summary: Officers responded to the facility in response to a missing person. Officers located the resident and transported her back to the facility.

raw_content:
Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
General Information
Incident Number: 2024-00079982 Incident Type: Missing Call Date/Time: 12/11/2024 11:30
Location 2466 S 48TH ST, Location OZARK GUIDANCE CENTER Originating Call (479) 595-1538
Formatted: SPRINGDALE, 72762 Common Name: Number:
Nature Of Call: Status: In Progress Priority: 2
Source: 911
Units/Personnel
Unit: 114 Primary Unit: No Call Date/Time: 12/11/2024 11:37
Personnel: 99 - Johnson, Bryan Primary: Yes
Unit: 308 Primary Unit: No Call Date/Time: 12/11/2024 11:32
Personnel: 116 - Lipscomb, John Primary: Yes
Unit: 312 Primary Unit: Yes Call Date/Time: 12/11/2024 11:32
Personnel: 29 - Buffington, Richard Primary: Yes
Vehicles
Subjects
Role: Caller Primary Caller: Yes Non-Disclosure: No
Subject Type: Adult Name Formatted: Unknown, ROMAN Location
Formatted:
Primary Contact (479) 595-1538 Date of Birth:
Information: Local Id Number:
License State:
License Number: License Expiration
Weight Range
Date:
Height Range Lower:
Lower: Race:
Ethnic Origin:
Sex: Hair Color:
Eye Color:
Disposition
Disposition: TRAFFIC STOP OR CITIZEN Count: 1 Unit:
CONTACT
Date/Time: 12/11/2024 11:55
Evidence
Call Log
Date/Time: 12/11/2024 11:30 User: monicade Action: Call Created
Description: New call created. Call Type:
>New Call<, Location:
<UNKNOWN>
Date/Time: 12/11/2024 11:30 User: monicade Action: Location
Description: Call Location Changed from
<UNKNOWN> to 2466 S
48TH ST, SPRINGDALE
User: monicade Action: Address Verified
Login Id: SPRD\jaquelinema Page 1 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Date/Time: 12/11/2024 11:30
Description: Call Location Changed from
Unverified To Verified
Date/Time: 12/11/2024 11:30 User: monicade Action: Location
Description: Cross streets updated,
SPRINGHOUSE DR / PRIVATE
DR, ATCHISON AVE
Date/Time: 12/11/2024 11:31 User: testing, cad - system Action: Alerts Retrieval
Description: Alerts Were Successfully
Gathered For Location At
Address 2466 S 48TH ST
Date/Time: 12/11/2024 11:31 User: monicade Action: Location
Description: Call Location Changed from
2466 S 48TH ST,
SPRINGDALE to 2466 S 48TH
ST, SPRINGDALE (OZARK
GUIDANCE CENTER)
Date/Time: 12/11/2024 11:31 User: monicade Action: Location
Description: Cross streets updated,
SPRINGHOUSE DR / PRIVATE
DR, ATCHISON AVE
Date/Time: 12/11/2024 11:31 User: testing, cad - system Action: Alerts Retrieval
Description: Alerts Were Successfully
Gathered For Location At
Address 2466 S 48TH ST
Date/Time: 12/11/2024 11:31 User: monicade Action: Call Updated
Description: Caller Phone Changed to
(479) 595-1538
Date/Time: 12/11/2024 11:31 User: monicade Action: Call Updated
Description: Caller Added: Role - Caller;
Date/Time: 12/11/2024 11:31 User: monicade Action: Agency Context Added
Description: Police Call Type Added. Call
Type: Missing, Status: Not In
Progress, Priority: 3
Date/Time: 12/11/2024 11:31 User: monicade Action: Call Updated
Description: Police Call Status Changed
from Not In Progress to In
Progress
Date/Time: 12/11/2024 11:31 User: monicade Action: Call Updated
Description: Police Priority changed from
3 to 2
Date/Time: 12/11/2024 11:31 User: monicade Action: Narrative Added
Description: PT THAT ESCAPED AND RAN
DOWN THE SIDE
Login Id: SPRD\jaquelinema Page 2 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Date/Time: 12/11/2024 11:32 User: monicade Action: Narrative Added
Description: LSW BLK TSHIRT AND PINK
PAJAMA PANTS B/F 14 YOA
FEMALE
Date/Time: 12/11/2024 11:32 User: monicade Action: Call Updated
Description: Call Source Changed From
Admin Phone Line To 911
Date/Time: 12/11/2024 11:32 User: monicade Action: Narrative Added
Description: DID NOT TAKE ANYTHING
WITH HER
Date/Time: 12/11/2024 11:32 User: jessicaar Action: Unit Status Action
Description: Unit 312 Dispatched
Date/Time: 12/11/2024 11:32 User: jessicaar Action: Call Ready for Dispatch
Description: Call marked ready for
dispatch
Date/Time: 12/11/2024 11:32 User: jessicaar Action: Incident Created
Description: Added Incident Number, ORI:
AR0720200, Number: 2024-
00079982
Date/Time: 12/11/2024 11:32 User: jessicaar Action: Unit Location
Description: Unit 312 Secondary Location:
Secondary Location Cleared
Date/Time: 12/11/2024 11:32 User: jessicaar Action: Unit Location
Description: Unit 308 Secondary Location:
Secondary Location Cleared
Date/Time: 12/11/2024 11:32 User: jessicaar Action: Unit Status Action
Description: Unit 308 Dispatched
Date/Time: 12/11/2024 11:32 User: monicade Action: Narrative Added
Description: LEFT TOWARDS JOHN
BROWN UNIVERSITY
Date/Time: 12/11/2024 11:33 User: monicade Action: Narrative Added
Description: THERE IS A PICTURE OF HER
Date/Time: 12/11/2024 11:33 User: jessicaar Action: Unit Status Action
Description: Unit 312 Responding
Date/Time: 12/11/2024 11:33 User: jessicaar Action: Unit Status Action
Description: Unit 308 Responding
Date/Time: 12/11/2024 11:33 User: monicade Action: Narrative Added
Description: ON THE SIDE OF 49
RUNNING
Date/Time: 12/11/2024 11:33 User: monicade Action: Narrative Added
Description: HAS A SORE ON THE LEFT
SIDE OF BOTTOM LIP
Login Id: SPRD\jaquelinema Page 3 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Date/Time: 12/11/2024 11:33 User: monicade Action: Narrative Added
Description: CALLER IS FOLLOWING HER
Date/Time: 12/11/2024 11:33 User: monicade Action: Narrative Added
Description: ON FOOT
Date/Time: 12/11/2024 11:34 User: monicade Action: Narrative Added
Description: ADV THAT SHE RAN ACROSS
THE HIGHWAY
Date/Time: 12/11/2024 11:34 User: monicade Action: Narrative Added
Description: RAN TOWARDS THE
CHURCH
Date/Time: 12/11/2024 11:34 User: monicade Action: Narrative Added
Description: NOW ON THE SIDE OF THE
WEST SIDE OF 49
Date/Time: 12/11/2024 11:35 User: stefanyca Action: Narrative Added
Description: RUNNING DOWN THE SIDE
OF 149 LOOKED LIKE SHE
WAS TRYING TO CROSS THE
HIGHWAY
Date/Time: 12/11/2024 11:35 User: monicade Action: Call Updated
Description: Caller Updated: Name
Changed from to , ROMAN
Date/Time: 12/11/2024 11:36 User: monicade Action: Narrative Added
Description: GOING N/B ON THE S/B SIDE
OF THE HIGHWAY AT THIS
TIME
Date/Time: 12/11/2024 11:37 User: stefanyca Action: Narrative Added
Description: RUNNING N/B IN PINK
PANTS AND DARK SHIRT
AND BAREFOOT
Date/Time: 12/11/2024 11:37 User: jessicaar Action: Unit Location
Description: Unit 114 Secondary Location:
Secondary Location Cleared
Date/Time: 12/11/2024 11:37 User: jessicaar Action: Unit Status Action
Description: Unit 114 On Scene
Date/Time: 12/11/2024 11:37 User: monicade Action: Narrative Added
Description:
Date/Time: 12/11/2024 11:37 User: jessicaar Action: Unit Status Action
Description: Unit 308 On Scene
Date/Time: 12/11/2024 11:37 User: jessicaar Action: Unit Status Action
Description: Unit 312 On Scene
User: jessicaar Action: Narrative Added
Login Id: SPRD\jaquelinema Page 4 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Date/Time: 12/11/2024 11:38
Description: 312/THEY ARE WALKING
BACK NOW
Date/Time: 12/11/2024 11:38 User: monicade Action: Narrative Added
Description: CALLER IS BY THE SIGN THAT
SAYS JOHN BROWN
UNIVERSITY ON THE
HIGHWAY ON THE EAST
SIDE OF THE ROAD
Date/Time: 12/11/2024 11:38 User: jessicaar Action: Narrative Added
Description: 312/SHE IS COMING UP
FROM THE RAMP
Date/Time: 12/11/2024 11:39 User: jessicaar Action: Narrative Added
Description: 308/I GOT EYES ON HER
Date/Time: 12/11/2024 11:41 User: jessicaar Action: Narrative Added
Description: 308/I GOT HER IN THE BACK
OF MY CAR
Date/Time: 12/11/2024 11:43 User: stefanyca Action: Narrative Added
Description: 312/ T12 WITH 2 BACK EN
ROUTE TO OGC
Date/Time: 12/11/2024 11:43 User: stefanyca Action: Unit Status Action
Description: Unit 312 Responding 2nd
Date/Time: 12/11/2024 11:43 User: stefanyca Action: Unit Location
Description: Unit 312 Secondary Location:
OGC
Date/Time: 12/11/2024 11:43 User: jessicaar Action: Narrative Added
Description: 308/IM GOING TO TAKE HER
BACK SHE THREW UP IN THE
BACK OF MY CAR
Date/Time: 12/11/2024 11:43 User: jessicaar Action: Narrative Added
Description: 114/SEND A SQUAD FOR
WHEN 308 GETS THER E
Date/Time: 12/11/2024 11:44 User: jessicaar Action: Unit Status Action
Description: Unit 114 Available
Date/Time: 12/11/2024 11:45 User: jessicaar Action: Unit Status Action
Description: Unit 312 On Scene 2nd
Date/Time: 12/11/2024 11:48 User: jessicaar Action: Unit Status Action
Description: Unit 308 Responding 2nd
Date/Time: 12/11/2024 11:48 User: jessicaar Action: Unit Status Action
Description: Unit 308 On Scene 2nd
User: jessicaar Action: Disposition Changed
Login Id: SPRD\jaquelinema Page 5 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Date/Time: 12/11/2024 11:55
Description: Added: TRAFFIC STOP OR
CITIZEN CONTACT Count 1
Date/Time: 12/11/2024 11:55 User: jessicaar Action: Unit Status Action
Description: Unit 312 Available
Date/Time: 12/11/2024 11:55 User: jessicaar Action: Unit Status Action
Description: Unit 308 Available
Date/Time: 12/11/2024 11:55 User: jessicaar Action: Call Cleared
Description: Close Call
Unit Log
Date/Time: 12/11/2024 11:32 Unit Number: 312 Action: Unit Status Change
Description: Dispatched Call Number:
555, Assigned Location: 2466
S 48TH ST, SPRINGDALE, Call
Type: Missing
Date/Time: 12/11/2024 11:32 Unit Number: 312 Action: Unit Location
Description: Secondary Location Cleared
Date/Time: 12/11/2024 11:32 Unit Number: 308 Action: Unit Status Change
Description: Dispatched Call Number:
555, Assigned Location: 2466
S 48TH ST, SPRINGDALE, Call
Type: Missing
Date/Time: 12/11/2024 11:32 Unit Number: 308 Action: Unit Location
Description: Secondary Location Cleared
Date/Time: 12/11/2024 11:33 Unit Number: 312 Action: Unit Status Change
Description: Responding
Date/Time: 12/11/2024 11:33 Unit Number: 308 Action: Unit Status Change
Description: Responding
Date/Time: 12/11/2024 11:37 Unit Number: 114 Action: Unit Status Change
Description: Dispatched Call Number:
555, Assigned Location: 2466
S 48TH ST, SPRINGDALE, Call
Type: Missing
Date/Time: 12/11/2024 11:37 Unit Number: 114 Action: Unit Status Change
Description: On Scene
Date/Time: 12/11/2024 11:37 Unit Number: 114 Action: Unit Location
Description: Secondary Location Cleared
Date/Time: 12/11/2024 11:37 Unit Number: 308 Action: Unit Status Change
Description: On Scene
Date/Time: 12/11/2024 11:37 Unit Number: 312 Action: Unit Status Change
Description: On Scene
Login Id: SPRD\jaquelinema Page 6 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Date/Time: 12/11/2024 11:43 Unit Number: 312 Action: Unit Status Change
Description: Responding 2nd
Date/Time: 12/11/2024 11:43 Unit Number: 312 Action: Unit Location
Description: OGC
Date/Time: 12/11/2024 11:44 Unit Number: 114 Action: Unit Cleared
Description: Unit Cleared From Call
Date/Time: 12/11/2024 11:44 Unit Number: 114 Action: Unit Status Change
Description: Available
Date/Time: 12/11/2024 11:45 Unit Number: 312 Action: Unit Status Change
Description: On Scene 2nd
Date/Time: 12/11/2024 11:48 Unit Number: 308 Action: Unit Status Change
Description: Responding 2nd
Date/Time: 12/11/2024 11:48 Unit Number: 308 Action: Unit Status Change
Description: On Scene 2nd
Date/Time: 12/11/2024 11:55 Unit Number: 308 Action: Unit Cleared
Description: Unit Cleared From Call
Date/Time: 12/11/2024 11:55 Unit Number: 308 Action: Unit Status Change
Description: Available
Date/Time: 12/11/2024 11:55 Unit Number: 312 Action: Unit Cleared
Description: Unit Cleared From Call
Date/Time: 12/11/2024 11:55 Unit Number: 312 Action: Unit Status Change
Description: Available
Contributing Officers
Report Narratives
Narratives
Entered By: monicade Date Entered: 12/11/2024 11:31
PT THAT ESCAPED AND RAN DOWN THE SIDE
Entered By: monicade Date Entered: 12/11/2024 11:32
LSW BLK TSHIRT AND PINK PAJAMA PANTS B/F 14 YOA FEMALE
Entered By: monicade Date Entered: 12/11/2024 11:32
DID NOT TAKE ANYTHING WITH HER
Entered By: monicade Date Entered: 12/11/2024 11:32
LEFT TOWARDS JOHN BROWN UNIVERSITY
Entered By: monicade Date Entered: 12/11/2024 11:33
THERE IS A PICTURE OF HER
Login Id: SPRD\jaquelinema Page 7 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Narratives
Entered By: monicade Date Entered: 12/11/2024 11:33
ON THE SIDE OF 49 RUNNING
Entered By: monicade Date Entered: 12/11/2024 11:33
HAS A SORE ON THE LEFT SIDE OF BOTTOM LIP
Entered By: monicade Date Entered: 12/11/2024 11:33
CALLER IS FOLLOWING HER
Entered By: monicade Date Entered: 12/11/2024 11:33
ON FOOT
Entered By: monicade Date Entered: 12/11/2024 11:34
ADV THAT SHE RAN ACROSS THE HIGHWAY
Entered By: monicade Date Entered: 12/11/2024 11:34
RAN TOWARDS THE CHURCH
Entered By: monicade Date Entered: 12/11/2024 11:34
NOW ON THE SIDE OF THE WEST SIDE OF 49
Entered By: stefanyca Date Entered: 12/11/2024 11:35
RUNNING DOWN THE SIDE OF 149 LOOKED LIKE SHE WAS TRYING TO CROSS THE HIGHWAY
Entered By: monicade Date Entered: 12/11/2024 11:36
GOING N/B ON THE S/B SIDE OF THE HIGHWAY AT THIS TIME
Entered By: stefanyca Date Entered: 12/11/2024 11:37
RUNNING N/B IN PINK PANTS AND DARK SHIRT AND BAREFOOT
Entered By: monicade Date Entered: 12/11/2024 11:37
Entered By: jessicaar Date Entered: 12/11/2024 11:38
312/THEY ARE WALKING BACK NOW
Entered By: monicade Date Entered: 12/11/2024 11:38
CALLER IS BY THE SIGN THAT SAYS JOHN BROWN UNIVERSITY ON THE HIGHWAY ON THE EAST SIDE OF THE ROAD
Entered By: jessicaar Date Entered: 12/11/2024 11:38
312/SHE IS COMING UP FROM THE RAMP
Entered By: jessicaar Date Entered: 12/11/2024 11:39
308/I GOT EYES ON HER
Login Id: SPRD\jaquelinema Page 8 of 9

