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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/7/2023
Date Received by DCCECE:11/8/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , Parent Custody, DOB: ) was
sent for an outpatient x-ray at Dallas County Medical Center. She was assessed by on-site
nursing after an episode of self-injury where she punched a wall. X-ray report indicates a
. Dallas County ER provided a splint, and she
was released to return to the facility. PCP will oversee her recovery from the injury.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/8/23 that on 11/8/23
client was sent for an
outpatient x-ray at Dallas County Medical Center. She was assessed by on-site nursing after
an episode of self-injury where she punched a wall. X-ray report indicates a minimally
displaced fracture of the fifth digit. Dallas County ER provided a splint, and she was
released to return to the facility. PCP will oversee her recovery from the injury. No licensing
concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


state: AR

facility_name: Millcreek Behavioral Health / Habilitation Center, Inc.

summary: A resident was sent to Dallas County Medical Center for an x-ray after kicking a door.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 11/7/2023
Date Received by DCCECE:11/8/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: (AR, DHS Custody, DOB: ) was sent for an
outpatient x-ray at Dallas County Medical Center. She was assessed by on-site nursing after
an episode of self-injury where she kicked a door. X-ray report indicates there were no
fractures present. She was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 11/8/23 that on 11/7/23
client (AR, DHS Custody, DOB: ) was sent for an outpatient x-
ray at Dallas County Medical Center. She was assessed by on-site nursing after an episode
of self-injury where she kicked a door. X-ray report indicates there were no fractures present.
She was released to return to the facility. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was sent to Dallas County Medical Center for treatment of a laceration she received from a fence gate.

raw_content:
to the facility. Her PCP will oversee any further medical care needs. The fence gate has been
secured to prevent any future injuries similar to this incident. Fence will be examined
during next scheduled visit 11/8/23.


summary: Licensing visited the facility to review video of the late night/early morning hours of 10/25/23, 10/27/23, and 10/29/23. 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
Millcreek of Arkansas PRTF Clayton DeBoer
1828 INDUSTRIAL DRIVE Donaghey Plaza
FORDYCE AR 71742 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 233
Date of Visit: 10/31/2023
Visit Type(s): Monitor Visit
Time: 10:00 AM - 10:50 AM
_______________________________________________________________________________________________
Visit Comment :
Facility visited from 10:00AM-11:00AM. Video reviewed of the late night/early morning hours of October
25th, 27th and 29th for Tiger Hall, Flamingo Hall and Zebra Hall.
18 clients are assigned to Tiger Hall.
Staff viewed in video 10/25/23: 3
Staff viewed in video 10/27/23: 3
Staff viewed in video 10/29/23: 3
16 clients are assigned to Flamingo Hall.
Staff viewed in video 10/25/23: 2
Staff viewed in video 10/27/23: 3
Staff viewed in video 10/29/23: 2
16 clients are assigned to Zebra Hall.
Staff viewed in video 10/25/23: 3
Staff viewed in video 10/27/23: 2
Page 1 of 2

Staff viewed in video 10/29/23: 2
All staff/client ratios viewed within licensing standard of staff/client ratio for sleeping hours 1:8.
CCL Staff Signature : Date: 10/31/2023
Provider Signature : Date: 10/31/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2

doc_type: Compliance Report


summary: Licensing visited the facility to conduct a Buildings and Grounds walkthrough. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
Millcreek of Arkansas PRTF Clayton DeBoer
1828 INDUSTRIAL DRIVE Donaghey Plaza
FORDYCE AR 71742 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 233
Date of Visit: 10/26/2023
Visit Type(s): Monitor Visit
Time: 9:30 AM - 10:18 AM
_______________________________________________________________________________________________
Visit Comment :
Buildings & Grounds conducted from 9:30AM-10:30AM. Census: 160
Outdoor play area staff/client ratio: 2:12.
Rock Hill observed to be clean, safe and in good repair except for previously identified worn down spots in
laminate tile. Millcreek is having tile replaced throughout facility, Rock Hill in line for the future. Bathrooms
observed to be clean and sanitary with functioning sinks, showers and toilets. Client rights and emergency
diagrams posted. Grounds clean and free of safety hazards.
MAR checked for:
Page 1 of 2

All initialed and up to date.
CCL Staff Signature : Date: 10/26/2023
Provider Signature : Date: 10/26/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/13/2023
Date Received by DCCECE: 10/16/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , MCD Custody, DOB: ) was sent to
Dallas County Medical Center for an outpatient x-ray. On the evening of 10.11.2023, she
became upset and punched a wall. The swelling was noted initially but could also be a
result of a previous injury sustained prior to admission that presented continued tissue
swelling without the presence of a fracture. She was seen by her PCP on 10.13.23 and
referred for x-ray. X-ray report reflects
without acute fracture or dislocation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received provider reported incident 10/16/23 that on
10/13/23 client , MCD Custody, DOB: ) was sent to Dallas
County Medical Center for an outpatient x-ray. On the evening of 10.11.2023, she became
upset and punched a wall. The swelling was noted initially but could also be a result of a
previous injury sustained prior to admission that presented continued tissue swelling
without the presence of a fracture. She was seen by her PCP on 10.13.23 and referred for x-
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

ray. X-ray report reflects moderate soft tissue swelling about the ulnar wrist without acute
fracture or dislocation. No licensing concerns noted from this report.


