summary: Multiple deficiencies were noted during the Inspection of Care performed on 5/16/2023. A Corrective Action Plan was submitted and approved.

raw_content:
Inspection of Care Summary
Facility Tour:
Upon arrival to facility, AFMC staff was promptly greeted at the locked entrance by a Woodridge of West
Memphis Behavioral Health staff member. AFMC was immediately taken to a conference room where
they were met by the Chief Executive Officer and the Director of Quality and Risk Management. AFMC
staff was given the completed and signed consent form listing approval for access to the AFMC portal.
A tour of the facility was completed with the Director of Nursing. The tour included one residential
inpatient unit, seclusion rooms, medication room, gymnasium, cafeteria, two outside courtyard areas, and
several classrooms. The facility environment was extremely clean, well-organized, and appeared to be in
good repair. Staff were able to answer questions regarding the facility.
AFMC staff noted during the tour of the residential unit there was one male staff member with two female
clients in the common area of the unit watching TV. The program that was being watched was a music
video with women dancing provocatively and dressed in a skintight leotard. AFMC staff overheard one
female client state, “Oh, those girls are naked.” This was immediately addressed with the Director of
Nursing who asked staff to change the channel due to inappropriateness of the programming.
Facility Review-Policies and Procedures:
Upon review of the site’s policies and procedures, the following deficiencies were noted:
Rule Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: HR records did not indicate The provider lacked evidence of
221.804; CFR 42 training in the use of nonphysical evidence that all direct care personnel are
482.130, 483.376 intervention skills, such as de- trained in the use of nonphysical
escalation on an annual basis. intervention skills, such as de-escalation,
mediation conflict resolution, active
listening, and verbal and observational
methods, to prevent emergency safety
situations on an annual basis.
Medicaid IP Sec. 2: HR records did not indicate that The provider lacked evidence of
221.804; CFR 42 all direct care personnel have evidence that all direct care personnel
482.130, 483.376 ongoing education, training, and have ongoing education, training, and
demonstrated knowledge of demonstrated knowledge of techniques
techniques to identify staff and to identify staff and resident behaviors,
resident behaviors that may events and environmental factors that
trigger an emergency safety may trigger emergency safety situations
situation semi-annually. on a semi-annual basis.
Medicaid IP Sec. 2; There is no documentation in the The provider lacked evidence of
CFR 42 482.130, HR records that all direct care evidence that all direct care personnel are
483.376 personnel are trained in facility's trained, as well as demonstrate
Restraint and Seclusion policy. competency, in facility's Restraint and
Seclusion policy and appropriate
procedures to be used in Restraint and
Seclusion interventions.
Medicaid IP Sec. 2: The facility has not submitted to Facility could not provide proof of the
221.801; 42 CFR: Arkansas Medicaid a Letter of letter of attestation from July 2022. New
483.374 Attestation that the facility letter dated May 16, 2023 (day of IOC)
follows CMS standards regarding was submitted for review.
Woodridge Northeast, LLC – IOC Report 2 | P ag e

the use of Restraint and
Seclusion.
Medicaid IP Sec. 2: There is no documentation that all The provider lacked evidence of
215.220, 218.000 direct care personnel hold current professional license for direct care
42 CFR: 441.156 licenses, as required by their personnel, as required by their position
position and profession and/or and profession and/or licensing
licensing authority. authority.
Personnel Records- Licenses, Certifications, Training:
There was a total of 23 personnel records reviewed. Eight (26%) professional staff and 15 (25%)
paraprofessional staff. During the review of the personnel records, the following deficiencies were noted:
Personnel Rule Credential Outcome Reviewer Notes
Record Validated
Number
SR013877 Medicaid IP Sec. 2: Restraint and Failed No file received.
SR013868 221.804; 42 CFR Seclusion Training
482.130, 483.376 (CPI) - IP Acute
SR013868 215.220, 218.000 Professional Failed The provider submitted a report
License or from Global HR Research that
Certificate - IP indicates the personnel held a
Acute professional license (Licensed
Master Social Worker) in the
state of Tennessee from
09/07/2021 to 04/30/2022. No
other professional licensure was
submitted for review.
SR013878 No file received.
SR013882 No file received.
SR013864 241.100B Child Maltreatment Failed No file received.
Check - IP Acute
SR013864 241.100B Federal Failed Provider lacked evidence of
Background federal background checks for
Check- IP Acute staff who have resided outside
of Arkansas within the last five
years.
SR013864 241.110B State Background Failed No file received.
SR013881 Check- IP Acute No file received.
SR013884 The provider submitted a report
from Global HR Research
however it does not indicate
that the Arkansas State Police
Date base was utilized.
Woodridge Northeast, LLC – IOC Report 3 | P ag e

Clinical Summary
As a part of the Quality of Care survey of the IOC, an active 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.
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.
Program Activity/Service Milieu Observation:
Clients were observed in the classroom. Staff were engaged with the clients and were providing a
therapeutic environment that was conducive to learning.
Medication Pass:
No FFS Medicaid clients received medications during medication pass. Due to the observation of non-
Medicaid clients not being complaint with the HIPAA minimal necessary rule, no medication pass was
observed. AFMC RN visited with the medication nurse who was able to show AFMC RN the facility
policies and procedures regarding medication administration, narcotic count/reconciliation/handling, and
medication discrepancies. Tour of medication room completed with a Woodridge Behavioral Health nurse
and no discrepancies with medication storage, cleanliness of medication room, and knowledge of
medication dispensing found.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report
available for review. The IOC Report and Request for Corrective Action can be accessed through the link
to AccessPoint, provided via email.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
AFMC Inspection Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge Northeast, LLC – IOC Report 4 | P ag e

doc_type: IOC Report


state: AR

facility_name: Perimeter Behavioral of West Memphis

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

raw_content:
Dispatch Call Detail
Call #: C655106 - Battery Complaint
Received Date/Time: 04/27/2023 15:45:20 Taken By: Ford, Mandi
Initial Call Type: Battery Complaint Caller Name
Cleared Date/Time: 04/27/2023 16:24:49 Phone: (870) 824 - 1103
Cleared By: Hopkins, Tiara Caller Loc.:
Location: 600 N 7Th ST
West Memphis, AR 72301
Units Dispatched
Dispatched Enroute Arrived Transport Trans Dest Cleared At Station Mileage Trns To
271 - Kimbrough, Amber - 2237 04/27/2023 04/27/2023 04/27/2023
(WMPD) 16:00:20 16:00:41 16:24:49
234 - Gbson, Mallory (WMPD) 04/27/2023 04/27/2023 04/27/2023
16:00:57 16:01:02 16:01:26
245 - Williams, Anquion - 2274 04/27/2023 04/27/2023 04/27/2023
(WMPD) 16:01:05 16:01:07 16:24:49
234 - Bennett, Mallory - 2237 04/27/2023 04/27/2023 04/27/2023
(WMPD) 16:01:32 16:01:35 16:24:49
Narrative
Date/Time Dispatcher Narrative
04/27/2023 15:45:22 Ford, Mandi PERIMETER - MAKE CONT WITH KEITH WILLIAMS OUT FRONT IN REF TO A
ASSAULTING HIM. WANTS TO FILE A REPORT
Dispositions
Incident Report,
Incidents
Agency Incident Officer
WMPD 23-01547 Gibson, Mallory
Copyright Relativity Inc.© - RPS(Relativity Public Safety) 1 of 1

Incident # 23-01547 West Memphis Police Report Date 04/27/23
Page 1 of 2 Incident Report Report Time 6:25 PM
Status Exception Clearance Date Reporting Officer ORI/Agency
Not Applicable 234 Gibson, Mallory AR0180100
Active
Assigned Officer Entered By Approving Officer
gibsonm Shelton, Jerry
Assisting Officers
Complainant
SSN/ID/TIN Title Name DOB Age Sex Resident Status
Williams, Keith L 46 M Unknown
Race Black / African Ethnicity DL (#, ST) Email
American Not Hispanic/Latino
Home Phone Work Phone Other Phone Personal Cell Work Cell
US Citizen Legal Alien Doc Type Immig Doc # Nationality
Yes
Home Address Employer
Perimeter Behavior Hospital
Work Address Occupation
600 N 7Th ST,West Memphis, AR 72301
Offenses
Incident Location Zone
600 N 7Th ST West Memphis, AR 72301 North East
Earliest Possible Date Time Latest Possible Date Time
04/27/2023 16:00 04/27/2023 18:25
# Statute/Code Description Fel/Misd Att/Comp Loc Bias Wpn CATypes
1 GENERAL INFO GENERAL INFORMATION Misd Completed 9 88 99
MO Method Of Entry # Prems
n/a 0
Location Types 13 Hway/Road/Alley 37 Abandoned/Condemned 48 Industrial Site Bias Motivation Codes
14 Hotel/Motel Structure 49 Military Installation 43Lesbian, Gay, Bisexual,
0 0 0 0 0 0 0 0 0 1 1 1 1 2 3 4 5 6 7 8 9 0 1 2 A B B C C C C D D F G G i i a a h o o o e r o r e r u o n r / u m n n p v l B / g d c k N t r s v t / m / e c u / / t e P D S W i S r h r s g n e u u y t i & / / s h r o i S r c T / b e / S c c L t o D t r l y n i i o i C a u o d a c n r c u i p n s l l a n e O / u B n e O g S b t T l f S r d / f f m S i T / e f t t g H o e t r B e a o m r o m l r e r d s k e i p n g p e l a t e l 1 1 1 1 1 F 2 2 2 2 2 5 6 7 8 9 0 1 3 4 5 a c J L L P R R R S S U i a l a i a e p e e e n i q t i k r r e y n s s k l u / k v e i t c n P t o d i a i a / i n c o W r r a e u l e i g w s S l n S r t / a a o y n G L c t t t o n n o / e o e S a O r t r / t r e s a t H / w t o G h g S o r a e a e e m t y r a ra e ti g o e n 3 3 g 4 4 N 4 4 4 M 4 4 8 9 r 0 1 2 4 5 6 7 e o o w A A A C D D F G d u A a a / n r T u a a o a U m e l r d t M m y c m o m n T s s u c k a p e b e / a / s D S C W F / / d l r e r S C i e e m e n a o m h p a t a g c l a i F i a a l n e m s i e d l a r r i a e n r f t i a p c / y u s l u t F t g i h m m P e l r i r i t e o a p y / f F r i u r g o k a n h m i d r t/ Bank 5 5 5 C 5 E 5 M 5 5 5 5 0 1 2 3 4 5 6 7 8 l o i e s l C m l s P R S S S S T C e i y r e o g a c c h h e o i b h h b n n e r e o s m e k o o a t / / t l p t a H U / r m o o e l A P p s r o n L l l r i p y u r l n a m i e - - a / - a n v g S y a n c e i e g t e d M e y r l r c e s s o C a o i s t u l y n s e l n d n d a te ry r A 1 1 A 1 A 1 1 1 O 2 2 N 1 2 3 4 5 6 1 2 m l t a h T W M J C B A A s e e N e k I l m s r a r u a h - a i w a i c t P l a c i e t h t t a i i N i k n e s v a r o - n i r h e c a c l o a i i a c t r f c H i i n v c e A a e s I f I w n r s , i d a c l G a a i i a i n r a n o n d n u e o p o r r r 2 2 2 2 2 3 3 3 L 4 4 3 4 5 6 7 1 2 3 a 1 2 t P I O M A A G L H N in s e r t r i o l t a o u h s o a a h s t y l p e t b m e b t H e i a i ( - r i s s i a m r i n c R s t e t n / i a a p A l c ( e i M n g l a g l e o i t i n g u n o ) r i i s o u c L o l s s a i n o m t t i g r i c n ) ro o up o G 4 4 5 5 6 6 7 7 8 9 r 4 5 1 2 1 2 1 2 8 9 r o T H B P M M F T G N U u r e r i h a e o n e e a p s a m y n t n k n n l e n e e ( s n s e d t x L a s r a g o o e u D G l g l e e w s r a e i D B s n e l N n n a i T d x s d o b e u ) a e n i r a l b r - , i l t C i M y li o ty i n xe fo d rming
Facility/Casino/Race Track
Suspected Of Using Criminal Activity Types Weapon Type(s) 20 Knife/Cutting Instr 65 Fire/Incendiary Device
None B P B P u o y s i s n e g s / s R in e g ce /C iv o in n g cealing C O C O u p l e ti r v a a t t in in g g / / P M ro a m nu o f t / i P n u g b /A li s s s h i i s n t g ing 1 1 1 2 F H i a re n a d r g m u n (A (A ut u o t ) o) 3 3 0 5 B M l o u t n o t r O V b e j h e i c c t le 7 8 0 5 D As ru p g h s y / x N ia a t r i c o . n /Sleeping Pills
D Distributing/Selling T Transport/Import/Transmit 13 Rifle (Auto) 40 Personal Weapons 90 Other
E Exploiting Children U Using/Consuming 14 Shotgun (Auto) 50 Poison 95 Unknown
15 Other Firearm 60 Explosives 99 None
A Simple/Gross Neglect I Intentional Abuse & Torment
F Organized Abuse S Sexual Animal Abuse
Copyright Relativity Inc.© - RPS(Relativity Public Safety)
Printed : 5/19/2023 11:38:55 AM

