance with facility protocol to prevent further escalation.

While attempting the restraint, Mr. Branch stated that actively
resisted and made multiple attempts to cause him physical harm. During the
struggle, reportedly bit Mr. Branch and also grabbed his groin area.
Mr. Branch indicated chat nes exhibited similar aggressive behavior in
the past, both toward him and other staff members.

This report has been documented, and further investigation and actions are
pending.

Reviewed By Approved Date
OffcerID DAVIS, JERIMIAH 585 DAVIS, CURTIS Yi 07/20/2025

ES
Printed By/On: 412 / 08/27/2025 14:16:22
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT


summary: A resident was sent for evaluation after injuring his hand by punching walls.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 031315
Date of Incident: 07/16/2025
Date Received: 07/17/2025
Facility Name: Woodridge Northwest LLC
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Complete
Report Description:
Resident, , reported pain and bruising to his right hand. APRN notified.
Resident stated that injury was from punching walls. Order for x-ray received. Resident
oriented to person, place, time, and situation. Breathes even and skin intact. Bruising noted
to knuckle area. Full movement noted to fingers and hand. Resident returned to the facility
with transportation from at approximately 1505 (3:05 pm).
Breathes even and skin intact. Vitals: Temperature, 98. BP 123/70. Heart rate 79 bpm. 18
respirations. Oxygen 100%
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Deficiencies were noted during the Complaint Survey performed on 7/14/2025. A Corrective Action Plan was submitted and approved.

raw_content:
Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
August 7, 2025
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
Dear Ms. Lockhart:
During the Complaint Investigation Survey conducted on July 14, 2025, your facility was found to be
in compliance with program requirements. Please email the signed CMS 2567
Breanna.marengo@dhs.arkansas.gov.
If you have any questions, please contact your reviewer:Breanna Maregno at 501-320-6280 or email
to Breanna.Marengo@dhs.arkansas.gov.
Sincerely,
for Jeff Rosenbaum
Breanna Marengo, RN QA Reviewer
DPSQA/Office of Long Term Care
Survey and Certification Section
bbm

Division of Provider Services
& Quality Assurance
P.O. Box 8059, Slot S404
Little Rock, AR 72203-8059
August 7, 2025
Charlotte Lockhart, Administrator
Woodridge Of Forrest City, Llc
1521 Albert St
Forrest City, AR 72335
Dear Ms. Lockhart:
On July 14, 2025, we conducted a Complaint Investigation Survey at your facility. You have alleged
that the deficiencies cited on that survey have been corrected. We are accepting your allegation of
compliance and have approved your plan of correction and presume that you will achieve substantial
correction by August 16, 2025.
We will be conducting a revisit of your facility to verify that substantial correction has been achieved
and maintained.
If you have any questions, please contact your reviewer: Breanna Marengo at 501-320-6280 or email
to: breanna.marengo@dhs.arkansas.gov.
Sincerely,
for Jeff Rosenbaum
Breanna Marengo, Reviewer
DPSQA/Office of Long Term Care
Survey & Certification Section
bbm
Charlotte Lockhart - Woodridge Of Forrest City, Llc -- -- (AOLTC-14) Page 1

doc_type: Complaint Survey


summary: A resident was sent to Forrest City Medical Center for assessment after complaining of pain from playing basketball.

raw_content:
Division of Provider Services & Quality Assurance
Office of Long-Term Care
P.O. Box 8059, Slot S404, Little Rock, AR 72203-1437
R
Notice of Serious Incident
Case Number: 031154
Date of Incident: 07/10/2025
Date Received: 07/11/2025
Facility Name: Woodridge Northwest LLC
Incident Type: DPSQA - Incident & Accident - OLTC
Case Status: Under Review
Report Description:
Client met APRN with complaint of achy left knee pain from ?playing basketball weeks
ago.? Orders for Resident to be sent out to Forrest City Medical Center for x-ray and for
Resident to be placed on activity restriction until results are received and pain subsides.
Client oriented to person, place, time, Name of Perimeter Staff Making Notification Date
Time Name of Person Notified Office of Long-Term Care Immanuel Morris 07/11/2025
2:15 pm cst ELS Disability Rights Center, Inc. Immanuel Morris 07/11/2025 2:15 pm cst
Ashlyn Whelchel, Reagan Stanford Fax #: 501-296-1779 and situation. No facial grimacing
noted. No deformities noted. Resident able to perform full range of motion to left knee. No
bruising noted
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humanservices.arkansas.gov


summary: A resident was transported for an x-ray after punching a wall in the gym.

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Notice of Incident
Case Number: 030846
Date of Incident:
Date Received: 6/30/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident was sent to for further evaluation of his
right hand. Resident punched a wall in the gym 06/26/2025. Swelling noted to his left pinky finger,
and ring finger knuckles. Resident rates pain 10/10 (ten being the highest). Gait steady with no
assistive devices. Respirations even and unlabored. No other injuries noted.
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humanservices.arkansas.gov


summary: An x-ray was ordered after a resident reported he fell on his hand and injured his finger while playing basketball.

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Notice of Incident
Case Number: 030712
Date of Incident:
Date Received: 6/25/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident informed nurse that while playing basketball yesterday in the gym, he
fell on his left hand and injured left ring finger. Swelling and pain noted to left ring finger. Orders
for x-ray received from physician. Resident oriented to person, place, time, and situation. Breaths are
even and skin intact. Resident denies pain at this time. Resident placed on activity restriction until
further evaluation by physician.
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humanservices.arkansas.gov


summary: A resident was sent for an x-ray after injuring his hand while playing flag football.

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Notice of Incident
Case Number: 030695
Date of Incident:
Date Received: 6/23/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident injured his left hand while playing flag football 6/18/2025.
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humanservices.arkansas.gov


summary: A resident was sent to the ER for evaluation after passing out while playing basketball in the gym.