summary: A resident reported that a peer forced him to perform a sexual act in exchange for clothes. The complaint was UNFOUNDED by Licensing.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 10/11/2023
Date Received by DCCECE: 10/12/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: Millcreek reported the following allegation to the Arkansas Mandated
Reporter Portal. The report was not accepted for investigation because of a duplicate entry.
Referral ID: in PRTF placement, reported events
alleged to have occurred on 10.05.2023: "The kid made me suck him off. I tried to say "No,"
but the kid said he would give me clothes, so I said OK, to make him shut up." Clothes
were exchanged between the two peers. indicated that the peer he referred to was
patient in the PRTF setting. Upon receiving the report,
was moved to a different living unit and placed on Close Observation to prevent
future occurrences. On 10.11.2023, Millcreek received notification that a report was made by
an outside entity and accepted for investigation by The report alleged that
woke from sleep to find a penis in his mouth. He was forced to continue to perform
oral sex until the peer ejaculated in his mouth. The report also alleged concerns with patient
supervision by direct care staff at Millcreek. Referral ID:
Interim Action Narrative: Clients were separated. A/V was moved to a different cottage.
Maltreatment Narrative: On 10.11.2023, Millcreek received notification that a report was
made by an outside entity and accepted for investigation by The report alleged that
woke from sleep to find a penis in his mouth. He was forced to continue to
perform oral sex until the peer ejaculated in his mouth. The report also alleged concerns
with patient supervision by direct care staff at Millcreek. Referral ID:
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humanservices.arkansas.gov

Licensing Narrative: Millcreek reported the following allegation to the Arkansas Mandated
Reporter Portal. The report was not accepted for investigation because of a duplicate entry.
Referral ID: in PRTF placement, reported events
alleged to have occurred on 10.05.2023: "The kid made me suck him off. I tried to say "No,"
but the kid said he would give me clothes, so I said OK, to make him shut up." Clothes
were exchanged between the two peers. indicated that the peer he referred to was
patient in the PRTF setting. Upon receiving the report,
was moved to a different living unit and placed on Close Observation to prevent
future occurrences. On 10.11.2023, Millcreek received notification that a report was made by
an outside entity and accepted for investigation by The report alleged that
woke from sleep to find a penis in his mouth. He was forced to continue to perform
oral sex until the peer ejaculated in his mouth. The report also alleged concerns with patient
supervision by direct care staff at Millcreek. Referral ID: 10/12/23 Licensing
obtained permission from Investigator Jennifer Harper to contact facility regarding
this incident. Ms. Harper stated that the A/V, stated that staff were absent from his
living area when this incident occurred. Facility visited 10/12/23 regarding complaint that
client sexually assaulted and interviewed to determine supervision concerns
when this alleged incident occurred. interviewed. denied this incident ever took
place. stated that is saying this because is afraid is going to beat him up over
some necklaces that was supposed to give added that is saying this to get
moved closer to his girlfriend who lives on the girl's unit at Millcreek. repeated that this
incident never took place adding that he has a girlfriend at home and is not homosexual.
stated that he has never seen all 3 staff (17 clients at Pine Ridge) leave Pine Ridge at any
given time. He stated that staff do take breaks but other staff relieve them. interviewed.
stated that when this incident took place "Mr. said he was going to the smoke
shack", " went out back to vape" and " went to get Taco Bell...I know
because I saw the big Taco Bell sack". stated the incident took around 3-4 minutes.
Licensing is not prepared to make a finding as of 10/12/23. Received notification 12/14/23
that maltreatment investigation was unfounded.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 10/12/2023
Home Visit Date: 10/12/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 10/12/23 regarding complaint that client sexually assaulted client and interviewed to determine
supervision concerns when this alleged incident occurred.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

interviewed. denied this incident ever took place. stated that is saying this because is afraid is going to
beat him up over some necklaces that was supposed to give added that is saying this to get moved closer to his
girlfriend who lives on the girl's unit at Millcreek. repeated that this incident never took place adding that he has a
girlfriend at home and is not homosexual. stated that he has never seen all 3 staff (17 clients at Pine Ridge) leave Pine
Ridge at any given time. He stated that staff do take breaks, but other staff relieve them.
interviewed. stated that when this incident took place " said he was going to the smoke shack", " went
out back to vape" and " went to get Taco Bell...I know because I saw the big Taco Bell sack". stated the
incident took around 3-4 minutes.
Licensing is not prepared to make a finding as of 10/12/23.
Provider Comments:
CCL Staff Signature : Date: 10/12/2023
Provider Signature : Date: 10/12/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing visited the facility to conduct a Buildings and Grounds Walkthrough. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
Millcreek of Arkansas PRTF Clayton DeBoer
1828 INDUSTRIAL DRIVE Donaghey Plaza
FORDYCE AR 71742 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 233
Date of Visit: 10/10/2023
Visit Type(s): Monitor Visit
Time: 9:30 AM - 11:03 AM
_______________________________________________________________________________________________
Visit Comment :
Buildings & Grounds conducted for Penguin Hall from 10:30AM-11:30AM. Census: 12
Penguin recently painted; new floors installed. Day area, bedrooms and hallway clean, safe and in good repair.
Bathrooms clean and sanitary with functioning sinks, toilets and showers. Client rights and emergency exit
diagrams posted.
MAR checked for:
All initialed and up to date.
Page 1 of 2