doc_type: Police Report


summary: Officers were dispatched to the facility in response to a missing juvenile report.

raw_content:
Dispatch Call Detail
Call #: C654861 - Missing Juvenile
Received Date/Time: 04/25/2023 12:09:37 Taken By: Field, Monieka
Initial Call Type: Missing Juvenile Caller Name
Cleared Date/Time: 04/25/2023 12:42:01 Phone: (615) 943 - 2382
Cleared By: Robinson, Jakiya Caller Loc.:
Location: 600 N 7Th ST
West Memphis, AR 72301
Units Dispatched
Dispatched Enroute Arrived Transport Trans Dest Cleared At Station Mileage Trns To
259 - Strayhorn, Lillian - 2212 04/25/2023 04/25/2023 04/25/2023
(WMPD) 12:31:26 12:33:32 12:42:01
281 - Pegues, Christopher - 2254 04/25/2023 04/25/2023 04/25/2023
(WMPD) 12:31:35 12:34:40 12:42:01
Narrative
Date/Time Dispatcher Narrative
04/25/2023 12:10:03 Field, Monieka REC A CALL FROM METRO POLICE IN REF TO A MISSING
WHOSE AT PERIMETER BEHAVIORAL...METRO POLICE HAVE SPOKEN TO THE
MOTHER AND WANTS TO MAKE SURE HE'S THERE .. IS A 1
04/25/2023 12:35:36 Field, Monieka
04/25/2023 12:35:37 Robinson, Jakiya 259-- ADV THAT THAT SUBJ IS THERE
04/25/2023 12:42:01 Robinson, Jakiya 281-- IS FINE
Dispositions
No Action Taken,
Copyright Relativity Inc.© - RPS(Relativity Public Safety) 1 of 1


summary: A resident was found with two shirts tied around her neck. The resident was placed on suicide precautions and 1:1 observation.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 4/24/2023
Date Received by DCCECE: 4/27/2023
Facility Name: Perimeter Behavioral of West Memphis
Facility Number: 231
Facility Type:
Incident Type: Licensing
Report Description: Upon my return to work from sickness, I was alerted to an incident
regarding the following: Resident tied two of her
roommate's shirts around her neck during hygiene time. Staff intervened and removed the
shirts immediately. Resident was noted to have some redness on her neck but no further
injuries were assessed by the RN on duty. Resident was alert and talking to staff, her vitals
were within normal limits. Resident stated that she sees bloody demons that tell her to kill
herself and also stated another resident told her to self-harm in the shower. Actions Taken:
Physician was notified and ordered Resident to be placed on suicide precautions, level of
observation was increased to 1:1 at all times, and placed in paper scrubs until able to
contract for safety.
Interim Action Narrative: Resident was assessed by the nurse. She was placed on suicide
precautions, level of observation increased to 1:1 at all times, and placed in paper scrubs
until able to contract for safety.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist was informed of provider reported incident on
4/27/2023 via email. 5/1/2023, Licensing Specialist reviewed provider reported incident.
Licensing Specialist followed up with facility. 5/2/2023, Licensing Specialist informed that
resident was doing better.

doc_type: Notice of Incident


summary: Technical assistance was provided to the facility regarding the current Arkansas mandated reporting law, R102.3.h and R110.9.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of West Memphis
Facility Number: 231
Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301
Licensing Specialist: Kendra Rice
Person In Charge:
Record Visit Date: 3/30/2023
Home Visit Date: 3/30/2023
Purpose of Visit: Technical Assistance Request Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 1. 102. 3 .h
Regulation Description: The following policies of the agency shall be current and available to all employees of
the agency and the Licensing Specialist:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 110. 9
Regulation Description: Any owner/operator, employee, foster parent, or volunteer in a child welfare agency
shall immediately notify the Child Abuse Hotline if he or she has reasonable cause to suspect that a child has
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

been subjected to child maltreatment, died as a result of child maltreatment or if they observe a child being
subjected to conditions or circumstances that would reasonably result in child maltreatment.
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
After review of your agency’s current mandated reporter policy, it has been determined that it does not
comply with the current law in the state of Arkansas nor the Minimum Licensing Standards.
Technical assistance was provided to the agency regarding the current Arkansas mandated reporting law,
R102.3.h, and R110.9
Please ensure that your current mandated reporter policy is updated to comply with A.C.A. 12-18-402 and the
Minimum Licensing Standards by 4/13/2023 and provide a copy to the Licensing Unit for review. Once the
needed changes have been made, please ensure that all staff are retrained on the new policy within two weeks
of the new policy going into effect.
Provider Comments:
CCL Staff Signature : Date: 3/30/2023
Provider Signature : Date: 3/30/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of West Memphis
Facility Number: 231
Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301
Licensing Specialist: Kendra Rice
Person In Charge: Summer Berryhill
Record Visit Date: 3/30/2023
Home Visit Date: 3/30/2023
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 12:30 pm to 1:30 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 18
Licensing Specialist attended Handle to with Care training at the facility to ensure that staff members are
being trained according to the facility’s policy on physical restraints. Also, to ensure that the facility’s policy
on physical restraints complies with the minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 3/30/2023
Provider Signature : Date: 3/30/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


summary: A complaint received reported that staff members curse at the children and talked about meth. The complainant’s daughter’s medication was increased without consent or notification.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 3/16/2023
Date Received by DCCECE: 3/27/2023
Facility Name: Perimeter Behavioral of West Memphis
Facility Number: 231
Facility Type: Residential
Incident Type: Licensing
Report Description: Staff members cursed at children and talked about meth. My daughters
medicine was increased without my consent or notification, when their handbook states
they mush have consent for psychiatric drug changes.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed complaint. Licensing Specialist
attempted to contact parent regarding complaint and a voicemail was left for parent to
return call. Licensing Specialist also sent parent a text message. Licensing Specialist spoke
with parent. Licensing Specialist will follow-up with facility to see if child is a resident.
3/28/2023, Licensing Specialist informed that resident was admitted from 3/16/2023 to
3/22/2023. 3/30/2023, Licensing Specialist reviewed resident's chart. It was determined
that incident happened on the acute side and not PRTF.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to review children’s records. No deficiencies cited.

raw_content:
521 Visit Compliance Report

Licensee: Perimeter Behavioral of West Memphis

Facility Number: 231

Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301

Licensing Specialist: Kendra Rice
Person In Charge: Rebecca Thomas
Record Visit Date: 3/14/2023

Home Visit Date: 3/14/2023

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time of Visit: 11:15 am to 2:00 pm

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

_ ARKANSAS
) DEPARTMENT OF

«| 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

Page 1 of 2

Census: 18
Licensing Specialist received the planned monthly (March) calendar of events for the residents.

Licensing Specialist reviewed five (5) residents' files:

All residents' files reviewed complied with the minimum licensing standards.

Provider Comments:

CCL Staff Signature : Date: 3/14/2023
/ W y
Provider Signature : Date: 3/14/2023

as
hard .
tf |

a

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

521 Visit Compliance Report

Licensee: Perimeter Behavioral of West Memphis

Facility Number: 231

Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301

Licensing Specialist: Kendra Rice
Person In Charge: Rebecca Thomas
Record Visit Date: 3/14/2023

Home Visit Date: 3/14/2023

Purpose of Visit: Personnel Records

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time of Visit: 11:15 am to 1:45 pm

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

_ ARKANSAS
) DEPARTMENT OF

«| 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

Page 1 of 2

Census: 18
Licensing Specialist reviewed five (5) personnel files:

K. Donaldson — PRN Therapist

J. Coker-Brown — PRN Assessment & Referral Specialist
S. Zolicofeer — Mental Health Technician

N. Hooks — Assessment and Referral Specialist

S. Gardner — Assessment and Referral Specialist

Licensing Specialist reviewed the personnel files to ensure that regulatory checks were complete. All
personnel files reviewed complied with the minimum licensing standards.

Provider Comments:

CCL Staff Signature : Date: 3/14/2023
ae LI
Provider Signature : Date: 3/14/2023

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


raw_content:
521 Visit Compliance Report

Licensee: Perimeter Behavioral of West Memphis

Facility Number: 231

Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301

Licensing Specialist: Kendra Rice
Person In Charge: Rebecca Thomas
Record Visit Date: 2/28/2023

Home Visit Date: 2/28/2023

Purpose of Visit: Child Record Review Visit

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Time of Visit: 12:15 pm to 2:30 pm

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

ARKANSAS
) DEPARTMENT OF

|\-7 HUMAN
» "2 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

y

Page 1 of 2

Census: 18

Licensing Specialist informed by Summer Berryhill, Director of Quality and Risk Management; one positive
case of Covid-19 was reported on the unit.

Licensing Specialist reviewed five (5) children files:

T/A provided: R902.13 — Licensing Specialist encouraged facility to follow-up on legal documents after a
request has been made. Requests were made for copies of residents’ social security cards and immunization
records.

Ms. Berryhill informed Licensing Specialist that she would follow-up with admissions on receiving legal
documents.