Incident Details
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Narratives
Entered By: jessicaar Date Entered: 12/11/2024 11:41
308/I GOT HER IN THE BACK OF MY CAR
Entered By: stefanyca Date Entered: 12/11/2024 11:43
312/ T12 WITH 2 BACK EN ROUTE TO OGC
Entered By: jessicaar Date Entered: 12/11/2024 11:43
308/IM GOING TO TAKE HER BACK SHE THREW UP IN THE BACK OF MY CAR
Entered By: jessicaar Date Entered: 12/11/2024 11:43
114/SEND A SQUAD FOR WHEN 308 GETS THER E
Login Id: SPRD\jaquelinema Page 9 of 9


state: AR

facility_name: Perimeter Behavioral of the Ozarks

summary: A resident reported that they did not feel safe after being restrained during an elopement attempt.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026057
Date of Incident: 12/8/2024
Date Received: 12/11/2024
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Incident Type: Dual
Report Description: Check appropriate box. Once form is completed, send to the Office of
Long-Term Care and the Disability Rights Center, Inc at the fax numbers listed below. ?
Serious injury requiring outside medical attention ? Resident?s attempted suicide X
Allegation of abuse/neglect related to a restraint ? Resident?s death ? AWOL/Elopement ?
Allegation of sexual/physical abuse ? Sexual Misconduct ? Other, Emergency Room
Treatment Patient/Resident Name/DOB: Date/Time of
incident: 12/8/24 at 17:45 Patient Insurance: Name of Perimeter Staff
Making Notification Date Time Name of Person Notified DHS Charriot Sales, Director of
Risk Management 12/11/24 15:00 Felicia Harris, Chelsea Vardell, Kendra Rice, Jarred
Parnell OLTC Charriot Sales, Director of Risk Management 12/11/24 15:00
Jeff.rosenbaum@dhs.arkansas.gov Disability Rights Center, Inc. Charriot Sales, Director of
Risk Management 12/11/24 15:00 incidentreporting@disabilityrightsar.org Perimeter
Charriot Sales, Director of Risk Management 12/11/24 15:00 Skyler Barnes, Shawna Stover,
Chris Perry, Brandy Pfeifer, Carey Ouzts, Rebecca Thomas Guardian/Caseworker Charriot
Sales, Director of Risk Management 12/11/24 09:05
Charriot R. Sales, Director of Risk Management 12/11/24 Signature and title of staff
completing this form Date: Name of Facility: Perimeter Behavioral of the Ozarks Phone
Number: 479-957-9857 ext. 108 Street Address, City, State, Zip: 2466 S. 48th Street Suite B.
Springdale, AR 72762? Please describe the incident: On 12/10/24, reported to the
Director of Risk that, hurt me in the restraint. I don't feel safe." On 12/8/24,
exited the gym into an unauthorized fenced outdoor area. Staff responded to the staff
support and attempted to escort back to the gym; during the escort, attacked
staff and was placed in a one-person restraint outside that transitioned to a three-person
supine restraint once and staff were inside. struggled off and on throughout
the restraint. was involved in both restraints. Camera review did not identify
excessive force or inappropriate staff behavior during the incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

on Handle with Care for staff upon return. Documentation for the retraining will be
sent to licensing by 1/17/2025. 1/17/2025 - Handle with care refresher training certificate for
received, and uploaded to ELS.

doc_type: Notice of Incident


summary: Licensing visited the facility to review restraint information for November 2024. All restraints reviewed contained required documentation and physician approval and were signed within the required time frame.

raw_content:
ARKANSAS
DEPARTMENT OF

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

521 Visit Compliance Report

Licensee: Perimeter of the Ozarks

Facility Number: 237

Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766

Licensing Specialist: Jarred Parnell
Person In Charge:

Record Visit Date: 12/6/2024
Home Visit Date: 12/9/2024

Purpose of Visit: Special Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

A visit was conducted to review restraint information for residents for the month of November.

www.arkansas.gov/dhs

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

The following resident restraint records were reviewed at the visit:
Chemical Restraints:

Restraint date 12/1/2024 - MAR entry completed
Restraint date 11/3/2024 - MAR entry completed
estraint date 11/3/24 - MAR entry completed
restraint date | 1/4/24- MAR entry completed
estraint date 11/9/24- MAR entry completed

All chemical restraints reviewed had documented doctor's contact and approval in the restraint log.

Physical restraints:

lestraint date 11/3/24
restraint date 11/3/24
restraint date 11/4/24
estraint date 11/11/24
straint date 11/28/24

All physical restraints reviewed were documented in the restraint log with accompanying restraint packets.

The restraints were approved by a physician and signed within the required time frame.