CCL Staff Signature : Date: 10/10/2023
Provider Signature : Date: 10/10/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for assessment after a physical altercation with another resident. The facility was cited 907.2 and 907.3 for issues identified during a review of the incident.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 10/1/2023
Date Received by DCCECE: 10/2/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , Parent Custody, DOB: ) was sent
to the Dallas County Medical Center ER for assessment following a physical confrontation.
On-site nursing indicated bruising and swelling to the facial area. The CT scan indicates no
fractures were present. He was released to return to the facility. Upon his return, he was
reassigned to an alternate living unit to provide safety and reduce the chance of future
incidents.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 10/2/23 that on 10/1/23 client
, Parent Custody, DOB: ) was sent to the Dallas
County Medical Center ER for assessment following a physical confrontation. On-site
nursing indicated bruising and swelling to the facial area. The CT scan indicates no
fractures were present. He was released to return to the facility. Upon his return, he was
reassigned to an alternate living unit to provide safety and reduce the chance of future
incidents. Phone call made 10/2/23 to Chris Butler of Millcreek. Incident happened at
Magnolia Hall. There is no camera footage of incident. Visit scheduled for 10/3/23 to
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humanservices.arkansas.gov

interview client for licensing concerns. Facility visited 10/3/23 in response to incident in
which client was assaulted by peers at Magnolia Hall 10/1/23. interviewed.
stated that there were two staff assigned to Magnolia Hall at the time of the incident but
that one staff member, , had "gone to get trays". Chris Butler of
Millcreek indicated that this would typically take 8-10 minutes. Facility cited 907.3.
stated that the other staff present was stated that he was "jumped" by
and ". stated that staff did not intervene.
indicated that the reason he believed peers to stopped assaulting him was because they
"had enough of it". presented today with swollen and bruised face. Staff, present and
absent from Magnolia, if even for a brief period, failed to ensure the safety and well-being of
client during this incident. Facility cited 907.2. Facility will conduct in-service training for
staff involved in this incident that staff/client ratio will be ensured at all times. Sign in sheet
will be provided to licensing by 10/10/23. In-service training for staff and
provided to licensing on 10/10/23.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 10/3/2023
Home Visit Date: 10/3/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulation Number: 9. 907. 2
Regulation Description: Child caring staff shall be responsible for providing the level of supervision, care, and
treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s
age, individual differences and abilities, surrounding circumstances, hazards and risks.
Findings Description: Staff did not ensure the safety and well-being of client during this incident resulting in
the swelling/bruising of face.
Action Due Date: 10/10/2023
Action Due Description: Staff involved in this incident will receive in-service training on staff/client ratio. Sign in
sheet will be provided to licensing by 10/10/23.
Comply Date:
Sub Regulation Description:
Regulation Number: 9. 907. 3
Regulation Description: Staff/child ratio shall be at least 1:6 during waking hours and 1:8 during sleeping hours.
Findings Description: One staff left Magnolia Hall resulting in staff/client ratio1:8.
Action Due Date: 10/10/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Action Due Description: Staff involved in this incident shall receive in-service training on staff/client ratio.
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 10/3/23 in response to incident in which client was assaulted by peers at Magnolia Hall 10/1/23.
interviewed. stated that there were two staff assigned to Magnolia Hall at the time of the incident but that one staff
member, , had "gone to get trays". Chris Butler of Millcreek indicated that this would typically take 8-10
minutes. Facility cited 907.3. stated that the other staff present was . stated that he was "jumped" by
" and stated that staff did not intervene. indicated that the reason he believed peers
to stopped assaulting him was because they "had enough of it". presented today with swollen and bruised face. Staff,
present and absent from Magnolia, if even for a brief period, failed to ensure the safety and well-being of client during this
incident. Facility cited 907.2. Facility will conduct in-service training for staff involved in this incident that staff/client ratio
will be ensured at all times. Sign in sheet will be provided to licensing by 10/10/23.
Provider Comments:
Risk Management Department conducted an internal investigation into the incident. Staff and patient statements
reflect that staff member did attempt to intervene in the physical confrontation and separate them
from the injured patient. All staff and patient statements contradict report that staff members allowed the
physical confrontation to continue.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3