Provider Comments:

CCL Staff Signature : Date: 2/28/2023

Provider Signature : Date: 2/28/2023

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


summary: A resident was sent to the ER for evaluation after complaining of chest pain.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/23/2023
Date Received by DCCECE: 2/24/2023
Facility Name: Perimeter Behavioral of West Memphis
Facility Number: 231
Facility Type: Residential
Incident Type: Licensing
Report Description: On 2/23/23 Resident DOB was in the
gym playing when she started complaining of chest pain. The nurse assessed the resident
and obtained vitals. Our Nurse Practitioner order that she be sent to the ER for further
evaluation. She was diagnosed with
and returned to our facility 2/23/23.
Interim Action Narrative: Resident was assessed by the nurse. Nurse Practitioner ordered
for resident to go to the emergency room for further evaluation. Diagnosis:
.
Maltreatment Narrative:
Licensing Narrative:Licensing Specialist reviewed provider reported incident. Licensing
Specialist will follow-up with facility on resident's placement. Licensing Specialist informed
resident is private placement. No licensing concerns noted.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to the hospital after she was injured while playing football.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/19/2023
Date Received by DCCECE: 2/20/2023
Facility Name: Perimeter Behavioral of West Memphis
Facility Number: 231
Facility Type: Residential
Incident Type: Licensing
Report Description: On February 19, 2023 Resident DOB
was playing football with the other residents in the gym. She was running full speed with the
ball when another resident attempted to stop her. T fell to the ground, resident
stated several times that it was an accident and was sent by ambulance to LeBonheur where
it was discovered she had . Resident returned from LeBonheur with a leg brace
and crutches and is to have a follow up apt to determine if surgery would be required.
Resident's mother stated she wanted to care for her at home and Dr. Hiatt agreed to
discharge the resident home and would accept her back following recovery if needed.
Residents have been informed there will be no more football allowed and only able to run if
they have appropriate shoes to do so.
Interim Action Narrative: Resident was assessed by nursing and doctor ordered for her to be
transported to LeBonheur via ambulance. She and was provided with a brace
and crutches. Resident will follow-up to see if surgery is needed. Resident's guardian
wanted to take
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative:Licensing Specialist reviewed provider reported incident. Licensing
Specialist will inquire about resident's guardianship and date of discharge. Licensing
Specialist informed that resident discharged on 2/19/2023 to her guardian. No licensing
concerns noted.


summary: A resident was sent to the emergency room after being involved in a physical altercation with two peers.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/15/2023
Date Received by DCCECE: 2/16/2023
Facility Name: Perimeter Behavioral of West Memphis
Facility Number: 231
Facility Type: Residential
Incident Type: Licensing
Report Description: AR DCFS custody, was involved in a physical
altercation with two peers. Resident was sent to the emergency room after being assessed by
the nurse practitioner. Baptist Emergency Room did an x-ray that showed a
Interim Action Narrative: Resident was assessed by the nurse practitioner and transported
to Baptist Emergency Room. X-ray revealed a . Peers placed on assault
precautions and all three placed on peer separation.
Maltreatment Narrative:
Licensing Narrative:Licensing Specialist will entered provider reported incident. Licensing
Specialist will inquire about resident's last name and if any safety precautions were
implemented. Licensing Specialist informed of resident last name and safety precautions.
Licensing Specialist inquired about location of the incident and camera footage. Licensing
Specialist informed incident took place in the day room and camera footage is available.
2/24/2023, Licensing Specialist informed camera system was down. 2/28/2023, Licensing
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Specialist informed that a technician was scheduled to come and repair the camera system.
Licensing Specialist reviewed resident's chart in record review.


summary: Officers were dispatched to the facility in response to a call from a parent who was concerned because she was unable to make contact with someone at the facility.

raw_content:
Dispatch Call Detail
Call #: C647228 - Welfare Concern
Received Date/Time: 02/15/2023 18:48:18 Taken By: Martinez, Kaleb
Cleared Date/Time: 02/15/2023 19:23:44 Caller Name JOY, AUBREY
Cleared By: Hopkins, Tiara Phone: (731) 478 - 4929
Caller Loc.:
Location: 600 N 7Th ST
West Memphis, AR 72301
Units Dispatched
Dispatched Enroute Arrived Transport Trans Dest Cleared At Station Mileage Trns To
231 - Bracey, Thomas - 2290 02/15/2023 02/15/2023 02/15/2023 02/15/2023
(WMPD) 19:06:03 19:06:06 19:17:41 19:23:44
229 - Mckee, Matthew - 2231 02/15/2023 02/15/2023 02/15/2023 02/15/2023
(WMPD) 19:06:04 19:06:05 19:10:20 19:23:44
Narrative
Date/Time Dispatcher Narrative
02/15/2023 18:48:57 Martinez, Kaleb REC A CALL FROM AUBREY JOY IN REF TO HER WANTING A WELFARE CONCERN
ON HER . SHE ADV SHE IS IN FEAR OF LIFE AFTER
ATTEMPTING TO MAKE CONTACT WITH THE FACILITY AND GETTING NO ANSWER.
CALLER ADV WHEN PERIMETER CALLED HER BACK TO GET AN UPDATE ON HER
THE NURSE SOUNDED INTOXICATED AND HUNG UP ON HER.
02/15/2023 19:23:44 Hopkins, Tiara 229 - THAT IS IN GOOD HELATH
Dispositions
No Report Required,
Copyright Relativity Inc.© - RPS(Relativity Public Safety) 1 of 1


summary: Licensing visited the facility to review personnel files. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of West Memphis
Facility Number: 231
Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301
Licensing Specialist: Kendra Rice
Person In Charge: Summer Berryhill
Record Visit Date: 2/7/2023
Home Visit Date: 2/7/2023
Purpose of Visit: Personnel Records
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 11:45 am to 1:45 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 18
Licensing Specialist reviewed ten (10) personnel files:
J. Evans – Registered Nurse
S. Crawford – Lead Mental Health Technician
C. Bryant – Registered Nurse
N. Granger – Mental Health Technician
C. Brown – Mental Health Technician
D. Vaughn – Mental Health Technician
E. Smith – Mental Health Technician
L. Bell – Registered Nurse
B. Wilson – Assessment and Referral Assistant
B. Mickens – Mental Health Technician
All regulatory checks have been initiated with some completed and pending. Ms. Kim, Human Resource
Generalist, informed Licensing Specialist that she has requested information on the pending personnel
regulatory check.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to perform a buildings and grounds walkthrough. No deficiencies were observed.

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 Behavioral of West Memphis
Facility Number: 231
Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301
Licensing Specialist: Kendra Rice
Person In Charge: Summer Berryhill
Record Visit Date: 1/24/2023
Home Visit Date: 1/24/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
Time of Visit: 1:45 pm to 2:15 pm
Census:18
Licensing Specialist spoke with Ms. Carla (Perimeter of Forrest City) and Ms. Summer to get an update on the
regulatory checks for Perimeter of West Memphis. Licensing Specialist was informed that Ms. Catherine
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

(Corporate) was working on the new hires. Ms. Kim, new Human Resources Generalist, started employment
on 1/23/2023.
Ms. Carla and Ms. Summer informed Licensing Specialist that an estimation of 30% have been completed on
the most recent list of employees. They are hoping to have the “No Match” completed by 2/7/2023. Licensing
Specialist was informed that they had to go back and complete the background forms because of the notary
date.
The “Not Approved” employees will be rescheduled to have their fingerprints completed. Ms. Carla informed
Licensing Specialist that she spoke with Cynthia (DCCECE Background Unit) regarding the Child
Maltreatment forms that will be resubmitted.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


summary: During the course of a complaint investigation, it was discovered that the current Clinical Director at the facility is not licensed as a mental health professional in the state of Arkansas. This is a violation of standard 906.1.c.

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 Behavioral of West Memphis
Facility Number: 231
Licensee Address: 600 NORTH 7TH STREET
WEST MEMPHIS AR 72301
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 1/13/2023
Home Visit Date: 1/13/2023
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulation Description: The agency shall have:
Sub Regulation Description:
Regulation Number: 9.906.1.c
Regulations Needing Technical Assistance:
Regulations Not Correctable:
Narrative:
No site visit conducted on this day.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 1 of 2

During the course of a complaint investigation on a different matter, it was discovered that the current Clinical
Director at the facility is not licensed as a mental health professional in the state of Arkansas as recognized by
the state of Arkansas.This is a violation of standard 906.1.c.
The licensing unit met with the management of the facility on 1/10/2023 to discuss this issue. The facility
reports that the current Clinical Director is licensed out of state and is working on gaining reciprocity in the
state of Arkansas. Please ensure that arrangements are made to have a therapist licensed in the state of
Arkansas fulfill the role of Clinical Director until the current Clinical Director is able to gain reciprocity in
Arkansas.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year
Page 2 of 2


facility_name: Timber Ridge / NeuroRestorative Timber Ridge

summary: A resident reported that a staff member cusses him, pushes his head down on the pillow, and pushes his neck down on a wall. This complaint has been UNFOUNDED by Licensing.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 029183
Date of Incident: 4/22/2025
Date Received: 4/22/2025
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: reported to
therapist in session today that, ? cusses at me and pushes my head down on the
pillow? and ?pushes my neck down on the wall?. The client could not give a date or time of
any incidents. Nursing assessed and no injuries noted. Guardian was present on session
when statements were made. Staffing ratio on shift today was 8:13.
. . We do not
have camera footage on property.
Interim Action Narrative: Staff suspending pending investigation.
Narrative:
Licensing Narrative: 4/22/25-Reviewed for licensing concerns. Phone call made to
of Neurorestorative Timber Ridge to ascertain that resident's admit date
was 9/3/24 and resident made complaint today, 4/22/25. 4/23/25-Phone conversation had
with for further information. Visit scheduled for 4/24/25 at 9:00AM. Resident
nursing note, therapy note, staff witness statements and hourly checks sent to licensing.
Staff 1 background checks and trainings sent to licensing. 4/24/25-Facility visited. No
citations. Licensing complaint unfounded.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the emergency room after having a seizure.

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: 028419
Date of Incident: 3/20/2025
Date Received: 3/20/2025
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: , is a resident in our
PRTF program at Timber Ridge. Staff to client ratio was 3:5. Staff notified nursing of a
medical event and followed protocol. Nursing responded immediately and began providing
care to who was having a seizure. 911 was called and MD was notified. has a
recent hx of seizures and is scheduled for in the coming weeks.
transported to Staff was sent with the client for supervision while at the
Guardian has been notified.
Interim Action Narrative: Resident transported to hospital.
Narrative:
Licensing Narrative: 3/20/25-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct and after hours visit. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Neurorestorative Timber Ridge
Facility Number: 102
Licensee Address: 15000 TIMBERIDGE LN
BENTON AR 72019-9636
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 3/19/2025
Home Visit Date: 3/19/2025
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
After hours visit conducted for Americana House and PRTF Building from 5AM-6AM.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Americana House staff alert, awake and able to answer questions. Staff/client ratio 1:2 Areas observed were
clean, safe and in good repair. Emergency diagrams and fire extinguisher observed. No noted concerns.
PRTF staff alert, awake and able to answer questions. Staff/client ratio 6:12. Staff nightly observation logs
observed. Some clients were awake and interacting with staff. Areas observed to be clean, safe and in good
repair. Emergency diagrams, fire extinguisher and client rights observed. No noted concerns.
Provider Comments:
CCL Staff Signature : Date: 3/19/2025
Provider Signature : Date: 3/19/2025
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was transported to the emergency room after reporting that he hit his head.