Provider Comments:

CCL Staff Signature | ~K i Date: 12/9/2024

Provider Signature : or wht oh Date: 12/9/2024
t AN

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

Page 2 of 2

doc_type: Compliance Report


summary: Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility. A Corrective Action Plan was submitted by the facility and approved.

raw_content:
November 27, 2024, 12:00 am to 7:00 am
November 30, 2024, 7:00 pm to 11:59 pm
December 01, 2024, 12:00 am to 7:00 am
Personnel Records – Licenses, Certifications, Training:
There was a total of fourteen personnel records reviewed, four (29%) professional and ten (26%)
paraprofessionals. There were no deficiencies noted during the personnel record review.
Observations:
At the conclusion of the onsite inspection, AFMC staff reviewed the final document request form with the Chief
Executive Officer and the Director of Risk Management at the completion of the on-site Inspection of Care and
the provider signed the acknowledgement of manual requirements that were not made available in the provider’s
policy and procedures.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in a free time group activity in the outside courtyard, in the
classroom setting on the school unit, and in the cafeteria eating lunch. Clients were engaged in schoolwork and
activities. Staff were calmly interacting with clients and providing a therapeutic environment that was conducive
for learning and treatment therapies. All areas with clients were noted to be staffed adequately and according to
the facility’s staffing ratio policy.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff were onsite.
Due to the observation of non-Medicaid clients not being compliant with the HIPAA minimal necessary rule, no
medication pass was observed. The AFMC RN visited with the Director of Nursing who was able to show the
AFMC RN the facility policies and procedures regarding medication administration,
count/reconciliation/handling of controlled substances, and medication errors/discrepancies.
The Director of Nursing was able to verbalize the step-by-step process of medication delivery including the
demonstration of the five rights of medication administration, documentation of medication delivery,
verification of client taking medication including mouth/cheek checks, and how clients are educated about each
medication. The facility nurse also verbalized the process utilized when a client refuses medication. A tour of
the medication room was completed. The medication room was found to be extremely clean and well organized.
As previously stated in the above facility tour, the facility has changed outside pharmacy companies to help with
the medication delivery system to increase safety in medication administration to the clients. The facility has
also purchased a brand-new medication cart. AFMC staff noted that the medication keys were hanging in the
lock of the medication cart and were not being carried on the medication nurse which is per facility policy. The
controlled substances are to remain double locked. The medication room door was locked, which is the first lock
but the medication cart which houses the controlled substance was not secured as the second lock. The Director
of Nursing took the keys to secure them until the keys could be given back to the medication nurse.
Clinical Record Review Deficiencies:
Woodridge of The Ozarks – Springdale, AR – IOC Report 3 | P ag e

There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge of The Ozarks – Springdale, AR – IOC Report 4 | P ag e

November 30, 2024, 7:00 pm to 11:59 pm
December 01, 2024, 12:00 am to 7:00 am
Personnel Records – Licenses, Certifications, Training:
There was a total of fourteen personnel records reviewed, four (29%) professional and ten (26%)
paraprofessionals. There were no deficiencies noted during the personnel record review.
Observations:
At the conclusion of the onsite inspection, AFMC staff reviewed the final document request form with the Chief
Executive Officer and the Director of Risk Management at the completion of the on-site Inspection of Care and
the provider signed the acknowledgement of manual requirements that were not made available in the provider’s
policy and procedures.
Clinical Summary
As a part of the Quality-of-Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Program Activity/Service Milieu Observation:
Staff and clients were observed throughout the facility in a free time group activity in the outside courtyard, in the
classroom setting on the school unit, and in the cafeteria eating lunch. Clients were engaged in schoolwork and
activities. Staff were calmly interacting with clients and providing a therapeutic environment that was conducive
for learning and treatment therapies. All areas with clients were noted to be staffed adequately and according to
the facility’s staffing ratio policy.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff were onsite.
Due to the observation of non-Medicaid clients not being compliant with the HIPAA minimal necessary rule, no
medication pass was observed. The AFMC RN visited with the Director of Nursing who was able to show the
AFMC RN the facility policies and procedures regarding medication administration,
count/reconciliation/handling of controlled substances, and medication errors/discrepancies.
The Director of Nursing was able to verbalize the step-by-step process of medication delivery including the
demonstration of the five rights of medication administration, documentation of medication delivery,
verification of client taking medication including mouth/cheek checks, and how clients are educated about each
medication. The facility nurse also verbalized the process utilized when a client refuses medication. A tour of
the medication room was completed. The medication room was found to be extremely clean and well organized.
As previously stated in the above facility tour, the facility has changed outside pharmacy companies to help with
the medication delivery system to increase safety in medication administration to the clients. The facility has
also purchased a brand-new medication cart. AFMC staff noted that the medication keys were hanging in the
lock of the medication cart and were not being carried on the medication nurse which is per facility policy. The
controlled substances are to remain double locked. The medication room door was locked, which is the first lock
but the medication cart which houses the controlled substance was not secured as the second lock. The Director
of Nursing took the keys to secure them until the keys could be given back to the medication nurse.
Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical records
reviews were conducted.
Woodridge of The Ozarks – Springdale, AR – IOC Report 3 | P ag e

Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC reports.
Additionally, any findings that were noted in any Health and Safety Inspection(s), which are governed by
certification rules and requirements, are shared with DPSQA and may result in other remedial actions, by
DPSQA, if warranted.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge of The Ozarks – Springdale, AR – IOC Report 4 | P ag e

doc_type: IOC Report


summary: Officers received a child abuse report related to the facility from the Arkansas State Police. Officers sat in as the ASP investigator interviewed the related parties.

raw_content:
Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
Case Status: Open Status Date: 11/26/2024 Changed By: TaylorJo
Date/Time 11/27/2024 11:42
Changed:
Case Status: Closed Status Date: 12/03/2024 Changed By: elizabethw
Date/Time 12/03/2024 16:48
Changed:
Disposition History
Disposition: Inactive Disposition Date: 12/03/2024 Disposition elizabethw
Changed By:
Date/Time 12/03/2024 16:48
Changed:
Supplemental Information
Action Taken: Reasons For No Purge Type:
Arrest:
Purge Date: Non-Fatal
Purge Review Shooting:
Date:
Associated Arrest Records
Summary Narrative
Report Narratives
Name: Narrative Author: 131 - Moreno, Maria Supervisor: 139 - Niccum, Chad Date Created: 11/26/2024 15:58
Description:
On 11/26/24 a report was received from Arkansas State Police Investigator Christina Duncan in
regards to a new report.
The DHS snapshot was reviewed and the following is a summary of the report.
Av is . PRFC is unknown. UJO is a peer of . This happened
between November 17 and 20. It was reported that said stated that her hormones are kicking
and told her to suck her titties. was afraid that if she didn’t would get her into some kind of
trouble, so she sucked her titties. touched coochie. It’s unknown if it was under or above
clothes. is a foster child from Texas, and both are in Perimeter Behavioral Health Facility.
MLM/624
Name: 393 Forensic Interview Author: 46 - Whitaker, Elizabeth Supervisor: Date Created: 12/03/2024 16:41
W/Olivia
Description:
On November 26, 2024 at approximately 4:11PM, I (Detective Whitaker #393) observed as State Police Investigator Christina Duncan forensically
interviewed at Perimeter of the Ozarks (2466 S 48th Street Side B) in reference to case 24-76780. The following is a brief summary please
see the original audio for full details.
Login Id: SPRD\jaquelinema Page 2 of 4

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
· advised that was going to go to jail and she didn’t want him to.
· Christina advised that she didn’t know who was.
· asked why we were here and Christina told her that she had been informed that something had happened that wasn’t okay with.
· advised that there was supposed to be an investigation on
· Christina asked rapport building questions and advised that she liked to crafts.
· advised she was from Dallas and her caseworker was her guardian.
· advised she shared a room with for approximately a week but had shared a room with and she was the reason we were here.
· advised that told her to “fuck her” and “I was scared” that if she didn’t, she would fight.
· advised she touched her private area.
· advised that told her that her hormones were kicking in and asked if liked girls. advised she told that she didn’t
like girls in mental hospitals.
· advised that told her to sit on her bed with her and that she felt threated and felt she was going to fight her.
· advised that was the only real one she had and that she was in love with someone older than her.
· advised that she was going to tell no matter what happened.
· advised that kissed her on the lips and told to suck her “titties” and I felt threated and that she would fight me.
· advised that had threatened to fight her after the incident in class because she found out that had told someone they were
dating.
· advised that was touching her in her private area on the skin.
· advised that told her to pull her pants down and pulled her pants and touched her private area with her hands.
· advised that it happened two days.
· advised she sucked on “titties” and she stopped because she knew she was doing something wrong and hands were on
her lap and hands were on her “titties”.
· advised she decided to tell because she was and was and that because she was older, she didn’t want the charges to fall on
her and that she already had charges.
· advised that had said in the classroom that she was going to fight but did not say it to her face.
· advised that was taller than her and was medium sized.
· advised that they had not dated.
· advised she had shared three or four nights in a room with
Login Id: SPRD\jaquelinema Page 3 of 4

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 12/17/2024 10:44
Agency #: AR0720200
· advised she wanted to be moved out of this place.
· confirmed that there was an investigation involving Texas.
**EW393**
Name: 393 Email Author: 46 - Whitaker, Elizabeth Supervisor: Date Created: 12/03/2024 16:43
Description:
On November 27, 2024 at approximately 12:45PM, I (Detective Whitaker #393) received the following email from Christina Duncan in reference to
case 24-76780.
“Got confirmation from TX case worker, that they will not allow to be interviewed. I spoke with both the girls’ case
workers and both girls have history of being sexual aggressors and that has made similar claims at other placements. The judge ordered a lock
down facility (Perimeter) since she has a history of running”.
**EW393**
Name: 393 Case Status Author: 46 - Whitaker, Elizabeth Supervisor: 139 - Niccum, Chad Date Created: 12/03/2024 16:48
Description:
On December 3, 2024 at approximately 4:44PM, I (Detective Whitaker #393) reviewed case 24-76780.
Due to being denied consent to speak with the alleged suspect and the alleged victim having an history of being a sexual aggressor as well as
her stating in her interview that she didn’t want the charges falling on her because she was older and that’s why she decided to tell, I have not been able
to prove forcible compulsion or physical helplessness that would be required to pursue charges. Therefore, I am forwarding this case to be reviewed to
be closed.
**EW393**
Login Id: SPRD\jaquelinema Page 4 of 4

doc_type: Police Report


summary: A resident reported that she and her roommate had engaged in inappropriate touching after lights out.

raw_content:
AR KANS A S&S
DEPARTMENT OF

i¢ SERVICES

Placement and Residential Licensing Unit
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident
Case Number: 025791
Date of Incident: 11/17/2024

Date Received: 11/27/2024

Facility Name: Perimeter of the Ozarks
Facility Number: 237
Incident Type: Dual

Report Description: ? Serious injury requiring outside medical attention ? Resident?s
attempted suicide ? Allegation of abuse/neglect related to a restraint ? Resident?s death ?
AWOL/Elopement ? Allegation of sexual/physical abuse X Sexual Misconduct ? Other,
Emergency Room Treatment Patient/Resident Name/DOB: PO
a ii i _ Date/Time of incident: After lights out on the 17th or
18th or the 18th and 19th of November 2024. Patient Insurance: ee end
Name of Perimeter Staff Making Notification Date Time Name of
Person Notified DHS Charriot Sales, Director of Risk Management 11/27/24 16:00 Felicia
Harris, Chelsea Vardell, Kendra Rice, Jarred Parnell OLTC Charriot Sales, Director of Risk
Management 11/27/24 16:00 Jeff.rosenbaum@dhs.arkansas.gov Disability Rights Center,
Inc. Charriot Sales, Director of Risk Management 11/27/24 16:00
incidentreporting@disabilityrightsar.org Perimeter Charriot Sales, Director of Risk
Management 11/27/24 15:00 Skyler Barnes, Shawna Stover, Chris Perry, Brandy Pfeifer,
Carey Ouzts, Rebecca Thomas Guardian/ Caseworker i. Case Manager
11/25/24 11/25/24 11:35 11:36
(Caseworker) Charriot R. Sales, Director of Risk Management 11/27/24 Signature and title
of staff completing this form Date: Name of Facility: Perimeter Behavioral of the Ozarks
Phone Number: 479-957-9857 ext. 108 Street Address, City, State, Zip: 2466 S. 48th Street
Suite B. Springdale, AR 72762? Please describe the incident: On 11/21/24,
disclosed to her therapist that she and her roommate Po engaged in sexual
activity on either the nights of 17 or 18 November or 18 or 19 November. She stated the
activity occurred two nights in a row shortly after lights out and that she Psucked
titties,? and they ?touched each other?s private parts?. Her roommate, FY denied the
allegation.