summary: A resident was sent to Dallas County Medical Center for an x-ray of an injury received when he became upset and punched a wall.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/24/2023
Date Received by DCCECE:9/25/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: (TX, CPS Custody, DOB: ) was sent to Dallas
County Medical Center for outpatient x-ray. He was referred as a precautionary measure
after reassessment of an injury from the previous day. He became upset and punched a wall
when he was instructed by staff members to give up a basketball. X-ray report indicates that
no fractures are present.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/25/23 that on 9/24/23 client
was sent to Dallas County Medical Center for outpatient x-ray. He was referred as
a precautionary measure after reassessment of an injury from the previous day. He became
upset and punched a wall when he was instructed by staff members to give up a basketball.
X-ray report indicates that no fractures are present.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent for an emergency dental appointment after one tooth was knocked out and a second tooth was damaged during a physical altercation with a peer.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/21/2023
Date Received by DCCECE:9/22/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , (AR, parent custody, DOB: ) was sent to
Dr. Patrick Moseley, DDS for an emergency dental appointment. was referred for
assessment after a physical confrontation with a peer, resulting in one tooth being knocked
out. During the dental visit, Dr. Moseley determined that a second tooth was damaged and
needed to be removed. He completed the removal during the visit. After the visit, was
released to return to the facility. Millcreek is developing a follow up plan to address the
missing teeth.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/22/23 that on 9/21/23 client
was sent to Dr. Patrick Moseley, DDS for an emergency dental
appointment. was referred for assessment after a physical confrontation with a peer,
resulting in one tooth being knocked out. During the dental visit, Dr. Moseley determined
that a second tooth was damaged and needed to be removed. He completed the removal
during the visit. After the visit, was released to return to the facility. Millcreek is
developing a follow up plan to address the missing teeth. Facility visited 9/26/23 in
response to incident in which client was assaulted by a peer. During the incident, one of
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

's teeth were knocked out. Subsequent visit to the dentist resulted in the removal of one
more tooth. interviewed. stated that he and another peer, had an argument/fight
during an outdoor activity. stated that staff were sitting on a bench and instructed
and to stop fighting and they did. stated that staff were approximately "5 feet" from
him when another client, , "hit me from behind", resulting in 's tooth being knocked
out. stated that staff immediately prevented him and from continuing to fight. Staff
Sheila Smith, who was present for this incident, interviewed today. Staff Smith stated she
and other staff were deescalating an argument with and other peers, when snuck up
and punched . Staff Smith stated they immediately prevented and from
continuing to fight and was taken to the nurse.


summary: A resident was sent for an x-ray after complaining of pain from punching on a punching bag during recreation time.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/21/2023
Date Received by DCCECE:9/22/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: (DOB: 1 , PRTF, Texas Resident, DFPS)
was sent out for an outpatient X-ray, The PCP stated that there were no broken bones from
the report. was returned to Millcreek without any restrictions.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/22/23 that on 9/21/23 client
was sent out for an outpatient X-ray, The PCP stated that there were no
broken bones from the report. was returned to Millcreek without any
restrictions. No licensing concerns noted from this report. Email sent 9/25/23 to obtain
additional information regarding why X-ray was performed. Received email from Chris
Butler of Millcreek 9/25/23 as follows: Looks like we have a clerical error on the patient
information. , (New Mexico, Parent Custody, DOB: ) was sent for x-
ray on 09.21.2023. She complained of pain to her hand after punching on the punching bag
during recreation time the previous evening. No fractures were found. was
indicated in the ELS report, that was incorrect. Sorry for the confusion.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to review random video of cottages during evening hours. 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
Millcreek of Arkansas PRTF Clayton DeBoer
1828 INDUSTRIAL DRIVE Donaghey Plaza
FORDYCE AR 71742 P.O. Box 1437
Little Rock, AR. 72203
Facility Visit Compliance Notice
__________________________________________________________________________
Facility#: 233
Date of Visit: 9/21/2023
Visit Type(s): Monitor Visit
Time: 12:30 AM - 0:54 AM
_______________________________________________________________________________________________
Visit Comment :
Facility visited and random video reviewed of cottages during evening hours.
Flamingo 9/18/23 at 6:30PM. 3 staff observed in hallway. 3 clients observed interacting in hallway.
Flamingo 9/18/23 at 7:00PM. 3 staff observed in hallway. Clients in bedrooms out of camera view.
Flamingo 9/19/23 at 8:00PM. 3 staff observed in hallway. Clients in bedrooms out of camera view.
Penguin 9/18/23 at 6:00 PM. Staff/client ratio observed in hallway 3:4.
Penguin 9/18/23 at 7:30PM. 3 staff observed in hallway. Clients in bedrooms out of camera view.
Penguin 9/19/23 at 11:00PM. 2 staff observed in hallway.
Zebra 9/19/23 at 5:30PM. Staff/client ratio lined up in the hallway 2:12.
Zebra 9/19/23 at 7:30PM. 2 staff observed in hallway. Clients in bedrooms out of camera view.
Zebra 9/19/23 at 1:00AM. 3 staff observed in hallway. Clients in bedrooms out of camera view.
Page 1 of 2