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: 028266
Date of Incident: 3/13/2025
Date Received: 3/14/2025
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: was playing with toys
yesterday afternoon and randomly reported to his staff that he hit his head. Staff notified
nursing, and nursing completed an assessment. Nursing notified MD, and then informed
staff that will be sent out for further evaluation. Nursing stated that will be
transported to . Two staff were sent with him to ensure safety and quick response if
needed as requested by nursing. completed assessments last night and admitted him
for monitoring. Guardian was notified. We do not have cameras on property. The client
cannot recall what day the fall happened. Client was transported by staff to the .
Interim Action Narrative: Client treated at hospital.
Narrative:
Licensing Narrative: 3/17/25-Reviewed for licensing concerns. Email sent to facility to
notify licensing if/when client returns to facility and to send hospital discharge paperwork.
Email received that client returned to facility 3/14/25 around 3PM. Nursing notes and
discharge paperwork to be sent to licensing. discharge paperwork sent to licensing.
Nursing note sent to licensing.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that he was scratched when a staff member attempted to implement Nonviolent Crisis Intervention (NCI) protocol. Staff members reported that the resident was hitting his head on a window and bed. This 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: 028059
Date of Incident: 3/6/2025
Date Received: 3/6/2025
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: Client was involved in an
incident on 3.6.25. Staff reported that client was hitting his head on window and bed
along with hitting window with fist. Client reported to the nurse that he had a scratch on his
left foot and on right lower cheek due to Life Skills Trainer (staff member)
attempted to implement NCI protocol. Nurse asked more specific details and the
client stated that it happened on the hinge of his room door with this staff member. This
was called into the and the nurse reported that reviewer
. Timber Ridge does not have camera
footage.
Interim Action Narrative: Staff allegedly involved in incident placed on administrative leave
pending investigation.
Narrative:
Licensing Narrative: 3/6/25-Phone call received from of Timber Ridge.
All documentation related to incident will be sent to licensing. Client is scheduled to
discharge from NTR /25. 3/7/25-Witness Statements, Therapy Note with Safety Plan,
Staff involved training and Behavior Report sent to licensing and reviewed. Therapy note
indicates that client injured himself, and was untruthful when alleging complaint. 3/10/25-
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Received notification that State and FBI background checks for staff mentioned in
complaint were ran 5/29/2024 and cleared. Maltreatment was cleared on 5/30/2024. Out of
State from TX was cleared 7/17/2024. Licensing complaint unfounded. 3/18/2025, case and
documentation reviewed. Case unfounded by licensing. 3/28/2025, case moved back to
under review. 4/1/25-Facility visited. Licensing complaint unfounded. As a precautionary
measure, staff retrained. Retraining provided to licensing. 4/21/2025, facility provided
documentation that was uploaded to the case. The case has been closed as founded by
licensing. Approved by Program Coordinator. Case complete.


summary: A Buildings and Grounds review was conducted for PRTF House and Americana Residential Building. The buildings were clean, safe, and in good repair. The grounds were clean and free of safety hazards.

raw_content:
521 Visit Compliance Report

Licensee: Neurorestorative Timber Ridge

Facility Number: 102

Licensee Address: 15000 TIMBERIDGE LN
BENTON AR 72019-9636

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 1/28/2025

Home Visit Date: 1/28/2025

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

ARKANSAS
) DEPARTMENT OF

\}v7 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

Buildings & Grounds conducted for PRTF House and Americana Residential Building. PRTF Census: 12,

Americana Census: 3.

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

Page 1 of 3

PRTF Building staff/client ratio: 3:3, staffed 6:12. Some clients at school and cafeteria. Buildings clean, safe,
and in good repair. Bathrooms clean and sanitary with functioning sinks, showers and toilets. Emergency
diagrams, fire extinguisher and client rights posted. Grounds clean and free of safety hazards.

MAR checked for:

Americana staffed 4:3. Clients at school and cafeteria.Buildings clean, safe, and in good repair. Bathrooms
clean and sanitary with functioning sinks, showers and toilets. Emergency diagrams and fire extinguisher
observed. Grounds clean and free of safety hazards.

MAR checked for:

***** Pursuant to A.C.A. § 9-24-406(e)(3-4): If you believe that the Department’s notice of
noncompliance is in error, you may ask for reconsideration. The request for reconsideration must be in
writing and delivered to the Department by certified mail within twenty (20) business days of receipt of
the notice of noncompliance. The request must specify the parts of the notice that are alleged to be in
error, explain why you believe those parts are in error, and include documentation to support the
allegation of error. Once received the Department shall issue a decision on your request within twenty
(20) days after receipt of the request.

Provider Comments:

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

CCL Staff Signature : Date: 1/28/2025

Date: 1/28/2025

—e
SS

IY,

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


summary: A resident was transported to Arkansas Children’s Hospital Emergency Room after becoming unresponsive to staff.

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: 026237
Date of Incident: 12/18/2024
Date Received: 12/18/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: OOS placement from he does have a
guardian private placement. was in education class when he stated he was tired and
said he needs to lay down. After a couple of minutes the staff recognized that he was having
issues with responding to staff. Nursing was notified immediately and upon assessment
notified MD of client being awake but not verbally responding. Nursing then called 911 to
transport him to Arkansas children?s hospital ER. Staff to client ratio was 4:3 and a staff was
sent to ACH.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/18/24-Reviewed for licensing concerns. Email sent to facility to
notify licensing when client returns to facility and send licensing ER discharge paperwork.
12/19/24-ER paperwork sent to licensing.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to complete a Buildings and Grounds walkthrough. 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: Neurorestorative Timber Ridge

Facility Number: 102

Licensee Address: 15000 TIMBERIDGE LN
BENTON AR 72019-9636

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 12/10/2024

Home Visit Date: 12/10/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted from 8:30AM-9:30AM. Census: 13.

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

Staff/client ratios:

3:1 inside
4:2 inside
4:8 outside

Buildings clean, safe and in good repair. Bathrooms observed clean and sanitary. Sleeping quarters furnished,
clean, safe and in good repair. Grounds clean and free of safety hazards. Emergency diagrams, fire
extinguisher and client rights observed.

MAR checked electronically for:

All recent administrations marked as given and by who distributed them.

Provider Comments:

CCL Staff Signature : Date: 12/10/2024
/

I) ,

Provider Signature : Date: 12/10/2024

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


summary: A resident was sent to Saline Memorial Emergency Room for assessment after another resident wrapped a Nintendo controller hanger around his neck in an attempt to strangle him.

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: 026022
Date of Incident: 12/9/2024
Date Received: 12/10/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: out of state placement with
earned his nintendo switch time and was walking with the staff to get it. He received
his switch and was walking with his staff to the TV where he plays it and he began messing
with the controllers. As he was approaching the spot he was supposed to be to play, he
rushed up behind peer private placement out of state
and wrapped the controller hangers around his neck in an attempt to strangle him. Staff
immediately intervened and separated them. Staff called nursing for assessment and called
911. Client was escorted to Arkansas Childrens Hospital for assessment for
psychiatric acute placement. guardian was notified. was
transported to Saline Memorial ER to be medically cleared due to scratches on his neck. He
was cleared and brought back to Timber Ridge. His guardian was notified and stated they
wanted to press charges. Timber Ridge called Saline County Sheriff to inform of the
incident and wishes of the parents to press charges. The reference number for the police
report is 2024-3738. remains at Arkansas Childrens Hospital and will be
transported back to for psychiatric acute placement tomorrow. Timber Ridge is
staffing him at Childrens Hospital until he leaves. This incident happened in the Americana
building and the staff to client ratio was 4:4.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 12/10/24-Reviewed for licensing concerns. Safety plan is client is
not to return to facility. Placement for has been secured in home state, awaiting
transportation. will remain at hospital until transported. remains at facility. Phone
call made to Kenleigh Bennett of Timber Ridge. Nursing note and ER paperwork for client
will be sent to licensing. ER paperwork for sent to licensing. 12/11/24-Nursing notes
sent to licensing. 12/23/2024, police documentation requested. Police documentation
received and Licensing Specialist informed. 12/26/24-Police report reviewed.


summary: A resident complained of pain after kicking his bed frame during an outburst. An x-ray was ordered.

raw_content:
Placement and Residential Licensing Unit
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Case Number: 026025
Date of Incident: 12/9/2024
Date Received: 12/10/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: private placement was engaged in
behavioral outburst when he kicked his bed frame. Nurse was notified and assessed. Doctor
was notified later when he complained of pain and gave orders for XRAY. Guardians were
notified. XRAY was clear from Saline Memorial. This was at the PRTF program staff to
client ratio 5:13.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/10/24-Reviewed for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched to the facility in response to a report of a patient strangling another patient.

raw_content:
INTERNAL INCIDENT EXCEPTIONAL

ORI NUMBER
4 4
ARO630000 ARKANSAS STATUS CLEARANCE STATUS:

INCIDENT NUMBER INCIDENT REPORT BB A) Active LO (A) Death of the Offender

D1 (CA) Closed by Arrest C (8) Prosecution Declined
2024-3738 APPROVED (Lieutenant Connell Latture)

CO (CE) Closed by Exception | [7] (C) Extradition Denied
DATE(S) OF INCIDENT AGENCY NAME ge
1 (CO) Closed by Other Means | (-] (D} Victim Ref. to Cooperate
12/09/2024 - 12/10/2024 Saline County Sheriff's Office , .
OD Inactive C1 (E) Juvenile, No Custody
TIME(S) OF INCIDENT DAY(S) OF INCIDENT .
20:19 - 02:07 Monday - Tuesday CO ) Unfounded Ih (N) Not Applicable
DISPATCHER TIME RECEIVED TIME ARRIVED | REPORTING AREA EXCEPT. CLEAR. DATE
emily.sulzberger - SULZBERGER, EMILY 20:20
UCRCODE | OFFENSE STATUS: OFFENDER USED: Hi (N) Not Applicable Burglary (220) Location 14819: FORCED ENTRY?
13A LD (AjAttempted ggg (C) Completed | [7] (A)Alcohol [7] (C)Cptr. Equip. [[] (D) Drugs | # PREMISES ENTERED? O Yes [J No
STATUTE OFFENSE DESCRIPTION ADDRESS OF OFFENSE
5-13-204 Aggravated Assault 15000 TIMBER RIDGE LN, Benton, AR 72015
LOCATION CODE = (Enter 1) [2 (17) Liquor Store (CO (46) Farm Facility WEAPON FORCE: (Max. 3)

‘ . : { For 11-15, place "A" in space next to box
DD (01) AirfBus/Train Terminal ( (18) Parking Lot/Drop Lot/Garage a (47) Gambling Facillty/Casino/Race if weapon was an Automatic.)

INCIDENT

LD (02) Bank/Savings & Loan (2 (19) Rental/Storage Facility Track
DD (03) Bar/Night Club CD (20) Residence/Home DD (48) industrial Site - — CF (11) Firearm (Type not stated) [[} (90) Other
C) (04) Church/Synagogue/Temple/Mosque [[] (21) Restaurant TO (49) Military Installation [O (12) Handgun CO (95) Unknown
1 (05) Commercial/Office Building 2 (23) Service/Gas Station 0 (50) Park/Playground —_ |
{| Cl (06) Construction Site CO (24) Specialty Store LD 651) Rest Area — D (13) Rifle D) (9) None
| 1 07) Convenience Store CD (25) Cther/Unknown D (52) School - College/University _. BD (14) Shotgun
Z. LD (08) Department/Discount Store DD (37) Abandoned/Condemned 11] (53) School - Elementary/Secondary CO (15) Other Firearm
fad] HE (09) Drug Store/Doctor’s Office/Hospital Structure (0 (54) Shelter - Mission/Homeiess ~_ | .
[| [C1 (10) FieldWoods DD (38) Amusement Park LD 655) Shopping Mail CO) (20) Knife/Cutting Instru. (Ax, etc.)
fq) 2) (14) Government/Public Building DD (39) Arena/StadiunvFairgrounds/ [7] (56) Tribal Lands 1 (30) Blunt Object (Club, etc.)
o) (O (12) Grocery/Supermarket Coliseum 0 (57) Community Center CO (35) Motor Vehicle (As weapon)
2 (13) Highway/Road/Alley/Street/Sidewalk [[] (40) ATM Separate From Bank
OO (14) HotelMotel/Ete. LD (41) Auto Dealership NewUsed {1 (40) Personal Weapons (Hands, etc.)
CO (15) JaivPrison/Penitentiary/Corrections [[) (42) Camp/Campground (1 (50) Poison
Facility DD (44) Daycare Facility

DD (60) Explosives
0 (65) Fire/lncendiary Device
(Max. 3) TYPEGANG ACTIVITY: = (Max.3) | 1 (70) Narcotics/Drugs!