. On 11/27/24, the Director of Risk
Management received notice from the Arkansas State Police that caseworker

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

Peers separated immediately upon notification; J was permanently moved to another
unit. Peer restriction implemented. Sexual acting out precautions ? LOS WA applied.
Opened investigation (ongoing)

Interim Action Narrative: Residents were separated and are no longer on the same unit.

Licensing Narrative: Program Coordinator checke and will
request permission to contact the facility. 12/2/2024, Program Coordinator will request
permission to contact the facility. Permission granted. The Q15s were requested. Facility
provided Q15s for both residents that has been uploaded to this case. 12/3/2024 Licensing
specialist reviewed the complaint. 12/6/2024 - A visit was conducted at the facility to review
video footage for Q15 checks and discuss weekly meetings for facility staff in regards to peer
to peer sexual contact. 12/9/2024, Program Coordinator checked
1/10/2025 - The report is unfounded by Licensing, 521 sent to facility for signature. Signed
521 has been uploaded to ELS. 2/13/2025, | i TT i
Licensing Specialist informed. 2/18/2025, case reviewed and unfounded by licensing. Case
complete.

.* SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

521 Visit Compliance Report

Licensee: Perimeter of the Ozarks

Facility Number: 237

Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766

Licensing Specialist: Jarred Parnell
Person In Charge:

Record Visit Date: 12/6/2024
Home Visit Date: 12/6/2024

Purpose of Visit: Complaint Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

A visit was conducted n 12/9/2024 for complaint 025791. Video footage review was conducted as well as
discussion in regards to weekly facility staff meetings to address inappropriate peer to peer interactions.

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

Video time stamp reviewed 11/17/2024 -20:00 - 00:02
Bed checks were conducted at:

2007, 2019 ,2023 2035 ,2056 ,2058, 2103 ,2105 ,2106 , 2108, 2115 ,2120 ,2121 ,2123, 2125, 2127, 2128,
2131, 2132 , 2132, 2147, 2158 , 2203 , 2217, 2240 , 2256, 2322 , 2338 ,2347.

20:35 - 20:56 - During this time frame the staff member can be seen attempting to complete a bed check but is
unable to because there are two residents in the day room. The staff member can be seen processing with the
residents.

Around the 21:00 time stamp residents alleged in the complaint can be seen looking out of the door way down
the hall.

Video time stamp review 11/18/2024 - 20:30 - 00:00
Bed checks were conducted at:

2021, 2023 ,2033 ,2046 ,2103, 2118 ,2132 ,2150 ,2201 ,2200 ,2201 ,2220 ,2232 ,2246 ,2303 ,2317 2333
.2346, 0002.

Video time stamp review 11/19/2024 - 20:30 - 00:02
Bed checks were conducted at

20:30, 20:32, 20:34, 20:35, 20:50, 21:02, 21:16, 21:31, 21:46, 21:58, 22:18, 22:32, 22:46, 23:01, 23:18, 23:31,
23:46, 00:01, 00:02

Licensing specialist spoke with facility risk manager in regards to weekly staff meetings to address peer to
peer inappropriate contact. The facility conducts weekly staff meetings to discuss how residents are doing.
The meetings include all direct care employees to assess if residents are in need of more treatment or
discussion of their behaviors and struggles.

Provider Comments:

CCL Staff Signature : — \ / Date: 12/6/2024

3
Provider Signature : QW Cols Date: 12/6/2024

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

521 Visit Compliance Report

Licensee: Perimeter of the Ozarks

Facility Number: 237

Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766

Licensing Specialist: Chelsea Vardell
Person In Charge:

Record Visit Date: 1/10/2025

Home Visit Date: 1/10/2025

Purpose of Visit: Complaint Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

No in person licensing visit conducted on this day.

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

KER, ARKANSAS
A DEPARTMENT OF

: a\ SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot $140, Little Rock, AR 72203-1437

P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Page 1 of 2

Licensing has investigated complaint case 025791 and determined it to be unfounded.

Review of camera footage during the hour surrounding lights out on 11/17, 11/18, and 11/19 showed required
checks were completed per the minimum licensing standards.

Provider Comments:

CCL Staff Signature : Chebeca Vartele Date: 1/10/2025

Provider Signature : (York G0) Date: 1/10/2025

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


summary: A resident began throwing up and reported intense pain after being kicked in the stomach during a peer altercation.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025389
Date of Incident: 11/9/2024
Date Received: 11/11/2024
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Incident Type: Licensing
Report Description: ?X Serious injury requiring outside medical attention ? Resident?s
attempted suicide ? Allegation of abuse/neglect related to a restraint ? Resident?s death ?
AWOL/Elopement/Arrest ? Allegation of sexual/physical abuse Victim: DOB:
Perpetrator:
Date/Time of incident: 11/9/24 17:23
Name of Perimeter Staff Making Notification Date Time Name of Person Notified Agency
Rep Sarah Whorton, RN, Director of Nursing 11/11/24 1300 See Below Sarah Whorton, RN
11/11/24 Name and title of staff completing this form Date: Name of Facility: Perimeter
Behavioral of the Ozarks Phone Number: 479-957-9857 Street Address, City, State, Zip: 2466
S. 48th Street Suite B. Springdale, AR 72762 Please give a description of the incident: On
11/9/24 at 17:23 became assaultive toward another resident. While staff were intervening
joined into help the resident being assaulted fight and was kicked by in the stomach.
started throwing up and reporting intense pain. The nurse called EMS at 17:25 and was
taken to the ER for evaluation. The resident had a urinalysis and x-ray done showing no
issues and was discharged from hospital at 20:32. Nursing staff of Perimeter continued to
monitor resident throughout the night to make sure there were no new complications or
issues. Resident does not report any pain as of today 11/11/24 and has no injuries. Actions
Taken: MR was sent to the emergency room for evaluation. Nursing continued to monitor
resident upon return for any complications. Both and placed on assault precautions
Parties notified of event: Skyler Barnes, CEO Brandy Pfeifer, Regional CEO Carey Outz, VP
Nursing Charriot Sales, Director of Risk and Quality
Chris Perry, VP Risk Compliance/Quality Shawna Stover ? Clinical
Director Kris Stewart, Reagan Stanford, and Ashlyn Whelchel (Disability Rights of AR)
Chelsea Vardell and Kendra Rice, and Felicia Harris (DHS) Jeff Rosenbaum, (OLTC)
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing reviewed the report and will follow up with the facility for
video footage, nursing notes and hospital discharge information. 11/14/2024 - A teams
meeting was conducted with facility risk manager to review footage for the incident.
Timeframes viewed: 11/9/2024 - 17:23 - 17:55 Residents can be seen in the day room. The
aggressor can be seen moving towards begins altercation at 17:23:40. Staff Telia
O. calls for staff support and initiates a body block and struggles with the resident moving
towards the corner. The second staff begins body blocking the victim who is standing and
engaging in he altercation. Staff support arrives within 10 seconds of the call and restrain the
aggressor in the hallway. The victim can be seen restrained in the top corner of the room.
EMT arrive at 17:34 because of a call on behalf of another resident who alleges she was
kicked in the stomach during the altercation. . Restraint packets requested from facility for
and Facility implemented assault precautions for both residents and increased
supervision. Nursing notes, hospital discharge and restraint packets reviewed and uploaded
to ELS.


summary: Officers responded to the facility in response to a report of a child that was kicked in the stomach and was spitting up blood. The resident was transported to Arkansas Children’s Hospital for evaluation.

raw_content:
Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
General Information
Case Number: 2024-00072992 Reporting 5970 - Strong, Marcus Reported 11/09/2024 17:28
Officer: Date/Time:
Location 2466 S 48TH ST B,
Location PERIMETER OF THE OZARKS County: Washington
Formatted: SPRINGDALE, 72762
Common Name:
Status: Closed Disposition: Inactive
Status Date: 11/14/2024
Disposition Date: 11/14/2024 Occurred From 11/09/2024 17:28
Occurred Incident Assault - Simple
Date/Time:
Occurred To 11/09/2024 17:28 Type:
Significant Event:
Date/Time:
Scene Processed
Campus Code: By: Exceptional
Clearance Date:
Exceptional
Clearance:
Assigned Personnel
Assigned Personnel: 10 - Baker, David Assigned By: 76 - Hammontree, Robert
Assignment Type: Lead Investigator Assignment 11/14/2024 10:00
Date/Time:
Assignment End
Date/Time: Assignment Notes:
Solvability Factors
Solvability Factor: Total Solvability
Factor:
Modus Operandi
Offenses
# Statute Group Group Agency Crime Code Statute Description Offense Date
1 State 13A - Aggravated 5-13-203a(3) BATTERY - 3RD DEGREE / NEGLIGENTLY 11/09/2024
Assault CAUSES INJURY USING A DEADLY
WEAPON
Subjects
Number Type Name Address Contact Information Race Sex DOB
1 Suspect 2466 48th ST, Springdale, AR Unknow Female
72764 n
2 Suspect 2466 S 48TH ST, SPRINGDALE, White Female
AR 72764
3 Suspect Unknow Female
n
4 Suspect 2466 S 48th, Springdale, AR Unknow Female
72764 n
5 Victim 2644 48th ST, Springdale, AR White Female
72764
Properties
# Date Type Property Loss Type Description Name Subject Role
Vehicles
Login Id: SPRD\baileyjo Page 1 of 4

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
Contributing Officers
Officer: 5970 - Strong, Marcus Supervisor: 146 - Pena, Jared Report 11/14/2024 09:46
Date/Time:
Report Type: Primary Approving User: fabiolama
Evidence
Status History
Case Status: In Field Status Date: 11/10/2024 Changed By: System
Date/Time 11/10/2024 16:16
Changed:
Case Status: Open Status Date: 11/10/2024 Changed By: fabiolama
Date/Time 11/14/2024 09:48
Changed:
Case Status: Closed Status Date: 11/14/2024 Changed By: davidba
Date/Time 11/14/2024 15:46
Changed:
Disposition History
Disposition: Inactive Disposition Date: 11/14/2024 Disposition davidba
Changed By:
Date/Time 11/14/2024 15:46
Changed:
Supplemental Information
Action Taken: Reasons For No Purge Type:
Arrest:
Purge Date: Non-Fatal
Purge Review Shooting:
Date:
Associated Arrest Records
Summary Narrative
Login Id: SPRD\baileyjo Page 2 of 4

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
Report Narratives
Name: Narrative Author: 5970 - Strong, Marcus Supervisor: 146 - Pena, Jared Date Created: 11/10/2024 16:16
Description:
On 11/10/2024 at approximately 1728 hours I responded to a disturbance at 2644 S 48th st.
dispatch advised that a 13 yoa female was kicked in the stomach and was spitting up blood.
Upon arrival I met with Kris Teel who advised the blue pod was fighting. I went
back into the pod and the staff had multiple juvinile females in holds on the ground. No staff was
able to tell me what had happened.
After the pod had calmed down I sat down with Mr. Teel the RN in charge at the time and he
advised me that some of the girls in the pod were talking about each other and a fight broke out.
Mr. Teel was unable to tell me who started it and who all was involved.
Mr. Teel stated that he does not believe there was blood being spat up but that the Victim who I
identifed as had eaten hotdogs for diner just a few moments
earlier had mashed them up and spit them up pretending it was blood. but it was unconfirmed.
was transported to childrens hospital for evaluation.
Axon Camera Activated.
Ms 411
Login Id: SPRD\baileyjo Page 3 of 4