CCL Staff Signature : Date: 9/21/2023
Provider Signature : Date: 9/21/2023
Your Signature indicates that this form has been reviewed with you; it does not imply your agreement with
it.
Right to Appeal: For more information on how to appeal these findings, refer to the minimum Licensing
Requirements or contact your Licensing Specialist.
Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for assessment of a leg laceration after slipping on the bleachers.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/16/2023
Date Received by DCCECE:9/18/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , (DOB: 1 , PRTF, Texas Resident, DFPS)
was having recreational time in the gym, slipped on the bleachers, and obtained a laceration
to her leg. The nurse assessed and she was transported to DCMC ER for treatment
per PCP. She was released to return to the facility. will follow up with her
PCP.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/18/23 that on 9/16/23 client
was having recreational time in the gym, slipped on the bleachers, and
obtained a laceration to her leg. The nurse assessed and she was transported to
DCMC ER for treatment per PCP. She was released to return to the facility.
will follow up with her PCP. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for treatment after injuring his ankle by falling while playing basketball.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/15/2023
Date Received by DCCECE:9/18/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , (DOB: 1 PRTF, Arkansas resident, Adoptive
parents) was playing basketball during recreational and went up for a rebound and came
down and fell in between two other players and hurt his right ankle. The nurse assessment
noted swelling to the right ankle. was transferred to DCMC ER for treatment
per PCP. will follow up with his PCP.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/18/23 that on 9/15/23 client
was playing basketball during recreational and went up for a rebound and came
down and fell in between two other players and hurt his right ankle. The nurse assessment
noted swelling to the right ankle. was transferred to DCMC ER for treatment
per PCP. will follow up with his PCP. No licensing concerns noted from this
report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Millcreek of Arkansas PRTF
1828 INDUSTRIAL DRIVE
FORDYCE AR 71742

ARKANSAS
| een eres OF

) HUMAN
» 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

Clayton DeBoer
Donaghey Plaza

P.O. Box 1437

Little Rock, AR. 72203

Facility Visit Compliance Notice

Facility#: 233

Date of Visit: 9/12/2023

Visit Type(s): Personnel Records
Time: 9:30 AM - 11:29 AM

Visit Comment :
Personnel Records Review conducted for:

All file licensing requirements were accounted for.

Page 1 of 2

CCL Staff Signature : Date: 9/12/2023

7)
MN

Provider Signature : Date: 9/12/2023

fA -

i]

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

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

Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for an outpatient gallbladder ultrasound.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/11/2023
Date Received by DCCECE:9/12/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: (Ohio, Fairfield County Custody, DOB: ) was
sent to Dallas County Medical Center for an outpatient gallbladder ultrasound. She was
referred for the test by her PCP. She was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/12/23 that on 9/11/23 client
was sent to Dallas County Medical Center for an outpatient gallbladder
ultrasound. She was referred for the test by her PCP. She was released to return to the
facility. Facility visited 9/12/23. ER report stated that client has "gallbladder sludge". No
sonographic evidence of acute cholecystitis. No licensing concerns noted from this report.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for assessment of a leg wound received before admission to the facility.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 9/11/2023
Date Received by DCCECE:9/12/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: ( , DHR Custody, DOB: ) was
sent to Dallas County Medical Center to assess a leg wound received before admission to
Millcreek. The wound became inflamed, tight, and hot to the touch despite taking several
rounds of antibiotics. He was later transferred to AR Children's Hospital ER by ambulance
for further assessment. No diagnosis or treatment plan has been received at this time.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 9/12/23 that on 9/11/23 client
was sent to Dallas County Medical Center to assess a leg wound received
before admission to Millcreek. The wound became inflamed, tight, and hot to the touch
despite taking several rounds of antibiotics. He was later transferred to AR Children's
Hospital ER by ambulance for further assessment. No diagnosis or treatment plan has been
received at this time. No licensing issues noted from this report. Facility visited 9/12/23.
Client remains at ACH at the time of visit.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: No deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted on 09/05/23.

raw_content:
September 08, 2023
Habilitation Center, Llc
1810 Industrial Dr
Fordyce, AR 71742-7110
The Division of Provider Services and Quality Assurance (DPSQA) of the Arkansas Department of Human
Services has contracted with Arkansas Foundation for Medical Care (AFMC) to perform Inspections of Care
(IOC) for Inpatient Psychiatric Services for Under 21. The Medicaid Manual for Inpatient Psychiatric Services
for Under Age 21 was used in the completion of this report.
Observations and any deficiencies noted are listed below for the inspection conducted at the following service
site on the following date:
Habilitation Center, Llc
Provider Medicaid ID:
Onsite Inspection Date: September 05, 2023
Onsite Inspection Time: 9:03a.m.
A summary of the inspection and any deficiencies noted are outlined below.
Inspection of Care Summary
Facility Tour:
Upon arrival to facility, AFMC staff was promptly greeted at the entrance by a Habilitation Centers, LLC staff
member and a COVID-19 screening was conducted and temperatures noted. AFMC was immediately taken to a
conference room where they were met by the Chief Executive Officer and the Director of Risk Management.
A tour of the facility was completed with the Chief Executive Officer. The facility environment was extremely
clean, well-organized, and appeared to be in good repair. Therapeutic groups and educational classes were in
session. Staff were able to answer all questions regarding the facility. There were no areas of concern noted
during the tour. All facility staff encountered during the day were exceptionally pleasant and hospitable toward
AFMC staff, other facility staff, and the clients.
Facility Review – Policies and Procedures:
Upon review of the site’s policies and procedures, there were no deficiencies noted.
Personnel Records – Licenses, Certifications, Training:
There were forty-eight personnel records requested; nine (27%) professional staff and thirty-nine
(25%) paraprofessional staff. During the review of the personnel records, no deficiencies were noted.
Observations:
During the personnel record review, it was noted that the child maltreatment registry for SR014781
was dated after the onsite inspection. The registry check was dated for September 7, 2023.