CD (16) Lake/Waterway/Beach
TYPE CRIMINAL ACTIVITY:

LD (45) DockWharfiFreight'Modal Terminal

CO (8) Buying 1 (0) Operating/Promoting/Assisting CO (G) Other Gang Sleeping Pills

CO (C) Cultivate/Manufacture/Publish LB (P) Possessing/Concealing 1 () Juvenile Gang BB (85) Asphyxiation

C (0) Distributing/Selling (2 (1) TransportTransmitiimport BIAS MOTIVATED CRIME:
C0 €) Exploiting Children LO (WU) Using/Consuming ) (N) None/Unknown

None (No Bias)

Last,

RESIDENT ADDRESS: Street
15000 Timber Ridge, Benton, AR

OCCUPATION RES PHO -
EMPLOYMENT PHONE
mo {M) Male O (F) Female 0 (J) Unknown

RELATIONSHIP OF THIS VICTIM TO OFFENDERS
(check relationship under appropriate offender number):
#1 «#2 «#3 «#4 45 46 47 HB OHO #10 VICTIM WAS:

BA BAR AAA BH  tsjconmenian spouse

HUOUOOUU  (AjParent

ood (SB) Sibling
(CH) Child
ETHNIC: na hg . . | 4 Hy 4 4 (GP) Grandparent
actAge _ 14 GC) Grandchild
OO ) Hispanic 1 (N) Nonhispanic i () Unknown s . oo i Anaoa {iy aw "
RACE: Range __j__ (SP) Stepparent
HE (W) White = [J ()) American indian C0 WU) Unknown (NN) Under 24 Hrs. Old 4 O00 D _ 6C)Stepchild
CJ (8)Black [J (A) Asian/Pacific Islander (NB) 1-6 Days Old (SS) Stepsibling
Sti RES STATS (BB) 7-364 Days Old ooog o G6 OOD _ (OF) Other Family Member
R 7 nt Nonresident Unk (oo) Unknown (AQ) Acquaintance
| a esiden' C1 (N) Nonresiden’ 0 () Unknown {] (00) Unknown a Hy 4 Oo oo (FR) Friend
Scorn VICTIM TYPE: HH (i) individual ([) (B)Business [Cj (F) Financial Institution (7) (U) Unknown Oo
eo 8) Government [[] (R) Religious [[] (S)Society/Public [7] (0) Other Oo (BE) Babysittee (baby)

: BG) Boyfriend/Girlfriend
ere uey: (Max. 5) Hl (M) Apparent Minor Injury (ee) end of So viriend/Gi friend
B' arent Broken Bones DO (0) Other Major Injury {HR) Homosexual Relationship
incase Internal injury (T) Loss of Teeth : (XS) Ex-Spouse
[_] (L) Severe Laceration (U) Unconsciousness (EE) Employee

AGGRAVATED ASSAULT/HOMICIDE CIRCUMSTANCES (ER) Employer

Aggravated Assault/Murder: (max. 2) Negligent Manslaughter: (enter 1} pt Ralttoeli tnhegen
(01) Argument (30) Child Playing With Weapon oO (ST) Stranger

(02) Assault On Law Enf. Officer (31) Gun-Cleaning Accident (VO) Victim was Offender
(03) Drug Dealing LD (32) Hunting Accident ,
a Gangland ang L (33) Other Negligent Weapon Handling ADDITIONAL [7 (A) Criminal Attacked Police Officer

(B) Criminal Attacked Fellow Police Officer
(06) Domestic Violence 1 (34) Other Negligent Killings JUSTIFIABLE (C) Criminal Attacked Civillan
(07) Mercy Killing | aa. HOMICIDE (D) Criminal Attempted Flight from a Crime
(08) Other Felony Involved dustifiable Homicide; —_(enter 1) CIRC.: (E) Criminal Killed in Commission of a Crime
{09) Other Circumstances CO (20) Criminal Killed by Private Citizen (enter 1) CO (F) Criminal Resisted Arrest

(] (10) Unknown Circumstances LJ (21) Criminal Killed by Police Officer LB (G) Unable to Determine/Not Enough Information

REPORT DATE DAY TIME (Military) REPORTING OFFICER CODE# | APPROVING SUPERVISOR DATE APPROVED
12/09/2024 Mon | 20:19 Deputy Jesse Taylor 2765 | Lieutenant Connell Latture 12/15/2024

INCIDENT REPORT

OF (12) Handgun Instr.

C) (AyAsian/Pacihc stander _[] (U) Unknown (0) Unknown E] (R) Referred outside Department C1 ca)Rife =] (17) Cub
OF (14) Shotgun Blackjack /

ES. STATUS: [ (R)Resident | UCR ARR. CODE ARREST DATE | ARREST TRANSACT.
D1 (N)Nonres. (F) (U) Unknown # DD (15) Other Firearm Brass Kn.
BUILD HAIR COLOR HAIR STYLE EYE COLOR SKIN TONE

ARRESTEE# | NAME Last, First, Middle,

f=) DATE INCIDENT NUMBER ORH ("8") | REPORTING OFFICER CODE# | VICTIM NAME
a4 12/09/2024 | 2024-3738 AR0630000 | Deputy Jesse Taylor 2765
<3}
fal] OFFENDER# | RESIDENTADDRESS Street City State Zip DATE OF BIRTH
& 1 15000 Timber Ridge Lane, Benton, AR 72015 Pe ee |
04] ARREST LOCATION OCCUPATION PLACE OF EMPLOYMENT ARRESTTYPE: [J (0) On View Arrest
<
C1 ($}SummonsiCited = [[] (1) Taken Into Cust.
™| SEX: WM) Male = fF) Female §=«[] (U)Unk. ~—— AGE: MULT. ARREST INDIC.: CO (M) Muttipie WEAPONS ATARREST: ;
nani rs EXACTAGE __ 14 (Max. 2) {Place “A” in blank if automatic)
Bs ETHNIC: LJ (H)Hispanic [J (N)Nonhisp. fig (U) Unk Nenana: en oO Coun inne 11 (NWA C1 (1) Unarmed) (16) Moga
i i * —— '~ —— | DISPOSITION OF JUVENILE: 44} Fi utting
5 RACE  (W) White [] (8)Black [[] ()) American Indian 0 (89) Over 98 Yrs. Old TJ () Handled within Department. O (11) Firearm
3)
fat
es
fo)

RES. STATUS: [] (R)Resident ] UCR ARR. CODE ARREST DATE | ARREST TRANSACT. CO (14) Shotgun Blackjack /
CO (N)Nonres. [CJ] (U) Unknown 8 [1 (15) Other Firearm Brass Kn.
HEIGHT ll HAIR COLOR HAIR STYLE EYE COLOR SKIN TONE

ea]

Ee OFFENDER# | RESIDENTADDRESS Street City State a ee

= EMPLOYMENT/SCHOOL PHONE DRIVER'S LICENSE DR. LI. STATE

a4

(2] ARREST LOCATION OCCUPATION PLACE OF EMPLOYMENT ARREST TYPE: [1] (0) On View Arrest

< OO (S)SummonsiCited [1] (1) Taken Into Cust.

~~T SEX: DO m)Male =D fF) Female =) (U) Unk. ~—«[AGE: MULT. ARREST INDIC.: OO () Muttipte WEAPONS 2 7 ;

~ : repr XACT AGE LO (C)Count Arrestee [1] (N) NIA (Wax. 2) (Pface "Ain Blank if automatic)

fa ETHNIC: [[] (H)Hispanic ([] (N)Nonhisp. [J (U) Unk. AGE RANGE: b 1 (01}Unarmed [[] (16) Itegal
(CE White [] (B) Black I) American Indi "a | DISPOSITION OF JUVENILE: O (14) Firearm Cutting

5 ne a rn , nae oo . men indian o he over $8 Yrs. Old B (H) Handled within Department. CO (12) Handgun Instr.

5 O ianfPacific Islander} (U) Unknown 1) (00) Unknown (R) Referred outside Department CO (t3)Rife = (i7) clubs

Vo

fae

°

SUBJECT DESCRIPTORS

INCIDENT REPORT
DATE INCIDENT # REPORTING OFFICER CODE #
12/09/2024 | 2024-3738 Deputy Jesse Taylor 2765
a
TOP/SOLID COLOR SECOND COLOR DISPOSITION OF RECOVERY:
CO () lmpounded [Fj (R) Released To Owner
a ic

TOP/SOLID COLOR SECOND COLOR DISPOSITION OF RECOVERY:

(1 (impounded [} (R) Released To Owner
ary. DESCRIPTION (Include serial number, make, model, primary color) (TEM VALUE RECOV. DATE

VICTIM NAME

LICENSE NUMBER

OF.CODE | P.LOSS

TOTAL NUMBER VEHICLES STOLEN: TOTAL NUMBER VEHICLES RECOVERED: TOTAL VALUE STOLEN: TOTAL VALUE RECOVERED:

D PROPERTY LOSS: {1)None (2)Burned (3) Counterfeited/Forged (4) Damaged/Destroyed/Vandalized (5)Recovered (6)Seized —_(7) Stolen, etc. (8) Unk.
a PROPERTY DESCRIPTION (14) Gambling Equipment {27) Recordings-AudiofVisual (42) Artistic Supplies/Accessories (68) Lawn/Vard/Garden Equipment

(01) Aircraft (15) Heavy Construction/industrial (28) Recreational Vehicles (43) Building Materials (69) Logging Equipment
o) (02) Alcohol Equipment (29) Structures-Single Occupancy (44) Camping/Hunting/Fishing (70) MedicalMedical Lab Equipment
1) (03) Automobiles (46) Household Goods (30) Structures-Other Dwellings Equipment/Supplies (71) Metals, Non-Precious

(04) Bicycles (17) Jewelry/Precious Metals/Goms (31) Structures-CommercialBusiness (45) Chemicals (72) Musical Instruments
~~ (05) Buses (18) Livestock (32) Structures-IndustriaWManufacturing (48) Collections/Collectibles (73) Pets
if (06) Cloths/Furs (19} Merchandise (33) Structures-Public/Community (47) Crops (74) Photographic/Optical Equipment
ft (07) Computer Hardware/Software (20) Money (34) Structures-Storage (68) Documents/Personal or Business (75) Portable Electronic Communications
[ea] (08) Consumable Goods (21) Negotiable Instruments (35) Structures-Other (49) Explosives (76) RecreationaliSports Equipment
Ay (09) Credit/Debit Cards (22) Nonnegotiabie Instruments (38) Tools (59) Firearm Accessories (77) Other
o) (10) Drugs/Narcotics (23} Office-Type Equipment (37) Trucks (64) Fuel (78) Trailers

(11) OrugiNarcotic Equipment (24) Other Motor Vehicles (38) Vehicle Parts/Accessories (65) Identity Documents (79) Watercraft EquipmentiParts/Accessories
PY] (12) Farm Equipment (25) Purses/Handbags/Wallets (39) Watercraft (86) Identity - Intangible (80) Weapons - Other
fui} (13) Firearms (26) Radlos/TVsiVCRs/DVD Players (41) Aircraft Parts/Accessories (67) Law Enforcement Equipment (88) Pending inventory (of Property)

TYPE DRUG MEASUREMENT:

DRUG TYPE WHOLE DRUG QUANTITY FRACTIONAL DRUG QUANTITY DRUG MEASUREMENT

WEIGHT
(GM) Gram
A (KG) Kilogram
(o) (02) Ounce
a (LB) Pound
o (ML) Milliiter
LT) Lite
Fo DRUG TYPE: FO) Fld Ounce
ra) (A) "Crack" Cocaine (F) Morphine (K) Other Hallucinogens r Depressan' (GL) Galion
(B) Cocaine (G) Opium (l) Amphetaminest {P} Other Drugs
(C) Hashish (H) Other Narcotics Methamphetamines (U) Unknown Type Drug us Unit Pills, et
(0) Heroin @LsD {M) Other Stimulants (X) Over 3 Drug Types (DU) Dosage Unit (Pills, etc.)