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
Name: Contact with Perimeter of Author: 10 - Baker, David Supervisor: 76 - Hammontree, Date Created: 11/14/2024 15:46
the Ozarks/Case status Robert
Description:
On Thursday, November 14, 2024 at approximately 3:30pm I made contact with one of the staff members at Perimeter of the Ozarks named John, by
phone call. Upon contact, I explained to John who I was and why I was calling. I explained to John there wasn't enough information in the original report
narrative to explain what exactly had happened. John said he could provide any information on the incident but was familiar with the persons involved.
John said there hadn't been any other issues since the incident occurred. I asked John if Kris Teel was working, and he replied, no. I explained to John
that I would be closing the case and showing inactive due to lack of information needed for prosecution and to completely understand what took place.
John said he understood.
At this time, I will be showing the case closed and inactive awaiting supervisor approval. No further information at this time.
End DB318
Login Id: SPRD\baileyjo Page 4 of 4

Incident Details
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:12
Agency #: AR0720200
General Information
Incident Number: 2024-00072993 Incident Type: Supplemental Call Date/Time: 11/09/2024 17:56
Location 2466 S 48TH ST B, Location PERIMETER OF THE OZARKS Originating Call
Formatted: SPRINGDALE, 72762 Common Name: Number:
Nature Of Call: Status: Not In Progress Priority: 3
Source: Admin Phone Line
Units/Personnel
Unit: 390 Primary Unit: No Call Date/Time: 11/09/2024 17:57
Personnel: 189 - Thoele, Samuel Primary: Yes
Unit: 411 Primary Unit: Yes Call Date/Time: 11/09/2024 17:56
Personnel: 5970 - Strong, Marcus Primary: Yes
Vehicles
Subjects
Disposition
Disposition: Complaint Only Count: 1 Unit:
Date/Time: 11/09/2024 18:32
Evidence
Call Log
Date/Time: 11/09/2024 17:56 User: jessicaar Action: Call Created
Description: New call created. Call Type:
>New Call<, Location:
<UNKNOWN>
Date/Time: 11/09/2024 17:56 User: jessicaar Action: Agency Context Added
Description: Police Call Type Added. Call
Type: Supplemental, Status:
Not In Progress, Priority: 3
Date/Time: 11/09/2024 17:56 User: jessicaar Action: Unit Location
Description: Unit 411 Secondary Location:
Secondary Location Cleared
Date/Time: 11/09/2024 17:56 User: jessicaar Action: Incident Created
Description: Added Incident Number, ORI:
AR0720200, Number: 2024-
00072993
Date/Time: 11/09/2024 17:56 User: jessicaar Action: Call Ready for Dispatch
Description: Call marked ready for
dispatch
Date/Time: 11/09/2024 17:56 User: jessicaar Action: Unit Status Action
Description: Unit 411 Responding
User: jessicaar Action: Address Verified
Login Id: SPRD\baileyjo Page 1 of 4

Incident Details
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:12
Agency #: AR0720200
Date/Time: 11/09/2024 17:57
Description: Call Location Changed from
Unverified To Verified
Date/Time: 11/09/2024 17:57 User: jessicaar Action: Location
Description: Call Location Changed from
<UNKNOWN> to 2466 S
48TH ST, SPRINGDALE
Date/Time: 11/09/2024 17:57 User: jessicaar Action: Location
Description: Cross streets updated,
SPRINGHOUSE DR / PRIVATE
DR, ATCHISON AVE
Date/Time: 11/09/2024 17:57 User: testing, cad - system Action: Alerts Retrieval
Description: Alerts Were Successfully
Gathered For Location At
Address 2466 S 48TH ST
Date/Time: 11/09/2024 17:57 User: jessicaar Action: Location
Description: Call Location Changed from
2466 S 48TH ST,
SPRINGDALE to 2466 S 48TH
ST, SPRINGDALE, B
(PERIMETER OF THE OZARKS)
Date/Time: 11/09/2024 17:57 User: jessicaar Action: Location
Description: Cross streets updated,
PRIVATE DR, ATCHISON AVE /
SPRINGHOUSE DR
Date/Time: 11/09/2024 17:57 User: samueltho Action: Unit Status Action
Description: Unit 390 Dispatched
Date/Time: 11/09/2024 17:57 User: samueltho Action: Unit Location
Description: Unit 390 Secondary Location:
Secondary Location Cleared
Performed by Mobile Unit
390
Date/Time: 11/09/2024 17:57 User: testing, cad - system Action: Alerts Retrieval
Description: Alerts Were Successfully
Gathered For Location At
Address 2466 S 48TH ST
Date/Time: 11/09/2024 17:57 User: jessicaar Action: Unit Status Action
Description: Unit 390 Responding
Date/Time: 11/09/2024 17:57 User: jessicaar Action: Narrative Added
Description: 411/SHOW ME BACK IN
ROUTE TO PERIMETER OF
THE OZARKS
Date/Time: 11/09/2024 18:07 User: samueltho Action: Narrative Added
Description: 390/out at ACH
Login Id: SPRD\baileyjo Page 2 of 4

Incident Details
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:12
Agency #: AR0720200
Date/Time: 11/09/2024 18:32 User: jasminepe Action: Unit Status Action
Description: Unit 390 On Scene
Date/Time: 11/09/2024 18:32 User: jasminepe Action: Unit Status Action
Description: Unit 411 On Scene
Date/Time: 11/09/2024 18:32 User: jasminepe Action: Disposition Changed
Description: Added: Complaint Only
Count 1
Date/Time: 11/09/2024 18:32 User: jasminepe Action: Unit Status Action
Description: Unit 390 Available
Date/Time: 11/09/2024 18:32 User: jasminepe Action: Unit Status Action
Description: Unit 411 Available
Date/Time: 11/09/2024 18:32 User: jasminepe Action: Call Cleared
Description: Close Call
Unit Log
Date/Time: 11/09/2024 17:56 Unit Number: 411 Action: Unit Status Change
Description: Dispatched Call Number:
583, Assigned Location:
<UNKNOWN>, Call Type:
Supplemental
Date/Time: 11/09/2024 17:56 Unit Number: 411 Action: Unit Status Change
Description: Responding
Date/Time: 11/09/2024 17:56 Unit Number: 411 Action: Unit Location
Description: Secondary Location Cleared
Date/Time: 11/09/2024 17:57 Unit Number: 411 Action: Unit Location
Description: Assigned Location: 2466 S
48TH ST, SPRINGDALE
Date/Time: 11/09/2024 17:57 Unit Number: 411 Action: Unit Location
Description: Assigned Location: 2466 S
48TH ST B, SPRINGDALE
Date/Time: 11/09/2024 17:57 Unit Number: 390 Action: Unit Status Change
Description: Dispatched Call Number:
583, Assigned Location: 2466
S 48TH ST B, SPRINGDALE,
Call Type: Supplemental
Performed by Mobile Unit
390
Date/Time: 11/09/2024 17:57 Unit Number: 390 Action: Unit Location
Description: Secondary Location Cleared
Performed by Mobile Unit
390
Date/Time: 11/09/2024 17:57 Unit Number: 390 Action: Unit Status Change
Description: Responding
Login Id: SPRD\baileyjo Page 3 of 4

Incident Details
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:12
Agency #: AR0720200
Date/Time: 11/09/2024 18:32 Unit Number: 390 Action: Unit Status Change
Description: On Scene
Date/Time: 11/09/2024 18:32 Unit Number: 411 Action: Unit Status Change
Description: On Scene
Date/Time: 11/09/2024 18:32 Unit Number: 411 Action: Unit Cleared
Description: Unit Cleared From Call
Date/Time: 11/09/2024 18:32 Unit Number: 411 Action: Unit Status Change
Description: Available
Date/Time: 11/09/2024 18:32 Unit Number: 390 Action: Unit Cleared
Description: Unit Cleared From Call
Date/Time: 11/09/2024 18:32 Unit Number: 390 Action: Unit Status Change
Description: Available
Contributing Officers
Report Narratives
Narratives
Entered By: jessicaar Date Entered: 11/09/2024 17:57
411/SHOW ME BACK IN ROUTE TO PERIMETER OF THE OZARKS
Entered By: samueltho Date Entered: 11/09/2024 18:07
390/out at ACH
Login Id: SPRD\baileyjo Page 4 of 4


summary: Officers received a child abuse report related to the facility from the Arkansas State Police. The report states that a resident complained that another resident touched her and digitally penetrated her vagina without her consent.

raw_content:
Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
Status History
Case Status: In Field Status Date: 11/07/2024 Changed By: System
Date/Time 11/07/2024 10:26
Changed:
Case Status: Open Status Date: 11/07/2024 Changed By: fabiolama
Date/Time 11/07/2024 14:57
Changed:
Case Status: Closed Status Date: 11/08/2024 Changed By: chrissa
Date/Time 11/08/2024 08:18
Changed:
Disposition History
Disposition: Inactive Disposition Date: 11/08/2024 Disposition chrissa
Changed By:
Date/Time 11/08/2024 08:18
Changed:
Supplemental Information
Action Taken: Reasons For No Purge Type:
Arrest:
Purge Date: Non-Fatal
Purge Review Shooting:
Date:
Associated Arrest Records
Summary Narrative
Report Narratives
Name: Narrative Author: 279 - Baker, Jaida Supervisor: 139 - Niccum, Chad Date Created: 11/07/2024 10:26
Description:
**Possible Sex Offense reported Hotline**
On 11/07/24 a Child Abuse report was received from Arkansas State Police Investigator, Christina
Duncan, in regards to a new report. Referral # 2304462.
The DHS snapshot was reviewed and the following is a summary of the report:
The Alleged Victim is . UJO .
reported to nursing staff that an incident occurred with in their bedroom after lights out on
11/5/2024. reported that went to her bed and started to kiss .
reported that she told to stop but continued to kiss her. also reported that
touched her on her privates but over the clothes. The two residents have been separated and are
no longer roommates or on the same unit.
Login Id: SPRD\baileyjo Page 2 of 5

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
On 11/07/24 we received an additional Child Abuse report was received from Arkansas State Police
Investigator, Ying Merritt, in regards to a new report with the same two subjects, a counter report. Referral
# 2304475.
The DHS snapshot was reviewed and the following is a summary of the report:
AV is . PRFCs are l and . AO is
(victim) reported to nursing staff that an incident occurred with
(offender) in their bedroom after lights out on 11/5/2024. reported that asked
to her bed and went to bed. started to kiss her on her neck and
then on her lips. reported that she told to stop but continued kissing her.
then reported that “touched my private parts” and clarified that it was under the
clothes. reported that digitally penetrated her vagina. told that she
was hurting her and then stopped. then returned to her own bed. No injuries reported.
Both of the original Hotlines is attached under the documents tab.
No further information at this time.
**END JB633**
Name: 304 narrative Author: 170 - Sanders, Supervisor: 139 - Niccum, Chad Date Created: 11/08/2024 08:16
Christopher
Login Id: SPRD\baileyjo Page 3 of 5