Clinical Summary
As a part of the Quality of Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list was
requested, client and/or guardian interviews were conducted, and a clinical record review was completed. The
following is a summary of findings and noted deficiencies.
Client/Guardian Interviews:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no client interviews
were conducted.
Clinical Record Review Deficiencies:
There was no active FFS Medicaid clients currently admitted at the time of IOC. Therefore, no clinical record
reviews were conducted.
Program Activity/Service Milieu Observation:
Clients were observed in the classroom and in a group activity on one of the units in the common area. Staff
were engaged with the clients and were providing a therapeutic environment.
Medication Pass:
No active FFS Medicaid clients received medications during a medication pass while AFMC staff was
onsite. Due to the observation of non-Medicaid clients not being complaint with the HIPAA minimal
necessary rule, no medication pass was observed. AFMC RN visited with the Habilitation Centers,
LLC Health medication nurse who was able to show AFMC RN the facility policies and procedures
regarding medication administration, narcotic count/reconciliation/handling, and medication
discrepancies.
Facility nurse was able to verbalize the step-by-step process of medication delivery including the
demonstration of the five rights of medication administration, documentation of medication delivery,
verification of client taking medication including mouth/cheek checks, and how clients are educated
about each medication. The facility nurse also verbalized the process utilized when a client refuses
medications. Tour of medication room completed with the Habilitation Centers, LLC medication nurse
and no discrepancies with medication storage, cleanliness of medication room, and knowledge of
medication dispensing found.
Respectfully,
Inspection of Care Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Habilitation Center, Llc – Fordyce, AR – IOC Report 2 | P ag e

doc_type: IOC Report


summary: Officers were dispatched to the facility in response to three runaway juveniles. The juveniles were caught by staff and officers and were transported back to the facility.

raw_content:
Incident # 23-00525 Fordyce Police Department ReportDate 09/03/23
Page 1of 2 IncidentReport ReportTime 5:51PM
Status ExceptionClearance Date ReportingOfficer ORl/Agency
NotApplicable 307 Johnson,James Ryan AR0200100
Closed
AssignedOfficer EnteredBy ApprovingOfficer
JJohnson Swiger,Canaan
AssistingOfficers
LatestPossibleDate
09/03/2023
MO
LocationTypes 13Hway/Road/Alley 37Abandoned/Condemned 48 Industrial Site BiasMotivationCodes
43Lesbian, Gay,Bisexual,
14Hotel/Motel Structure 49 Military Installation ANTI- orTransgender, Mixed
01Air/BusfTrain Terminal 15Jail/Prison 38 Amusement Park 50 Park/Playground 23Protestant Group (LGBT)
02Bank/S&L 16LakelWaterway 39Arena/Stadium/Fair 51 RestArea 11White 24Islamic (Muslim) 44Heterosexual
0 0 3 4 B C a h r u /N rc i h g / h S t yn C a lu g b fTemple 1 1 7 8 L P i a q r u k o in r g S L to o r V e Garage g 4 r 0 ou A n T d M s/C S o e l p is a e r u a m te fromBank 5 C 2 olle S g c e h / o U o n l iversity A 1 m 2 e B r l i a c c a k n orAfrican 2 2 5 6 O M t u h l e ti- r re R li e g l i i o g u io s n group 4 5 5 1 B P i h s y e s xu D a i l sability
05Commercial/Off Bldg 19Rental Storage 41AutoDealership 53 School 13American Indianor 27AtheisVAgnostic 52Menial Disability
06Construction Site Facility New/Used Elementary/Secondary Alaska Native 31Arab 61Male
07Convenience Store 20Residence/Home 42Camp/Campground 54 Shelter 14Asian 32Hispanic orLatino 62Female
0 0 9 8 D D r e u p g VD S i t s r/ c D o r un O t ff/ S H to o r s e p 2 2 1 3 R Se e r s v ta ic u e r / a G n a t s Station 4 4 4 5D D o a c y k c lW ar h e ar F f/ a F c re ili i t g y hV 5 M 5 iss S io h n o / p H p o in m g ele M s a s ll 1 1 6 5M N U a l t t i i v - e rac H e a s w , a G iia ro n up or 3 L 3 ati N no otHispanic or 7 7 1 2 T G r e a n n d s e g r en N d o e n r -Conforming
10FieldlWoods 24Specialty Store ModalTerminal 56 Tribal Lands Other Pacific Islander 41Gay(male) 88None
11GovVPublic Bldg 25Unknown/Other 46FarmFacility 57 Community Center 21Jewish 42Lesbian 99Unknown
12Grocery/Supermarket 47Gambling 58Cyberspace 22Catholic
Facility/Casino/Race Track
SuspectedOfUsing CriminalActivityTypes WeaponType(s) 20Knife/Cutting Instr 65Fire/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 0 C O u p l e ti r v a a t t i i n n g g / / P M ro a m nu o f t / i P n u g b /A lis s h si i s n t g ing 1 1 1 2 F H i a re n a d r g m un (A (A ut u o t ) o) 3 3 5 0 M Bl o u t n o t r O V b e j h e i c c t le 8 7 5 0 A D s ru p g h S yx /N ia a ti r o c n .lSleeping Pills
oDistributing/Selling TTransportllmportlTransmit 13Rifle(Auto) 40Personal Weapons 90Other
EExploiting Children UUsing/Consuming 14Shotgun (Auto) 50Poison 95Unknown
15Other Firearm 60Explosives 99None
A Simple/Gross Neglect I Intentional Abuse &Torment
F Organized Abuse S Sexual Animal Abuse
Race Unknown
HomePhone Cell
USCitizen LegalAlien DocType ImmigDoc# Nationality
Yes
HomeAddress Employer
WorkAddress Occupation
Narrative -Johnson, James Ryan -9/3/2023 6:01:39PM(Initial)
On September 2,2023, at approximately 6:00 p.m., I, Officer Ryan Johnson,
Officer Johnathen Taylor, and Officer Jacob Murry were dispatched to Millcreek
CopyrightRelativity Inc.©-RPS(Relativity Public Safety)
Printed: 9/8/2023 9:32:06 AM