(J) PSP (N) Barbiturates (NP) Number of Plants

(E) Marijuana

us SEX:
CO () Male AGE; 61 RACE:
DO (F) Female CO white
Burgett, Joann D fn O wt mom rte

RESIDENT ADDRESS: Street

City CO ( American indian
C (A) Asian/Pacific Islander

OC () Unknown

COMPLNT.

EMPLOY'T. PHONE

6741 North East 12 AVE, Plesant Hill, |A

INCIDENT REPORT
PAGE# | DATE INCIDENT NUMBER REPORTING OFFICER CODE# VICTIM NAME
4 12/09/2024 | 2024-3738 Deputy Jesse Taylor 2765 .
NAME: Last, First, Middle SEX: [J U)Unk. | AGE: 25 RACE: CO yunk.
(M) Male (W) White {B) Black
Maharin, ANNA rb C1 (00) Unknown a mn hworeateten
RESIDENT ADDRESS: Street City State Zip PRSINEMT AUD EMPL. PHONE | [-] (A) Asian/Pacific
15000 TIMBER RIDGE LN, Benton, AR 72015 po | Islander
RTH — | OCCUPATION PLACE OF EMPLOYMENT
NAME: Last, First, Middle SEX: = [J (U) Unk. | AGE:
{M) Male (W) White (B) Black
Johnson, Tamika (F) Female 1 (00) Unknown a 0 hmareacbien
RESIDENT ADDRESS: Street City State a ee eee D1 Asian/Pacific
Islander

DATE OF BIRTH OCCUPATION PLACE OF EMPLOYMENT

RACE: LD ) Unk.

AAU ZS

See Supplement for further.

SUPPLEMENT #1 Deputy Jesse Taylor - 2765 12/10/2024 02:18

On December 9, 2024 I, Deputy Taylor, was dispatched to 15000 Timber Ridge Lane in reference to a

Upon arrival I spoke with Tamika Johnson who advised

strangled another kid,

with a Nintendo switch cord. Johnson stated it happened for about three seconds before

the staff broke the altercation up. Tamika state that _ advised he was just horseplaying.

Approximately 20 or 30 Minutes later mother, Joann called wanting to press

charges on Joann advised 1 stated he was reading a book after dinner time and

just came up behind him and choked him. . further advised he was scared.

a. was transported by Pafford to Children’s Hospital. Joann was unsure where her kid was
transported to due to her living in Iowa. This report will be pasted on to Juvenile services. Both
kids are at Timber Ridge Neuro Restorative. All BWC footage was uploaded.

ee sé#éséeée...#... wae


summary: A resident was transported to the emergency room due to seizure activity.

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: 025932
Date of Incident: 12/5/2024
Date Received: 12/6/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: Private Placement resides in the
Americana building. Staff to client ratio 4 to 4. Client transported by ambulance to ER due
to seizure activity. While there it was determined
. Client was admitted to hospital and while admitted continued to
have seizure activity. Timber Ridge continues to provide supervision while client is in
hospital. Guardian has been notified.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 12/6/24-Reviewed for licensing concerns. Email sent to facility to
notify licensing when client returns to facility and send ER discharge paperwork.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to the Arkansas Children’s Hospital emergency room after experiencing suicidal ideations and racing and unorganized thoughts.

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: 025784
Date of Incident: 11/26/2024
Date Received: 11/27/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description:
Staff to client ratio was 5:5. This incident happened at the pediatric Americana
building. Client reported he?s going to break the window in his room so that he can jump
off the cliff to end it all. He then started exhibiting racing and unorganized thoughts
laughing irrationally and talking about bloodborn pathogens getting injected in his body.
Nursing received order to send to ER and police and ambulance transported him. I sent a
staff with him while he?s at children?s. Children?s stated to me on the phone that they will
not be able to find acute placement and that he will be sent back to us.
guardian notified of incident and got consent for further evaluation, assessment, and
treatment.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 11/27/24-Reviewed for licensing concerns. Email sent to facility to
notify licensing if/when client returns to facility. Phone call made to Kenleigh Bennett of
Timber Ridge. Safety Plan upon client's return will be Intensive Supervision with 1:1
staff/client ratio. 11/27/24-Received email that client is being admitted to Bridgeway.
12/6/24-Received email that client returned to facility 12/4/24. Safety plan in place.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was transported to Arkansas Children’s Hospital Emergency Room after breaking out in a rash.

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: 025124
Date of Incident: 10/31/2024
Date Received: 11/1/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: Client
broke out in a rash and was sent to ACH ER. ER gave medication and set follow-up
appointment with either them or PCP. Guardian was notified.
Interim Action Narrative: Resident was taken to the ER for an evaluation.
Maltreatment Narrative:
Licensing Narrative: Program Coordinator reviewed provider reported incident for
licensing concerns. Program Coordinator will request a copy of the ER paperwork from the
facility. Facility provided documentation for this provider reported incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Buildings and Grounds conducted for Americana and PRTF buildings. MAR checked for multiple residents. No issues were noted by Licensing.

raw_content:
ARKANSAS
) DEPARTMENT OF

|\-7 HUMAN
» "2 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

y

521 Visit Compliance Report

Licensee: Neurorestorative Timber Ridge

Facility Number: 102

Licensee Address: 15000 TIMBERRIDGE LANE
BENTON AR 72019

Licensing Specialist: Clayton DeBoer
Person In Charge:

Record Visit Date: 10/10/2024

Home Visit Date: 10/10/2024

Purpose of Visit: Subsequent Building and Grounds

Regulations Out of Compliance:

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Buildings & Grounds conducted for Americana and PRTF buildings.

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

Americana House staff/client ratio 3:3. Kids were present and leaving for school. Grounds clean and free of
safety hazards. Buildings clean, safe and in good repair. Bathrooms clean and sanitary with functioning sinks,
showers and toilets. Emergency diagrams and fire extinguishers observed.

MAR checked for:

All initialed and up to date.

PRTF Building staff/client ratio 8:12. Kids were present and leaving for school.Grounds clean and free of
safety hazards. Buildings clean, safe and in good repair. Bathrooms clean and sanitary with functioning sinks,
showers and toilets. Emergency diagrams, client rights and fire extinguishers observed.

MAR checked for:

All initialed and up to date.

Provider Comments:

CCL Staff Signature : Date: 10/10/2024
At)
fy Mh,

Provider Signature : Date: 10/10/2024

/
| i/

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

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


summary: A resident was sent to Arkansas Children’s Hospital ER due to the nurse being unable to retrieve toilet paper the resident put up his nose.

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: 024211
Date of Incident: 9/23/2024
Date Received: 9/24/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Licensing
Report Description: medical director sent
to the ACH ER due to him putting toilet paper up his nose, and nurse couldn?t
retrieve it. Guardian was notified stated this is a pattern that he has always done.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 9/24/24-Reviewed for licensing concerns. Client has been placed on
increased observation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident made an allegation that a staff member slapped him. 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: 023791
Date of Incident: 9/1/2024
Date Received: 9/6/2024
Facility Name: Neurorestorative Timber Ridge
Facility Number: 102
Incident Type: Dual
Report Description: , made an allegation
against on 9.6.24 stating that she slapped him. Staffing documentation states
that the client slapped staff but that staff continued on in the intervention. was
monitoring intervention in case staff needed to switch out and she stated that she never saw
slap the client. We are waiting on the other witness statement who is
We have notified the guardian and she stated that she is sorry this happened and he has a
history of making allegations against her. Nursing notes state no injuries reported.
is on administrative leave. Staff to client ratio 5:7.
Interim Action Narrative: placed on administrative leave.
Maltreatment Narrative:
. mentioned that he
slaps staff, and they slap him back. said that slapped him in the mouth.
There was an incident with headbutting, kicking, and hitting staff. They put a
physical hold on but got free and backhanded and hit on her lip. They
got a hold of again when he said that they?re going to ?do what they want to me? and
mentioned that he?s going to report them. Other staff didn?t see hitting and
stated that he doesn?t remember the day she did it. No further concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 9/6/24-Reviewed for licensing concerns. Email sent and voice
message left for asking permission to contact facility
and/or AV. For clarification, phone call made to Kenleigh Bennett of Timber Ridge. Client
disclosed the allegation to his therapist 9/6/24, stating that it happened last weekend.
was notified timely. 9/6/24-Received email from
granting permission for licensing to contact facility and/or AV. Staffed with
Program Manager Chelsea Vardell and Program Coordinator Kendra Rice. No visit
scheduled at this time. Witness statements and nursing note provided to licensing and
reviewed. 9/9/24-Received email from facility as follows: When came to investigate
this morning and spoke with the client involved, he (A/V) named as the
alleged offered who was terminated in August from our facility. We will be calling and
updating the .
9/10/24-Received phone call from Kenleigh Bennett of Timber Ridge that
instructed facility to submit a new report with new A/O. Email sent to facility to notify
licensing of new ref#. Later instructions were that another report could not be submitted
due to being a duplicate, thus ref# remains the same. The correct A/O is
per the resident's interview. However, was terminated from the
facility at the beginning of August 2024. 9/28/24-Received completed training sign in for
10/21/24-Received notification that maltreatment was unfounded. 10/22/2024,
Approved by Progam Coordinator. Case complete.


summary: A resident was engaged in a behavioral outburst when one staff member grabbed the resident’s shirt, causing the resident to hit a wall. The facility was cited 109.1.g and 905.4.g as a result of this incident.

raw_content:
ARKANSAS
DEPARTMENT OF

»-¢ Services

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: 023248
Date of Incident: 8/16/2024

Date Received: 8/16/2024

Facility Name: Neurorestorative Timber Ridge
Facility Number: 102

Incident Type: Dual

Report Description:
behavioral outburst and two staff intervened to maintain safety. One staff
utilized improper intervention by grabbing his shirt and while grabbing his shirt he hit the
wall. The second staff immediately asked for the staff to leave. Another staff
came to assist in intervening to maintain safety and the client stated that the staff who was
asked to leave, grabbed him too tight and that the staff scratched him. The nurse did

complete a follow up and noted the scratches, the nurse cleaned and treated the area. The

was engaged ina

therapist completed a follow up as well, the information that client and witnesses provided

. Staff to client ratio
6:8 and have been suspended on active investigation leave
pending HR decision on employment and investigation.

Interim Action Narrative: Resident was assessed by the nurse and two staff members were
placed on suspension.