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
Description:
On 11/07/24, I was assigned 2 hotlines originating from Perimeter of the Ozarks. One hotline listed the victim to be years old),
who claimed that years old) went to bed kissed her and continued when told to stop, and touched her private parts over
the clothes. The second hotline involved the same two subjects. This hotline listed the victim as and the suspect as claimed
that on 11/5, asked her into 's bed. started to kiss on her necks and lips. reported that she told
to stop but continued kissing her. reported that "touched my private parts" and clarified that it was under the
clothes. also reported that had digitally penetrated her vagina.
I was informed that State Police Investigator had been assigned hotline and State Police Investigator Duncan was assigned
hotline. I spoke with Ying and was notified that she would contact Perimeter of the Ozarks and schedule the interview. The interview with was
scheduled at 1400 and Duncan and I would conduct the interview with after. Looking at the hotlines, it appeared that both girls had notified the
staff about the incident around the same time.
Upon arrival, Ying and I spoke with staff briefly about the incident but the employee knew only limited information about the incident. was
brought into the conference room where Ying conducted the interview of When was asked what she was there to talk about, she
stated it was about something she did with She stated that the two were separated, with being on the blue unit and being
moved to the green unit.
stated that the incident happened at night after hygiene. They were moving rooms and asked staff if she could room with
and was allowed to. stated that had asked to touch her. admitted that the two girls touched each other.
stated that prior to this night, the two had never roomed together before.
continued with more detail, stating that was in s bed when this happened. had asked to touch her and
stated that she did not care. The two then began kissing each other and telling each other "I love you". admitted to touching
over her clothes on her thights. described clothes as shorts and a shirt. stated that she was kissing on the
lips during the incident. also stated that was touching her as well during the incident. stated that had touched her
on the butt over the clothes, on the breast over the clothes and under on the skin, and "down there" on top of the clothes and never on the skin. The
incident stopped when they heard the staff coming to do the routine room checks. stated that she told the nurse when she got scared about
the incident. When asked if she was ok with the touches, stated that she as "halfway ok" with it. She stated initially she said no and then said
ok to doing it.
After was taken back to her pod, I asked the staff how the allegations were made to the staff. I was informed that was the first to
disclose any information to the staff. After that disclosure was made, the staff confronted about the event. When confronted, then made
her disclosure about what occurred. This information was concerning to my criminal investigation for a few reasons. The first was that there are
disciplinary consequences for the girls if caught engaging in inappropriate sexual behaviors and admitted to being scared about the incident
which led to her disclosure. The second was that did not disclose anything until she was confronted by staff. The third was that stated
the two girls were telling each other "I love you" during the incident.
Login Id: SPRD\baileyjo Page 4 of 5

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:11
Agency #: AR0720200
Duncan arrived and was brought in for the interview, which Duncan conducted. After building rapport and learning about , Duncan asked
to tell her about what she wanted to talk about. stated that something happened Tuesday at night. She stated that she and
were "dating". stated she had a problem with saying no and was afraid of not having friends. She stated she had just moved rooms and when
inside the room, told her when the lights go out it was going to get crazy. asked into her bed and then started
touching inappropriately. The staff told to get into bed, she did, and they went to sleep.
was questioned about the touching. She stated that was touching her on her "private places" over and under the clothes. She stated
that held her hand over mouth during the incident. stated that she was lying on bed and was
standing next to the bed during the incident. started to touch her boobs over the clothes and then started touching her boobs under the
clothes on the skin. stated that was kissing her on the mouth and skin of her boobs, legs, and neck. stated that
touched her private parts and then grabbed hand and forced it onto her boob. stated that then put her fingers
inside of her and then was trying to put her fingers in mouth.
stated that all of this happened around 2100 hours, because they went to bed around 2030 hours. She described the staffs rounds of checking
the rooms about every 15 minutes. stated that told her not to tell anyone about it and was upset that had told the staff
what they did. She described their dating relationship a little further. She stated that the two were dating previously and then broke up. She stated that
the two then started their relationship back about 2-3 weeks ago. stated that prior to this incident, had kissed her as well.
Both interviews were audio recorded through the Axon Capture and uploaded to Evidence.com. I notified Ying and Duncan that I would contact the
prosecutor and get their decision on prosecution. After the interviews, I contacted Joanne Clarie with the Washington County Juvenile Prosecutor's
Officer and notified her of the information disclosed. I informed her that the two were involved in a relationship, one had moved into the room of the
other, and what events took place. I informed her that one party stated it was all consensual, while the other alleged that it was not. I informed her that
one party informed us that they had been caught by a faculty member, one was scared and then went to the staff, and the other made the disclosure to
staff after being confronted about the event. I was informed by Claire that they would not prosecute any charges related to this case. I then contacted
Ying and Duncan and informed them of the prosecutors decision.
I am forwarding this case to my supervisor with a closed status based on the prosecutor's decision not to prosecute.
Login Id: SPRD\baileyjo Page 5 of 5


summary: Licensing visited the facility to review chemical restraint administration policies and procedures. No deficiencies cited.

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: Perimeter of the Ozarks

Facility Number: 237

Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766

Licensing Specialist: Jarred Parnell
Person In Charge: Charriot Sales
Record Visit Date: 11/7/2024
Home Visit Date: 11/7/2024

Purpose of Visit: Special Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

11/7/2024 - A visit was conducted at the facility to speak with facility staff and review information for
policies and procedures for administering chemical restraints. Medical administration record was reviewed for

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

three recent restraints administered to ensure chemical restraint documentation was up to date and approved

by a doctor before administration.

The following resident restraint records were reviewed at the facility:

BE chemical restraint administered on 11/3/2024 - record was complete upon review
ma - chemical restraint administered on 11/3/2024 - record was complete upon review
HB chemical restraint administered on 11/6/2024- record was complete upon review.

Provider Comments:

CCL Staff Signature : Date: 11/7/2024

Provider Signature : Date: 11/7/2024

Ww

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

Page 2 of 2


summary: A resident reported that her peer came to her bed during the night and kissed and touched her without consent, digitally penetrating her vagina. The facility was cited 907.6 as a result of this incident. The complaint was UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 025321
Date of Incident: 11/5/2024
Date Received: 11/7/2024
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Incident Type: Dual
Report Description: ? Serious injury requiring outside medical attention ? Resident?s
attempted suicide ? Allegation of abuse/neglect related to a restraint ? Resident?s death ?
AWOL/Elopement ? Allegation of sexual/physical abuse X Sexual Misconduct ? Other,
Emergency Room Treatment Patient/Resident Name/DOB:
Date/Time of incident: Evening of 5 November 2024
Patient Insurance: of Perimeter Staff
Making Notification Date Time Name of Person Notified DHS Charriot Sales, Director of
Risk Management 11/07/24 15:00 Felicia Harris, Chelsea Vardell, Kendra Rice, Jarred
Parnell OLTC Charriot Sales, Director of Risk Management 11/07/24 15:00
Jeff.rosenbaum@dhs.arkansas.gov Disability Rights Center, Inc. Charriot Sales, Director of
Risk Management 11/07/24 15:00 incidentreporting@disabilityrightsar.org Perimeter
Charriot Sales, Director of Risk Management 11/07/24 15:00 Skyler Barnes, Shawna Stover,
Chris Perry, Brandy Pfeifer, Carey Ouzts, Rebecca Thomas Guardian/Caseworker
LPN 11/06/24 18:00
Charriot R. Sales, Director of Risk Management 11/07/24 Signature and title of
staff completing this form Date: Name of Facility: Perimeter Behavioral of the Ozarks
Phone Number: 479-957-9857 ext. 108 Street Address, City, State, Zip: 2466 S. 48th Street
Suite B. Springdale, AR 72762 Please describe the incident: On the eve of 11/6/24,
asked to speak to a nurse. During their conversation, reported
that during the night of 11/5/24, went to bed and started to
kiss her. She stated she told to stop, but continued to kiss the resident and
touch her on her privates over the clothes. Nursing staff spoke to and she reported
that asked to her bed and began to kiss her on the neck and lips.
reported she told to stop, but she continued. then reported
touched her private parts under her clothes and digitally penetrated her vagina.
stated she told the peer it was hurting her and stopped. Actions Taken: ?
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Peers
separated immediately upon notification; was moved to another unit while
investigation is ongoing. ? Peer restriction implemented. ? Sexual acting out precautions. ?
Opened investigation (ongoing) ? Nurse assessed for reported pain.
Interim Action Narrative: The residents were placed on peer restriction and moved to
different units.
Licensing Narrative: 11/7/2024 - The report was reviewed by Licensing. Licensing
specialist obtained permission from to visit the facility and obtain Q15 bed checks
for the report. Permission was given by Y. A visit was conducted at the facility to
initiate the report. Licensing specialist reviewed and uploaded the Q15 report logs to ELS.
Licensing specialist spoke to staff concerning the safety plan implemented. The residents
have been separated to different units. No camera footage available for review. Requested
witness statements for staff and residents. 11/13/2024 - Resident and staff statements
received, reviewed, and uploaded to ELS. 11/14/2024 - Video review meeting over teams
was conducted with facility staff. Video footage for bed checks was reviewed. Timestamp
for the review was 11/5/2024 - 20:41 - 00.03 Bed checks were conducted at 20:53, 21:02, 21:32,
21:40, 21:48, 22:02, 22:47, 23:02, 23:19, 23:37, 23:48, 00:03. The time frame for bed check 22:02
and 22:47 does not meet minimum standards for bed checks which is required every 30
minutes. The facility will be issued a citation for 907.6. Facility will provide retraining
documentation for bed checks with a due date of 11/19/2024 for staff D. Rice. Facility
policies for bed checks was requested from facility staff. 11/15/2024 - Licensing received
retraining documentation for bed checks for staff D. Rice, and facility policies for
observation checks. The documents were reviewed and uploaded to ELS. 12/10/2024,
Program Coordinator checked . Licensing Specialist
informed. 12/16/2024, complaint unfounded by Licensing. Facility cited on 11/14/2024 for
907.6. Case approved by Program Coordinator and closed.


summary: A corrective action inspection was completed at the facility to review restraint logs, restraint packets, ensuring packets were signed by a doctor within two business days, camera audit logs for the month of October, and UAMS training logs.