Fordyce Police Department ReportDate 09/03/23
Incident # 23-00525
Page 2 of 2 IncidentReport ReportTime 5:51 PM
Narrative & Statements
Narrative -Johnson, James Ryan -9/3/2023 6:01:39PM(Initial)
Behavioral Unit for three runaway male juveniles. Upon my arrival, employees of
Millcreek were directing me down the road to where other employees had one
juvenile on the ground. Once I got to those employees, they pointed to other
employees who had the second juvenile caught. After making sure they had the
second juvenile, it was told to us that the third male juvenile ran into the woods
across the street from Industrial Drive. Officer Murry and I made contact with the
juvenile about 50 yards from the roadway and secured him in handcuffs. We
escorted him to my patrol unit, where he was placed in the backseat and taken
to his dorm. After dropping him off, I went back and took the first juvenile that
was caught back to the same dorm. All three juveniles were dropped off at the
dorm, and no further incidents happened.
CopyrightRelativity Inc.©-RPS(Relativity Public Safety)
Printed: 9/8/2023 9:32:06 AM

doc_type: Police Report


summary: Three residents eloped from the facility. The residents were located by Fordyce Police Department and escorted back to the facility.

raw_content:
the door to the cabin was still open from being broken by . Clients and who staff
Maddox was responsible for supervising, exited the door to the cabin. Staff Maddox exited
the cabin, client walking behind. Staff Maddox remained outside with clients
and for about 20 minutes, attempting to discourage them from eloping while staff Lucky
remained inside with the other clients. Eventually, the 3 clients ran out of sight from Mr.
Maddox. Mr. Maddox indicated that staff/client ratio during this incident was 2:7, allowing
for 1:1 with client .


summary: Licensing visited the facility to conduct a Buildings and Grounds walkthrough. The facility was cited 911.15 for issues identified during the review.

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

Millcreek of Arkansas PRTF Clayton DeBoer
1828 INDUSTRIAL DRIVE Donaghey Plaza
FORDYCE AR 71742 P.O. Box 1437

Little Rock, AR. 72203
Facility Visit Compliance Notice

Facility#: 233

Date of Visit: 8/29/2023
Visit Type(s): Monitor Visit
Time: 11:00 AM - 0:01 AM

Regulation# 9.911 .15
Result : Non-Compliant
Action Due Date : 8/29/2023 Date Corrected: 8/29/2023

Action Due : Drawstrings immediately removed. Email sent to RSD (Residential Service Directors) to inventory
client's clothing in living areas.

Comment : Room 4 of Deerfield Hall had drawstrings in a pair of sweatpants.

Visit Comment :
Buildings & Grounds conducted from 11:00AM-12:30PM. Census: 162

3 outdoor groups observed. Ratios: 2:10, 9:34 and 3:14. All grounds well-kept and free of safety hazards.
Client Ij observed outside being escorted by one staff.

Deerfield observed to be clean, safe and in good repair except Room 4 had a pair of drawstrings in the waist
area of a pair of sweatpants. Drawstrings immediately removed by J of Millcreek. Facility cited
911.15f: Areas used by children shall be designed, constructed, and furnished to reduce the risk of suicide and
assault including without limitation: f) Children's personal items that contain pull-ties, strings, or other parts
that could be used to inflict self-injury shall not be left in the child's room unless the dangerous component

Page 1 of 2

has been removed. Email sent during today's visit by of Millcreek to RSD's (Residential Services
Directors) for all client living areas to be inventoried for strings and/or cords in client rooms. Bathrooms clean
and sanitary with functioning sink, showers and toilets.

MAR checked for:

All initialed and up to date.

CCL Staff Signature : Date: 8/29/2023
Provider Signature : Date: 8/29/2023
NA

VY

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

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

Page 2 of 2


summary: A resident reported that a staff member forcefully pushed him into a chair after the resident attempted to continue a fight with a peer. The complaint was FOUNDED by Licensing. The facility was cited 905.4.g and 109.1.g for the staff member’s actions.