Maltreatment Narrative: AV is 10yo AO is ’
but potential AOs include and . caseworker?s name is
, out of pulled AV up by shirt and shoved AV into the wall.

threatened AV stating Pyou better be luc
on AV, there were scratches left on AV?s arm.

staff saved you?. When other staff checked
was attempting to de-escalate a
situation involving AV prior to the incident with grabbed AV by the arm and
walked AV to his room to try to take AV to a lower stimulation area. AV reported that

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

grabbed him really hard while outside. There are reported to be skin discoloration and
scratches currently on AV?s arm from the incidents. The injuries were cleaned at the facility,
and the involved staff are currently suspended pending investigation. AV has a current
discharge date from Timber Ridge Behavioral Health in Benton iim

Licensing Narrative: 8/16/24-Facility provided documentation that has been uploaded.
Program Coordinator requested the and facility reported more information
will be provided once received. - Phone call received from of
Timber Ridge that staff have been placed on leave pending certain termination. Witness
statements and nursing note support that unprofessional conduct and disciplinary action
that resulted in physical injury and threat of bodily harm did indeed occur. Facility will be
cited 109.1g and 905.4g. 8/19/24-Email sent to and

to get permission to contact facility and A/V regarding allegation. Visit scheduled for
8/19/24. PF granted permission for licensing to contact facility and/or alleged
victim. Facility visited and cited 109.1g and 905.4g.

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: Neurorestorative Timber Ridge

Facility Number: 102

Licensee Address: 15000 TIMBERRIDGE LANE
BENTON AR 72019

Licensing Specialist: Clayton DeBoer
Person In Charge: Kenleigh Bennett
Record Visit Date: 8/19/2024

Home Visit Date: 8/19/2024

Purpose of Visit: Complaint Visit

Regulations Out of Compliance:

Regulation Number: 100.109.1.g

Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:

Finding Description: Staff engaged in behavior that could be viewed as physically harmful to children.
Action Due Date: 2024-08-16

Action Due Description: Staff immediately suspended pending certain termination.

Comply Date:

Sub-Regulation Level 1 Description: Engaging in behavior that could be viewed as sexual, dangerous,
exploitative, or physically harmful to children.

Action Due Description: Staff immediately suspended pending certain termination.
Regulation Number: 900.905.4.g

Regulation Description: The following actions shall not be used, including as discipline:
Finding Description: Staff used disciplinary action that resulted in physical harm.
Action Due Date: 2024-08-16

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

Action Due Description: Staff immediately suspended pending certain termination.
Comply Date:
Sub-Regulation Level 1 Description: Physical injury or threat of bodily harm;

Action Due Description: Staff immediately suspended pending certain termination.

Regulations Needing Technical Assistance:

Regulation Not Applicable:

Regulations Not Correctable:

Narrative:

Facility visited 8/19/24 in response to complaint that staff J} and used inappropriate physical
force with client Witness statement from staff supports that staff was both unprofessional
and used excessive force resulting in physical injury to client wi. Nursing note supports that | | received
scratches after this incident. The nursing note supports that staff may have been responsible for
physical injury to client J Facility cited 109.1g and 905.4g. my and J immediately
suspended pending certain termination.

Provider Comments:

CCL Staff Signature : Date: 8/19/2024
},) |}
if"
Provider Signature : Date: 8/19/2024

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


summary: An after-hours visit was conducted for Timber Ridge and the Americana building. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Neurorestorative Timber Ridge
Facility Number: 102
Licensee Address: 15000 TIMBERRIDGE LANE
BENTON AR 72019
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/15/2024
Home Visit Date: 8/15/2024
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Afterhours visit conducted for Timber Ridge and Americana building.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Americana staff/client ratio: 3:3. Clients sleeping. Staff answered the door in less than a minute. Staff alert
and able to answer questions. Buildings & grounds that were observed to be clean, safe and free of safety
hazards.
Timber Ridge PRTF building staff/client ratio: 4:9. Staff awake, alert and engaged in paperwork. Clients
sleeping. Buildings & grounds that were observed clean, safe and free of safety hazards.
Provider Comments:
CCL Staff Signature : Date: 8/15/2024
Provider Signature : Date: 8/15/2024
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Officers received a referral from the Arkansas Child Abuse Hotline regarding an allegation of sexual abuse.

raw_content:
INTER
STATUS:
a (A) Active

INCIDENT

EXCEPTIONAL
CLEARANCE STATUS:
(1 (A) Death of the Offender

(11 (CA) Closed by Arrest Gy (8) Prosecution Declined
DD (CE) Closed by Exception (7) {C) Extradition Denied
C7 (CO) Closed by Other Means | [7] (D) Victim Ref. to Cooperate

ORINUMBER
| [amosoco
INCIDENT NUMBER INCIDENT REPORT

2024-2389 UNAPPROVED

DATE(S) OF INCIDENT "| AGENCY NAME
08/12/2024 Saline County Sheriff's Office .
TIME(S) OF INCIDENT DAY(S) OF INCIDENT 1 (inactive D €€) Juvenile, No Custody
08:36 Monday 1 ) Unfounded Bil (N) Not Applicable
DISPATCHER TIME RECEIVED | TIMEARRIVED | REPORTING AREA EXCEPT. CLEAR. DATE
kaylee.smoke - SMOKE, KAYLEE 8:36 8:36

UCRCODE | OFFENSE STATUS: OFFENDER USED: Hl (N)Not Applicable | Burglary (220) Location 14819: FORCED ENTRY?

1A CD AjAttempted ggg (C)Completed |] (A)Alcoho! [7] (C)Cptr. Equip. [1] (D) Drugs } # PREMISES ENTERED? O Yes [J No

STATUTE OFFENSE DESCRIPTION ADDRESS OF OFFENSE
§-14-125 Sexual Assault in the Second Degree 15000 TIMBER RIDGE LN, Timber Ridge, Benton, AR 72019

ARKANSAS

INCIDENT

LOCATION (Enter 1) 1 (17) Liquor Store TD (46) Farm Facility WEAPON FORCE: (Max. 3)
0 (01) Air/Bus/Train Terminal 1 (18) Parking LovDrop LotiGarage [] (47)Gambling Facility/Casino/Race _| {For 11-15, place “A” in space next to box

CO (02) Bank/Savings & Loan (C1 (19) Rental/Storage Facility Track if weapon was an Automatic.)

1 (03} BarfNight Club Hl (20) Residence/Home DO (48) Industrial Site __ 00 (14) Firearm (Type not stated) [7] (90) Other
CD (04) Church/Synagogue/Temple/Mosque ((] (21) Restaurant GB (49) Military Installation
E (05) Commercial/Office Building LI (23) Service/Gas Station LD (50) ParkiPlayground — C112) Handgun CZ (85) Unknown
ty] C1 (08) Construction site I (24) Specialty Store DD 61) Rest Area — 0 (13) Rifle C1 (88) None
G| C1 (07) Convenience Store (0 (25) Other/Unknown 1 (52) School - CollegeMniversity ___ TD (14) Shotgun
Zz. 1] (08) Department/Discount Store (0 (37) Abandoned/Condemned 1 (53) School - Elementary/Secondary (0 (15) Other Firearm
[xj] 21 (09) Drug Store/Doctor's Office/Hospital Structure (C1 (54) Shetter - Mission‘Homeless ~~ | .
fe) 2 (10) Field Woods (1 (38) Amusement Park (0 665) Shopping Mall C1 @20) Knife/Cutting instru. (Ax, etc.)
faa] (2) (11) Government/Public Building (1 (39) Arena/StadiunvFairgrounds/ = [) (56) Tribal Lands LD (30) Blunt Object (Club, etc.)
©] Ci (12)Grocery!supermarket Coliseum D. 657) Community Center 7 (85) Motor Vehicle (As weapon)
C1 (13) Highway/RoadiAlley/Street/Sidewalk [] (40) ATM Separate From Bank
Cy (14) HotevMotelEtc. Ly (41) Auto Dealership New/Used Hi (40) Personal Weapons (Hands, etc.)
{0 (45) Jail’Prison/Penitentiary/Corrections [[] (42) Camp/Campground LD {60} Poison
Facility CO (44) Daycare Facility

C1 (60) Explosives

DO (65) Fire/incendiary Device

1 (70) Narcotics/Drugs/
Sleeping Pills

L (85) Asphyxiation

BIAS MOTIVATED CRIME:
None (No Bias)

poe Seen pats cen ——— DR. Lt STATE | DATE OF BIRTH

RELATIONSHIP OF THIS VICTIM TO OFFENDERS
(check relationship under appropriate offender number):

DD (16) Lake/Waterway/Beach
TYPE CRIMINAL ACTIVITY:

O (8) Buying LD (0) Operating/Promoting/Assisting
CO (C) Cuttivate/Manufacture/Publish DO (P) Possessing/Concealing

DB (D) Distributing/Selling 0 (1) Transport/Transmit/lmport

DD €) Exploiting Children DO () Using/Consuming

VICTIM #
1
RESIDENT ADDRESS:

0 (45) DockWhartiFreight/Modal Terminal

(Max. 3) TYPE ACTNITY: (Max. 3)

DO (G) Other Gang
OF J) Juvenile Gang
LT (N) None/Unknown

Last,

Street

toceipaTion #1 #2 #3 84 #5 #6 #7 #8 «#9 #10 «© VICTIM WAS:

{SE} Spouse
- i (CS} Common-Law Spouse

EMPLOYMENT PHONE SEX: (PA) Parent
WH (M) Male CO (F) Female 1 (U) Unknown cy ening

ETHNIC: AGE: (GP) Grandparent

CO @)Hispanic == (N) Nonhispanic D W) unknown ExactAge _413__ ie) Grandchid

“a
RACE: Range __/__ (SP) Stepparent

fi (W) White D) (I) American Indian DD ) Unknown 17 (NN) Under 24 Hrs. Old (SC) Stepchild

D1 )Slack =] (A) Asian/Pacific slander Ly (NB) 1-6 Days Old (SS) Stepsibling
=| RES. STATUS: (om over 88 Yee. Old (OF) Other Family Member

(AQ) Acquaintance

(FR) Friend

(NE) Neighbor

{BE) Babysittee (baby)

(BG) Boyfriend/Girlfriend

(CF) Child of Boyfriend/Girifriend
(HR} Homosexual Relationship
(XS) Ex-Spouse

(EE) Employee

(ER) Employer

(OK) Otherwise Known

(RU} Relationship Unknown

= [i (R)Resident MM (N)Nonresident == 7] (U) Unknown 1 (00) Unknown
VICTIM TYPE: Wl () Individual [J (6) Business [() (F) Financial Institution {[] (U) Unknown
DD ©)Government [] (R) Religious [[] (S)Society/Public [} (0) Other
VICTIM INJURY: (Max. 5} C1] (M) Apparent Minor Injury

Wi (N) None a
(B) Apparent Broken Bones 5 (0) Other Major Injury

pe

THIS VICTIM RELATED
TO WHICH OFFENSES?