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: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Jarred Parnell
Person In Charge: Charriot Sales
Record Visit Date: 10/29/2024
Home Visit Date: 10/29/2024
Purpose of Visit: Corrective Action Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

11/7/2024 - A corrective action inspection was completed at the facility to review restraint logs, restraint
packets ensuring packets were signed by a doctor within two business days, camera audit logs for the month
of October and UAMS training logs. Documentation for the reviewed information was sent to licensing.
Provider Comments:
CCL Staff Signature : Date: 10/29/2024
Provider Signature : Date: 10/29/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted at the facility.

raw_content:
reporting timeframe of the next business day.
Medicaid IP Sec. 2; There is no documentation in the HR The provider lacked evidence of semi-annual training
CFR 42 482.130, records that all direct care personnel for all direct care personnel, as well as demonstrated
483.376 are trained in the facility's Restraint competency in facility's Restraint and Seclusion policy
and Seclusion policy. and appropriate procedures to be used in Restraint and
Seclusion interventions.
Medicaid IP Sec. 2: HR records did not indicate that all The provider lacked evidence of all direct care personnel
221.804; CFR 42 direct care personnel have ongoing have ongoing education, training, and demonstrated
482.130, 483.376 education, training, and demonstrated knowledge of techniques to identify staff and resident
knowledge of techniques to identify behaviors, events and environmental factors that may
staff and resident behaviors that may trigger emergency safety situations on a semi-annual
trigger an emergency safety situation basis.
semi-annually.
Observation:
AFMC conducted an additionally ordered inspection of care on August 27, 2024. At that time the provider lacked evidence
of submission by July 21st of the current year to Arkansas Medicaid a Letter of Attestation that the facility is in compliance
with CMS standards regarding the use of Restraint and Seclusion. The provider was able to show evidence that a current
Letter of Attestation was signed by the CEO on 08/28/24 (the day after the last IOC) and was submitted by mail on 09/04/24.
Facility Tour:
Upon arrival to facility, AFMC staff was greeted at the locked entrance by a staff nurse who stated they would let someone
in administration know AFMC was onsite to conduct an Inspection of Care. AFMC staff signed the visitor log in the lobby
while waiting. Another staff member returned to the lobby and AFMC staff were taken to the conference room to begin the
Inspection of Care. The Chief Executive Office and the Director of Human Resources came to the conference room
immediately. Facility staff were given the Document Request Form and AFMC staff discussed the requirements for the
Inspection of Care. AFMC staff received the completed and signed consent form listing approval for access to the AFMC
portal prior to arrival for site visit.
AFMC staff requested a tour of the facility with the Director of Nursing. When questioned by the CEO regarding whether
it had to be the Director of Nursing conduct the tour AFMC shared with the CEO that at the last several inspections of care
the Director of Nursing had been unaccounted for either due to being on Paid Time Off or because they had chosen not to
be engaged in the inspection of care. The CEO informed AFMC staff that the Director of Nursing had requested PTO for
that day but had decided to come in to work.
A tour of the facility was completed with the Chief Executive Officer and the Director of Nursing. Areas toured included
the seclusion room, medication room and nurses’ station, cafeteria, three girls’ units, gymnasium, an outdoor courtyard, and
the educational classroom unit. The three girls’ units, Orange Unit (younger girls), Blue Unit (middle school aged girls),
and Green Unit (teenage girls), each have a day room with a television, a small table and several chairs. The area provides
adequate space for group sessions and activities. Each unit also has five client rooms with two beds in each room. Each
room includes a bathroom with a sink, toilet, and shower. Beds are wooden frames that have previously had a piece of
pressed wood holding the mattress within the solid wood frame. Recently, the Director of Maintenance has replaced the
pressed wood with a solid piece of plywood as the clients were peeling back pieces of the pressed wood to use for self-
harm. AFMC staff did observe graffiti with profanity on the wall of the day room on the Green Unit. The CEO immediately
notified maintenance to remove/paint over graffiti.
AFMC staff observed one staff member standing at the central nurses’ station yelling “hold on” several times over their
shoulder at what appeared to be a client. Two other staff members were observed at the desk calmly completing tasks.
Staff and clients were noted in the outside courtyard in what appeared to be free time. Several clients were sitting with staff
at a picnic table and were engaged in conversations. Several other clients were noted to be sitting on the ground quietly
enjoying the cooler weather and fresh air. Staff members were noted to be calmly interacting with clients and providing a
therapeutic environment. Staffing was in ratio with facility policy.
Woodridge of the Ozarks- Springdale, AR. - IOC Report 2 | P ag e

shared with the CEO and Director of Risk Management who stated that evening shift change is a really hard time
for staff and clients, and they have also noticed that trend.
• Upon review of the Restraint and Seclusion Log and the Emergency Safety Intervention Packets received for
September 28, 2024, and September 29, 2024, the following observations were noted:
o There were fourteen episodes of restraints and seclusion initiated during a one hour and thirty-four-minute
time frame (from 7:53 p.m. until 9:27 p.m.) involving nine clients.
o There were ten episodes of restraints and seclusion initiated during a one hour and twenty-five-minute
time frame (from 7:11 p.m. until 8:36 p.m.) involving four clients.
o The nursing narrative note in the Emergency Safety Intervention Packets were noted to be the same note
copied and placed in multiple packets instead of being individualized to each client’s behavior. The
nursing narrative notes that were copied to multiple packets referred to all residents being dysregulated
and verbally aggressive and “some became physically aggressive”. The note describes the milieu as a
whole and not the individual client that was restrained. By reading the nursing narrative, a physical
restraint was not always warranted.
o The front page of the Emergency Safety Intervention Packet has an area for short answer justification of
why the restraint and seclusion of the client was needed. Documentation from nursing staff included
statements such as, “physical aggression toward staff” or “resident had aggressive behavior”, but the
narrative note does not state any actual behaviors leading up to why they needed restraint or seclusion.
o One nursing narrative note for September 29, 2024, it was noted that the nurse documented “the attitude
and defiance toward staff has continued all day from last night”, but no serious occurrences or incidents
with any clients or staff requiring restraint or seclusion was documented on the dayshift.
• Upon review of the staffing versus client ratios for both dayshift and nightshift for September 28, 2024, and
September 29, 2024, it was noted that all shifts were staffed within the facility’s policy and the regulatory
standard for staff to client ratio.
• AFMC staff did note that one of the Serious Occurrence Forms was not reported within the correct timeframe.
The incident occurred on Sunday, September 29, 2024, at 1:00 a.m., where a client had a piece of wood and self-
harmed, resulting in a laceration to the right forearm. The client was transported to
and received six stitches. The occurrence should have been reported
within 24 hours on the next business day. The report was not received to the appropriate agencies until Tuesday,
October 01, 2024, due to the Director of Risk Management did not send it before the close of business the next
day. The Director of Risk Management stated that they did not realize that close of business meant receiving by
5:00 p.m.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge of the Ozarks- Springdale, AR. - IOC Report 4 | P ag e


summary: Staff advised dispatch that they have a juvenile that is acting out, and they are having issues with her and currently have her restrained.

raw_content:
Incident Details
Agency: Springdale Police Department Print Date/Time: 10/22/2024 10:24
Agency #: AR0720200
General Information
Incident Number: 2024-00064444 Incident Type: Disorderly Conduct Call Date/Time: 10/05/2024 16:33
Location 2466 S 48TH ST B, Location PERIMETER OF THE OZARKS Originating Call (817) 680-5929
Formatted: SPRINGDALE, 72762 Common Name: Number:
Nature Of Call: Status: Just Occurred Priority: 3
Source: 911
Units/Personnel
Unit: 333 Primary Unit: Yes Call Date/Time: 10/05/2024 16:41
Personnel: 62 - Flores, Daniela Primary: Yes
Vehicles
Subjects
Role: Caller Primary Caller: Yes Non-Disclosure: No
Subject Type: Adult Name Formatted: Unknown, SABRINA Location
Formatted:
Primary Contact (817) 680-5929 Date of Birth:
Information: Local Id Number:
License State:
License Number: License Expiration
Weight Range
Date:
Height Range Lower:
Lower: Race:
Ethnic Origin:
Sex: Hair Color:
Eye Color:
Disposition
Disposition: Complaint Only Count: 1 Unit:
Date/Time: 10/05/2024 16:58
Evidence
Call Log
Date/Time: 10/05/2024 16:33 User: katemo Action: Call Created
Description: New call created. Call Type:
>New Call<, Location:
<UNKNOWN>
Date/Time: 10/05/2024 16:33 User: katemo Action: Location
Description: Call Location Changed from
<UNKNOWN> to 2466 S
48TH ST, SPRINGDALE
Date/Time: 10/05/2024 16:33 User: katemo Action: Address Verified
Description: Call Location Changed from
Unverified To Verified
User: katemo Action: Location
Login Id: SPRD\baileyjo Page 1 of 5

Incident Details
Agency: Springdale Police Department Print Date/Time: 10/22/2024 10:24
Agency #: AR0720200
Date/Time: 10/05/2024 16:33
Description: Cross streets updated,
SPRINGHOUSE DR / PRIVATE
DR, ATCHISON AVE
Date/Time: 10/05/2024 16:33 User: testing, cad - system Action: Alerts Retrieval
Description: Alerts Were Successfully
Gathered For Location At
Address 2466 S 48TH ST
Date/Time: 10/05/2024 16:33 User: katemo Action: Location
Description: Call Location Changed from
2466 S 48TH ST,
SPRINGDALE to 2466 S 48TH
ST, SPRINGDALE, B
(PERIMETER OF THE
OZARKS)
Date/Time: 10/05/2024 16:33 User: katemo Action: Location
Description: Cross streets updated,
PRIVATE DR, ATCHISON AVE
/ SPRINGHOUSE DR
Date/Time: 10/05/2024 16:33 User: testing, cad - system Action: Alerts Retrieval
Description: Alerts Were Successfully
Gathered For Location At
Address 2466 S 48TH ST
Date/Time: 10/05/2024 16:33 User: katemo Action: Call Updated
Description: Caller Phone Changed to
(817) 680-5929
Date/Time: 10/05/2024 16:33 User: katemo Action: Call Updated
Description: Caller Added: Role - Caller;
Date/Time: 10/05/2024 16:33 User: katemo Action: Call Updated
Description: Call Source Changed From
Admin Phone Line To 911
Date/Time: 10/05/2024 16:34 User: katemo Action: Agency Context Added
Description: Police Call Type Added. Call
Type: Disorderly Conduct,
Status: Not In Progress,
Priority: 3
Date/Time: 10/05/2024 16:34 User: katemo Action: Call Updated
Description: Police Call Status Changed
from Not In Progress to Just
Occurred
User: katemo Action: Narrative Added
Login Id: SPRD\baileyjo Page 2 of 5

Incident Details
Agency: Springdale Police Department Print Date/Time: 10/22/2024 10:24
Agency #: AR0720200
Date/Time: 10/05/2024 16:34
Description: CALLER IS AN EMPLOYEE OF
PERIMETER OF THE OZARKS
AND IS ADVISING THAT
THEY HAVE A JUVENILE
THAT IS ACTING OUT AND
THEY ARE HAVING ISSUES
WITH HER AND THEY
CURRENTLY HAVE HER
RESTRAINED.
Date/Time: 10/05/2024 16:35 User: katemo Action: Narrative Added
Description: SHE CALLED 911 AND IS
TELLING ME THAT SHE
DOESN'T NEED AN OFFICER
TO RESPOND BUT WANTS
THIS DOCUMENTED.
Date/Time: 10/05/2024 16:35 User: katemo Action: Call Updated
Description: Caller Updated: Name
Changed from to , SABRINA
Date/Time: 10/05/2024 16:37 User: katemo Action: Narrative Added
Description: SHE SAID THAT THEY MAY
NEED POLICE EVENTUALLY
BUT NOT RIGHT NOW.
Date/Time: 10/05/2024 16:37 User: katemo Action: Narrative Added
Description: THERE WERE AT 2 TIMES
WHAT SOUNDED LIKE A
JUVENILE SCREAMING IN
THE BACKGROUND OF THE
CALL.
Date/Time: 10/05/2024 16:37 User: katemo Action: Narrative Added
Description: I TOLD THE CALLER I WOULD
HAVE AN OFFICER CALL HER
TO "DOCUMENT THE
INCIDENT" AND EXPLAIN
WHAT CAN BE DONE ABOUT
THE SITUATION.
Date/Time: 10/05/2024 16:41 User: roxxanaan Action: Incident Created
Description: Added Incident Number, ORI:
AR0720200, Number: 2024-
00064444
Date/Time: 10/05/2024 16:41 User: roxxanaan Action: Call Ready for Dispatch
Description: Call marked ready for
dispatch
Date/Time: 10/05/2024 16:41 User: roxxanaan Action: Unit Status Action
Description: Unit 333 On Scene
User: roxxanaan Action: Unit Location
Login Id: SPRD\baileyjo Page 3 of 5