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Notice of Incident
Case Number: 030584
Date of Incident: 6/18/2025
Date Received: 6/19/2025
Facility Name: Woodridge Northwest LLC
Report Description: Nursing called to the gym by Staff. Staff stated ?He (the Resident,
passed out.? Nurse found Resident sitting upright on the floor with his head
slumped down and arms being held up by Staff. Resident was not responding to verbal or tactile
stimuli. They laid him down on his back. Resident started responding immediately. Skin warm and
dry to touch, respirations even and unlabored. No abnormalities noted to Resident?s color. Resident
reports feeling nausea. Resident also reports feeling ?fuzzy? inside. He said he was playing basketball
and the next thing he felt was laying on the floor and water being poured on him.
Resident alert and oriented
able to ambulate back into facility. Denies pain or discomfort. Orders received from APRN to send
Resident to for further evaluation. Additional Information: Resident returned to the facility at
approximately 2105 (9:05 pm). . A/C
in the gym was working properly and still working properly. Resident encouraged by the Nurse, to
intake more fluids, to rest if feeling tired, and to immediately report any abnormal feelings to
Staff/Nursing. Guardian Notified: , Guardian, notified 06/18/2025, at approximately
1840 (6:40 pm cst).
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humanservices.arkansas.gov


summary: A resident was sent for evaluation after complaining of shortness of breath after playing basketball.

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Notice of Incident
Case Number: 030585
Date of Incident: 6/18/2025
Date Received: 6/19/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident, , came to Nurse Station with
complaint of shortness of breath and stated ?It started after playing basketball in the gym.? Resident
was able to walk without difficulty.
Resident monitored at Nurse?s station for signs of distress. Resident stated again,
?I feel like I have trouble breathing.? At this point, APRN notified and order received to send
Resident to for further evaluation. Additional Information:
.
Resident educated to notify the Nurse if he has any further symptoms. Once inhaler is received,
Resident will be educated on proper use of inhaler. Guardian Notified: ,
Guardian, notified 06/18/2025, at approximately 1900 (7:00 pm cst).
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humanservices.arkansas.gov


summary: A resident was transported to the ER for evaluation after complaining of shortness of breath upon exertion.

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Notice of Incident
Case Number: 030513
Date of Incident: 6/13/2025
Date Received: 6/16/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident, , complained of shortness of
breathe on exertion. Physician notified and order received for Resident transport to the for
further evaluation. No pain or injuries noted.
Guardian, notified
06/13/2025, at approximately 1002 (10:02 am cst).
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humanservices.arkansas.gov


summary: A resident was transported to the emergency room due to redness and swelling to the right index finger from punching a white board.

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Notice of Incident
Case Number: 030515
Date of Incident: 6/13/2025
Date Received: 6/16/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident, , transported to for redness
and swelling to his right index finger. Resident rates pain 2/10 (10 being the highest) but it hurts
when touched. No other injuries noted. Gait steady with no assistive device. Respirations even and
unlabored. Additional Information: Resident informed Director of Nursing upon inquiry that he
punched a white board ?over a month ago? but incident was not reported.
Guardian Notified: , Guardian, notified 06/13/2025, at approximately 1029 (10:29
am cst).
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humanservices.arkansas.gov


summary: A resident was sent to the emergency room for evaluation after a physical altercation with a peer.

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Notice of Incident
Case Number: 030514
Date of Incident: 6/13/2025
Date Received: 6/16/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident, , was involved in a physical
altercation with his peer. Resident has swelling and shifting to the nose, minimal swelling to right
side of face by temporal bone, scratches to both sides of face and small amount of bleeding to left
ear. Resident oriented to person, placed, time, and situation; full range of motion, and has a steady
gait. Pain rated 8/10 (ten being the highest). Tylenol 325mg administered for pain. Resident sent to
for further evaluation. Corrective Actions Taken: Resident and peer were peer restricted and
placed on assault precautions. Additional Information:
t. Resident
placed on activity restriction pending appointment. Guardian Notified: ,
Guardian, notified 06/13/2025, at approximately 1029 (10:29 am cst).
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humanservices.arkansas.gov


summary: A resident reported that a staff member punched him in the chest while he and the staff member were playing ball in the gym.

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Notice of Incident
Case Number: 030399
Date of Incident: 6/9/2025
Date Received: 6/10/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident, , came to Nurses Station and reported that while
in the gym he (the Resident) and Staff member were playing basketball and the Staff member
?punched? Resident in the chest. Bruise noted to left lower rib area. Resident denies pain, gait
steady, and skin intact.
Staff member has been suspended pending investigation. Upon camera review, Staff member is
shooting a shot that the Resident is attempting to block. The shot is missed and the Staff turns
around to go to the other side of the court. As Staff is turning around, the Resident appears to tap
the top of Staff member's head. Staff appears to reflexively motion for the Resident to stop with the
back of his wrist but does not appear to punch/strike the Resident.
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humanservices.arkansas.gov


summary: A resident was transported for evaluation after experiencing a syncope episode.

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Notice of Incident
Case Number: 030400
Date of Incident: 6/8/2025
Date Received: 6/10/2025
Facility Name: Woodridge Northwest LLC
Report Description: Resident, had syncope episode in the hallway. Resident easily
aroused to painful stimuli. PERRLA noted, pupils size 3mm. No bump, bruises, or legions noted to
head.
. Provider notified and orders received
to send Resident to for further evaluation for syncope. Resident returned from
same day.
notified 06/08/2025, at approximately 1047 (10:47 am cst).
We Care. We Act. We Change Lives.
humanservices.arkansas.gov