BH OM OF #0
(I) Possible Intemal Injury (T) Loss of Teeth
[_] (L} Severe Laceration (U) Unconsciousness

f #2 | #5 £1 #8 others:
Os #6 (#9
AGGRAVATED ASSAULT/HOMICIDE CIRCUMSTANCES
Aggravated Assault/Murder, (max. 2) Negligent Manslaughter: (enter 1)

(01) Argument (30) Child Playing With Weapon (ST) Stranger
(02) Assault On Law Enf. Officer (31) Gun-Cleaning Accident (VO) Victim was Offender
(03) Drug Dealing 0 (32) Hunting Accident .
H pa Gangland, C1 (3) Other Negligent Weapon Handling (A) Criminal Attacked Police Ooer
juvenile Gang ; (B) Criminal Atta Fellow Pol icer
Gs) Lovers avarre CO (34) Other Negligent Killings ES eeee ©) Criniaal Attacked Civilian nach
(08) Other Felony Involved stifiable Homicide: (enter 1) CIRC: fe Criminal Killed n Commission ofa Crime
{09) Other Circumstances CO (20) Criminal Killed by Private Citizen (enter 4) (F) Criminal Resisted Arrest
1 (10) Unknown Circumstances DB (21) Criminal Killed by Police Officer i. (G) Unable to Determine/Not Enough Information

REPORT DATE DAY | TIME (Military) REPORTING OFFICER CODE# | APPROVING SUPERVISOR DATE APPROVED
08/12/2024 Mon 8:36 Detective Joseph Amundson! 2633

INCIDENT REPORT
DATE INCIDENT NUMBER OR# ("B") REPORTING OFFICER CODE# | VICTIM NAME
08/12/2024 | 2024-2389 AR0630000 | Detective Joseph Amundson 2633
Ol RESIDENT ADDRESS = Straat City State Zip DATE OF BIRTH
72455

FFENDER #
1 .
RESIDENT PHONE _ i EMPLOYMENTISCHOOL PHONE [pabesnetes DR. Ll. STATE
ARREST LOCATION OCCUPATION PLACE OF EMPLOYMENT ARREST TYPE: [J (0)On View Arrest
D0 (S)SummonsiCited [[] (T) Taken Into Cust.
WEAPONS AT ARREST:

SEX. (Male —L) (F)Female J (U)Unk. MULT. ARREST INDIC.: CO (M) Multiple
EZHNI: LJ (H)Hispanic [J (N)Nonhisp. ig (U) Unk. Co (C) Count Arrestee [1] (N) NA

, ; AGE RANGE: __to ___ | DISPOSITION OF JUVENILE:
RACE [J (W)White [1] (6)Black [[] (1) American Indian LO (8) Over 88 Yrs. Old (H) Handled within Department.
CO (A) Asian/Pacific slander) (U) Unknown 0 (00) Unknown (R) Referred outside Department
CO (14) Shotgun Blackjack /

RES. STATUS: [] (R)Resident | UCR ARR. CODE ARREST DATE | ARREST TRANSACT.
I (N)Nonres. [J (U) Unknown # CO (15) Other Firearm Brass Kn.
WEIGHT | BUILD HAIR STYLE HAIR LENGTH EYE COLOR SKIN TONE

NAME Last, First, Middle,

|

(Max. 2) (Place "A" in blank if automatic)
0 (01}Unarmed [J (16) Illegal
CO (11) Firearm Cutting
EB (12) Handgun instr.

OF (13) Rife = (17)Club/

AGE:
EXACT AGE __13__

OFFENDER / ARRESTEE |AD

DD A)Asian/Pacific Islander = [] (U) Unknown DD (00) Unknown (R) Referred outside Department CO (13) Rifle OF (17) clubs

RES. STATUS: [J (R)Resident | UCR ARR. CODE ARREST DATE | ARREST TRANSACT. CO (14) Shotgun Blackjack /
(0 (NjNonres. ([(] (U) Unknown # 1 (15) Other Firearm Brass Kn.

||

fal OFFENDER# | RESIDENTADDRESS Street City State aa DATE OF BIRTH

4 RESIDENT PHONE EMPLOYMENT/SCHOOL PHONE DRIVER'S LICENSE DR. LI. STATE sy
%

(2) ARREST LOCATION OCCUPATION PLACE OF EMPLOYMENT ARREST TYPE: [1] (0) On View Arrest

<i C1 (S)SummonsiCited [] (T) Taken Into Cust.

~~] SEX: D (M) Male (F) Female (U)Unk. AGE: MULT. ARREST INDIC.: CD (M) Muttiple WEAPONS AT ARREST: j
ft T AGE (Max. 2) (Place "A” in blank if automatic)
PET ETHNIC: C] Hispanic C] W)Nontisn. C1 (0) Unk — (1 (C) Count Arrestee [1] (N) NIA (O (1) Unarmed [] (16) legal
Go| RACE) (W)White [] (G) Black} (American Indian ee. “ab Vee Gur | DISPOSITION OF JUVENILE: I (11) Firearm = Cutting
7 C7 (9) Over 98 Yrs. (H) Handled within Department. CO (12) Handgun Instr.

tal

cs

(aa

lo)

SUBJECT DESCRIPTORS

INCIDENT REPORT
DATE INCIDENT # REPORTING OFFICER CODE #
08/12/2024 | 2024-2389 Detective Joseph Amundson 2633
La
TOP/SOLID COLOR SECOND COLOR DISPOSITION OF RECOVERY:
0 (impounded [[] (R) Released To Owner
TOPISOLID COLOR SECOND COLOR DISPOSITION OF RECOVERY:
DO (impounded [] (R) Released To Owner

{TEM VALUE RECOV. DATE

VICTIM NAME

LICENSE NUMBER

RQ
Ez
i=)
Py
Qo
2
3
o
=z
=
2
FI
£
3
E
3
g
2
z
FA
2
Py
3

TOTAL NUMBER VEHICLES STOLEN: TOTAL NUMBER VEHICLES RECOVERED: TOTAL VALUE STOLEN: TOTAL VALUE RECOVERED:

PROPERTY LOSS: (1)None (2})Burned (3)Counterfeited/Forged (4) Damaged/Destroyed/Vandalized (5)Recovered (6)Seized —_(7) Stolen, etc. {8) Unk.

RM
B PROPERTY DE HETION: {14) Gambiing Equipment (27) Recordings-Audio/Visual (42) Artistic Supplies/Accessories (68) Lawn/Yard/Garden Equipment

(01) Aircraft (15) Heavy ConstructionIndustrial (28) Recreational Vehicles (43) Building Materials {69} Logging Equipment
fo) (02) Alcohol Equipment (29) Structures-Single Occupancy (44) Camping/Hunting Fishing (70) Medical’Medical Lab Equipment
if) (03) Automobiles (16) Household Goods {30) Structures-Other Dwellings Equipment/Supplies (71) Metals, Non-Precious

(04) Bicycles (17) Jewelry!Precious Metals/Gems {31) Structures-CommercialBusiness (45) Chemicals (72) Musical Instruments
> (05) Buses (18) Livestock (32) Structures-IndustriavManutacturing (46) Collections/Collectibles (73) Pets
fm] (08) ClothsiFurs (19) Merchandise (33) Structures-Public/Community (47) Crops (74) Photographic/Optical Equipment
[a (07} Computer Hardware/Software (20) Money (34) Structures-Storage (48) DocumentsiPersonal or Business (75) Portable Electronic Communications
[ea {08} Consumable Goods (21) Negotiable Instruments. (35) Structures-Other (48) Explosives (76) Recreational’Sports Equipment
A {09) CreditiDebit Cards (22) Nonnegotiable Instruments (36) Tools (59) Firearm Accessories (77) Other

(10) Drugs/Narcotics (23) Office-Type Equipment (37) Trucks {64} Fuel {78} Trailers
jo) (11) CrugiNarcotic Equipment (24) Other Motor Vehicles (38) Vehicle Parts/Accessories (65) Identity Documents (79) Watercraft Equipment/Parte/Accessories
[a (12) Farm Equipment (25) Pursas/Handbags/Wallets (39) Watercraft (66) identity - Intangible (80) Weapons - Other
fa} (13) Firearms (26) Radios/TVsIVCRs/DVD Players (41) Aircraft PartelAccessories (67) Law Enforcement Equipment (88) Pending Inventory (of Property)

DRUG TYPE WHOLE DRUG QUANTITY FRACTIONAL DRUG QUANTITY DRUG MEASUREMENT TYPE DRUG MEASUREMENT:
WEIGHT
(GM) Gram
es es eae
© (OZ) Ounce
fore {LB) Pound
(ML) Milliliter
iS (LT) Liter
4 {FO) Fluid Ounce
a (A) “Crack” Cocaine (F) Morphine {K} Other Hallucinogens {0} Other Depressants {GL) Gallon
(B) Cocaine (G) Opium rm) Amphetamin es! (P) Other Drugs
(C) Hashish {H) Other Nargotics Methamphetamines (U) Unknown Type Drug UNITS _
(D) Heroin (DLSD (a) Other Stimulants (X) Over 3 Drug Types (DU) Dosage Unit (Pills, etc.)

(J} PSP (N) Barbiturates (NP) Number of Plants

(E) Marijuana

Middle SEX:
0 (M) Male AGE: RACE:
CO (F) Female 1 W) White
CO wyunk. CO (00) Unknown Ty (@) Black

RESIDENT ADDRESS: Street BB @) American Indian
C1 (A) Asian/Pacific Islander

OD () Unknown

COMPLNT.

RESIDENT PHONE | EMPLOY'T, PHONE

INCIDENT REPORT

RACE: C W)Unk.
CD Mite C (8) Black
CO () American indian

L @) Asian/Pacific

Hiren PHONE EMPL. PHONE
islander
DATE OF BIRTH | OCCUPATION PLACE OF EMPLOYMENT

RESIDENT ADDRESS: Street City State

SEX: D W)unk | A RACE: 0 (U) Unk.

T) (M) Mal (W) White EJ (B) Black
=} (F) Female Coo) Ueinowm GB i inetcaaien

State RESIDENT PHONE EMPL. PHONE LO (A) AsianiPacific
klander
DATE OF BIRTH OCCUPATION PLACE OF EMPLOYMENT
NARRATIVE:

On August 9, 2024,

RESIDENT ADDRESS: Street City

“a ay a

I, received a referral from the Arkansas Child Abuse

Detective J. Amundson,

Hotline.

See supplement for further.

SUPPLEMENT #1 Detective Joseph Amundson - 2633 08/12/2024 :

The referral read as follows:

“AV is 13 y/o . AO is an unknown (approx. 10 y/o at the time of the incident).

The AO is out of home and reported to be another resident that was admitted into the Timber Ridge

facility. The AO was lOyrs old at the time of the incident. . and ire the AV’s
On 08/07/2024,
During the MAYSI-2

parents and PRFCs. a FINs officer met with the AV and his FINS intake

family for a

interview. Questionnaire, . was asked if he has ever been raped or been in

danger of being raped. He responded with a simple "yes". was asked if he was raped or if he

was in a situation where he could have been raped, and he responded by saying "I was raped."

was asked how long ago he was raped, and he responded by saying "When I was in Timber

Ridge." s parents were asked if they were

They were then asked if it was ever reported.

is/was a Staff member at the facility but “nothing was ever done about it." The family

aware of this allegation, and they said "

stated that she reported it to "Mr. Mims" who

was asked

stated he “couldn't remember if it

if the incident was reported to DHS or DCFS.

reported to DHS.” On 08/08/2024, FINs officer

(over the phone with mother present) the spoke with

AV to clarify allegations. said, "I don't want to say what happen." The officer

with his mother present if they were able to ask yes or no questions.
if the AO touched him. HE esponded "no.”™

e officer asked if the AO made touch the Ao. responded "yes."

agreed. With

mother’s permission, the officer asked

was asked if

was asked if AO made him touch

touched the AO’s

AO made him touch anyone else. . cesponded "no,"

AO’s privates. responded "yes." The officer then asked if

privates with his hand. responded "yes." was asked if the AO made him touch the AO’sS

privates with any other part of his body. responded "no." was asked if the AC
touched anyone else. AV responded "no." This incident is reported to have happen when

an inpatient resident at Timber Ridge Neuro Restorative Residential Facility in Benton,

(approx, in 2021-2022)
O_o eee