Incident Details
Agency: Springdale Police Department Print Date/Time: 10/22/2024 10:24
Agency #: AR0720200
Date/Time: 10/05/2024 16:41
Description: Unit 333 Secondary Location:
Secondary Location Cleared
Date/Time: 10/05/2024 16:57 User: danielfl Action: Narrative Added
Description: 333/ spoke to sabrina, she
informed me a resident just
arrived back from JDC and
was starting to cause some
issues but is fine now.
Sabrina stated me the judge
advised them to contact
police when she got out of
hand so it could be
documented.
DF333
Date/Time: 10/05/2024 16:58 User: gingerev Action: Disposition Changed
Description: Added: Complaint Only
Count 1
Date/Time: 10/05/2024 16:58 User: gingerev Action: Unit Status Action
Description: Unit 333 Available
Date/Time: 10/05/2024 16:58 User: gingerev Action: Call Cleared
Description: Close Call
Unit Log
Date/Time: 10/05/2024 16:41 Unit Number: 333 Action: Unit Status Change
Description: Dispatched Call Number:
684, Assigned Location: 2466
S 48TH ST B, SPRINGDALE,
Call Type: Disorderly Conduct
Date/Time: 10/05/2024 16:41 Unit Number: 333 Action: Unit Status Change
Description: On Scene
Date/Time: 10/05/2024 16:41 Unit Number: 333 Action: Unit Location
Description: Secondary Location Cleared
Date/Time: 10/05/2024 16:58 Unit Number: 333 Action: Unit Cleared
Description: Unit Cleared From Call
Date/Time: 10/05/2024 16:58 Unit Number: 333 Action: Unit Status Change
Description: Available
Contributing Officers
Report Narratives
Login Id: SPRD\baileyjo Page 4 of 5

Incident Details
Agency: Springdale Police Department Print Date/Time: 10/22/2024 10:24
Agency #: AR0720200
Narratives
Entered By: katemo Date Entered: 10/05/2024 16:34
CALLER IS AN EMPLOYEE OF PERIMETER OF THE OZARKS AND IS ADVISING THAT THEY HAVE A JUVENILE THAT IS ACTING OUT AND
THEY ARE HAVING ISSUES WITH HER AND THEY CURRENTLY HAVE HER RESTRAINED.
Entered By: katemo Date Entered: 10/05/2024 16:35
SHE CALLED 911 AND IS TELLING ME THAT SHE DOESN'T NEED AN OFFICER TO RESPOND BUT WANTS THIS DOCUMENTED.
Entered By: katemo Date Entered: 10/05/2024 16:37
SHE SAID THAT THEY MAY NEED POLICE EVENTUALLY BUT NOT RIGHT NOW.
Entered By: katemo Date Entered: 10/05/2024 16:37
THERE WERE AT 2 TIMES WHAT SOUNDED LIKE A JUVENILE SCREAMING IN THE BACKGROUND OF THE CALL.
Entered By: katemo Date Entered: 10/05/2024 16:37
I TOLD THE CALLER I WOULD HAVE AN OFFICER CALL HER TO "DOCUMENT THE INCIDENT" AND EXPLAIN WHAT CAN BE DONE ABOUT
THE SITUATION.
Entered By: danielfl Date Entered: 10/05/2024 16:57
333/ spoke to sabrina, she informed me a resident just arrived back from JDC and was starting to cause some issues but is fine now.
Sabrina stated me the judge advised them to contact police when she got out of hand so it could be documented.
DF333
Login Id: SPRD\baileyjo Page 5 of 5


summary: A report was received from Arkansas DHS of an abuse allegation related to the facility.

raw_content:
Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:13
Agency #: AR0720200
General Information
Case Number: 2024-00063546 Reporting 131 - Moreno, Maria Reported 10/02/2024 08:34
Officer: Date/Time:
Location 2466 S 48TH ST,
Location County:
Formatted: SPRINGDALE, 72762
Common Name:
Status: Closed Disposition: Inactive
Status Date: 10/29/2024
Disposition Date: 10/29/2024 Occurred From 10/02/2024 08:33
Occurred Incident Assault - Simple
Date/Time:
Occurred To 10/02/2024 08:33 Type:
Significant Event:
Date/Time:
Scene Processed
Campus Code: By: Exceptional
Clearance Date:
Exceptional
Clearance:
Assigned Personnel
Assigned Personnel: 190 - Thompson, Samuel Assigned By: 139 - Niccum, Chad
Assignment Type: Lead Investigator Assignment 10/02/2024 13:24
Date/Time:
Assignment End
Date/Time: Assignment Notes:
Solvability Factors
Solvability Factor: Total Solvability
Factor:
Modus Operandi
Offenses
# Statute Group Group Agency Crime Code Statute Description Offense Date
1 State 13B - Simple Assault 5-13-203a(1) BATTERY - 3RD DEGREE / PURPOSE OF 10/02/2024
CAUSING INJURY, CAUSES INJURY
Subjects
Number Type Name Address Contact Information Race Sex DOB
1 Suspect Black Male
2 Other Unknow Female
n
3 Victim White Female
Properties
# Date Type Property Loss Type Description Name Subject Role
Vehicles
Contributing Officers
Officer: 131 - Moreno, Maria Supervisor: 139 - Niccum, Chad Report 10/02/2024 09:12
Date/Time:
Report Type: Primary Approving User: fabiolama
Evidence
Login Id: SPRD\baileyjo Page 1 of 3

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:13
Agency #: AR0720200
Status History
Case Status: In Field Status Date: 10/02/2024 Changed By: System
Date/Time 10/02/2024 08:38
Changed:
Case Status: Open Status Date: 10/02/2024 Changed By: fabiolama
Date/Time 10/02/2024 10:20
Changed:
Case Status: Closed Status Date: 10/29/2024 Changed By: samuelth
Date/Time 10/29/2024 16:35
Changed:
Disposition History
Disposition: Inactive Disposition Date: 10/29/2024 Disposition samuelth
Changed By:
Date/Time 10/29/2024 16:35
Changed:
Supplemental Information
Action Taken: Reasons For No Purge Type:
Arrest:
Purge Date: Non-Fatal
Purge Review Shooting:
Date:
Associated Arrest Records
Summary Narrative
Report Narratives
Name: Narrative Author: 131 - Moreno, Maria Supervisor: 139 - Niccum, Chad Date Created: 10/02/2024 08:38
Description:
On 10/2/24 a report was received from Arkansas DHS in regards to a new report.
The DHS snapshot was reviewed and the following is a summary of the report.
AV is . PRFC is . PRFC/AO is . is a
resident of Perimeter Behavioral of the Ozarks and is a staff member. On 9/30/24, staff
received a grievance form stating, " put bruises on me. " For context, this resident has been
involved in four restraints since 9/26/24 with various staff members. Each restraint was reviewed by
camera by multiple leadership personnel and no misconduct was noted. Additionally, was
medically assessed after each incident and did not present with bruising.
MLM/624
Login Id: SPRD\baileyjo Page 2 of 3

Case Report
Detail
Agency: Springdale Police Department Print Date/Time: 11/18/2024 11:13
Agency #: AR0720200
Name: Case Status Author: 190 - Thompson, Supervisor: 76 - Hammontree, Date Created: 10/29/2024 16:35
Samuel Robert
Description:
I called and spoke with Cathey Coleman who advised that she had responded to the report but that it was assigned to another case worker who was
out. Cathey advised that she spoke with staff who said that they had received multiple reports from alleging physical abuse and that
none had been verified. Staff said that had been suspended during their investigation as part of their policy. One incident was observed where
had restrained during an active fight between and another resident. only ever restrained and did not strike her.
Lastly Cathey told me the only the only injury observed were bruises on biceps and were consistent with restraining her. I requested
video and images when they were obtained, and I have not received anything at this time.
Due to video footage only showing restraining as part of his job and no evidence of abuse, I am closing he case as inactive and
submitting for supervisor review. Once the video footage is recieved the case can be reopened if there is evidence to the contrary.
*305*
Login Id: SPRD\baileyjo Page 3 of 3


summary: A resident was sent to Arkansas Children’s Hospital after causing a laceration on her forearm with a piece of wood.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Case Number: 024387
Date of Incident: 9/30/2024
Date Received: 9/30/2024
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Incident Type: Licensing
Report Description: X Serious injury requiring outside medical attention ? Resident?s
attempted suicide ? Allegation of abuse/neglect related to a restraint ? Resident?s death ?
AWOL/Elopement ? Allegation of sexual/physical abuse ? Sexual Misconduct ? Other
Patient/Resident Name/DOB: Date/Time of incident:
09/29/24 at 01:00 Patient Insurance: Name of Perimeter Staff
Making Notification Date Time Name of Person Notified DHS Charriot Sales, Director of
Risk Management 09/30/24 18:00 Felicia Harris, Chelsea Vardell, Kendra Rice, Jarred
Parnell OLTC Charriot Sales, Director of Risk Management 9/30/24 18:00
Jeff.rosenbaum@dhs.arkansas.gov Disability Rights Center, Inc. Charriot Sales, Director of
Risk Management 09/30/24 18:00 incidentreporting@disabilityrightsar.org Perimeter
Charriot Sales, Director of Risk Management 09/30/24 18:00 Skyler Barnes, Shawna Stover,
Chris Perry, Brandy Pfeifer, Carey Ouzts, Rebecca Thomas Guardian/Caseworker Keith
Bohannon, RN 09/30/24 01:04 Michael Walton Charriot R. Sales, Director of Risk
Management 09/30/24 Signature and title of staff completing this form Date: Name of
Facility: Perimeter Behavioral of the Ozarks Phone Number: 479-957-9857 ext. 108 Street
Address, City, State, Zip: 2466 S. 48th Street Suite B. Springdale, AR 72762 Please describe
the incident: On 09/29/24, self-harmed with a piece of wood, resulting in
a laceration on the right forearm. Resident was sent to the Arkansas Children?s Hospital
She returned to Perimeter at approximately 04:00. Actions
Taken: ? Resident taken to the Emergency Room. ? Resident was placed on self-harm
precautions for 72 hours and is under line of sight observation. ? Provider consulted prior to
transport and for aftercare follow-up. ? Guardian notified.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: 10/1/2024 - The provider reported incident was reviewed by the
licensing specialist. Licensing specialist will follow up with the facility for where the wood
came from, what the safety plan is, nursing notes, and any precautions the resident was put
on. 10/1/2024 - Facility response received- "The wood came from the resident?s bed. The
mattress sits atop a piece of particle board and the resident peeled off a piece. The facility is
doing a risk assessment regarding the boards and determining a course of action. The
resident is on Self-Harm precautions for 72 hours and is line-of-sight while sleeping."
10/1/2024 - Nursing notes received from the facility, reviewed and uploaded to ELS.
10/8/2024 - A visit was conducted to do a walkthrough of the facility in regards to the report
and inspect beds with pressed wood board. Residents rooms on blue and green unit which
have pressed wood boards was inspected for damage to the beds. Upon inspection the
boards appeared in good repair, and not chipped. It was not verified that the resident
acquired the wood from the bed as there are no obvious signs of damage. The facility will be
replacing all pressed wood board in the residents rooms as a precaution. Housekeeping staff
will conduct regular inspections of the beds until the boards are replaced. Facility grounds
keeping staff state the beds will be finished by 10/18/2024 and will provide photos of the
beds. 10/15/2024 - the facility sent documentation that the fiberboards have been replaced
in the bedrooms. Pictures have been uploaded.