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
8/22/2023R
Notice of Serious Incident
Date of Incident: 8/21/2023
Date Received by DCCECE: 8/22/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: Allegation: During a casual card game, got into an
argument with a fellow player, and things escalated into a physical altercation. Staff
members intervened and separated the two patients. When questioned about the incident,
claimed that , one of the staff members, had restricted him to
sitting in a chair. According to he got up and tried to continue the fight, but
forcefully pushed him to be seated in the chair. Nursing assessment following
the incident reveals redness and petechia to the right inner arm. No other injuries are noted.
A report was made to the AR Mandated Reporter Portal. Reference ID: The
report was for investigation. Report Number: is
currently on administrative leave pending the results of the investigation.
Interim Action Narrative: is currently on administrative leave pending the
results of the investigation.
Maltreatment Narrative: A report was made 8/21/23 to the AR Mandated Reporter Portal
regarding staff forcefully pushing client into a chair.
Reference ID: The report was for investigation. Report Number:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing received facility reported complaint 8/22/23 that on
8/21/23 video was reviewed by Chris Butler of Millcreek from 8/20/23 of Pine Ridge which
showed client get into an argument with a fellow player, and things escalated
into a physical altercation. Staff members intervened and separated the two patients. When
questioned on 8/21/23 about the incident, claimed that , one of the
staff members, had restricted him to sitting in a chair. According to he got up and
tried to continue the fight, but forcefully pushed him to be seated in the
chair. Nursing assessment following the incident reveals redness and petechia to the right
inner arm. No other injuries are noted. A report was made to the AR Mandated Reporter
Portal. Reference ID: The report was for investigation. Report
Number: is currently on administrative leave pending the results
of the investigation. Facility visited 8/22/23 and video reviewed of incident 8/20/23 in Pine
Ridge. Child Abuse Hotline notification was made 8/21/23 after video review of incident.
Seemingly after staff were breaking up an altercation off camera, staff is
seen grabbing client and shoving him into a chair. gets up out of the chair and staff
takes of his glasses, staff slapped his own ( ) head, chest
bumped client then shoved him back into the chair. Facility cited 109.1g:
Unprofessional conduct in the practice of child welfare activities shall include without
limitation: g) Engaging in behavior that could be viewed as sexual, dangerous, exploitative,
or physically harmful to children and 905.4g: The following disciplinary actions shall not be
used: g) Physical injury or threat of bodily harm. Chris Butler of Millcreek stated that after
review of video, staff will be terminated subsequent administrative leave.
Received email 11/10/23 that maltreatment complaint is unfounded.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/22/2023
Home Visit Date: 8/22/2023
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulation Number: 9. 905. 4 .g
Regulation Description: The following actions shall not be used, including as discipline:
Findings Description: Seemingly after staff were breaking up an altercation off camera, staff is
seen grabbing client and shoving him into a chair. gets up out of the chair and staff takes of his
glasses, staff slapped his own head, chest bumped client then shoved him back into
the chair.
Action Due Date: 8/22/2023
Action Due Description: Staff terminated subsequent administrative leave.
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 109. 1 .g
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Seemingly after staff were breaking up an altercation off camera, staff is
seen grabbing client and shoving him into a chair. gets up out of the chair and staff takes of his
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

glasses, staff slapped his own head, chest bumped client , then shoved him back into
the chair.
Action Due Date: 8/22/2023
Action Due Description: Staff will be terminated subsequent administrative leave.
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 8/22/23 and video reviewed of incident 8/20/23 in Pine Ridge. Child Abuse Hotline
notification was made 8/21/23 after video review of incident. Seemingly after staff were breaking up an
altercation off camera, staff is seen grabbing client and shoving him into a chair. gets
up out of the chair and staff takes of his glasses, staff slapped his own
head, chest bumped client , then shoved him back into the chair. Facility cited 109.1g: Unprofessional
conduct in the practice of child welfare activities shall include without limitation: g) Engaging in behavior that
could be viewed as sexual, dangerous, exploitative, or physically harmful to children and 905.4g: The
following disciplinary actions shall not be used: g) Physical injury or threat of bodily harm.
of Millcreek stated that after review of video, staff will be terminated subsequent
administrative leave.
Provider Comments:
The employee involved in this incident completed all required training and met competency standards, but they
failed to adhere to the established expectations, policies, and procedures of our facility. Such a violation of
company policy necessitated disciplinary action, including termination of employment, and reporting to the AR
Child Abuse Hotline. It is imperative to underscore that this incident did not reveal any system, procedure,
process, or practice within our facility that failed. This unequivocally proves that Millcreek has effective practices
for responding to situations where an employee deviates from company policy.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 8/23/2023
Provider Signature : Date: 8/23/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident reported that a peer entered his room and began touching him inappropriately.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/21/2023
Date Received by DCCECE: 8/21/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Patient , DHS Custody, DOB: )
reported that he was in his room in Magnolia Hall with his door shut, masturbating. Patient
, DCFS Custody, DOB: ) entered the room, grabbed hold of
him, and started "jacking him off." stated that this went on for about 5 minutes and
then requested that stop. stopped and left the room. Reported to the Mandated
Reporter Portal. Reference ID: . No return correspondence has been received at
this time. 's report is the only evidence supporting this claim. This notification is in
accordance with the Corrective Action Agreement, which requires reporting of incidents
that suggest inadequate supervision. According to patient safety plan, he
should have one staff member assigned to him at all times until he is discharged. Staff
member who was assigned to , reported that did not enter
bedroom. For safety reasons, was relocated to Tiger Hall, where
he was separated from the alleged offender. The staff received training on the rules that
require patients under 1:1 staffing to always remain within arm?s length of their caregivers.
Although a safety plan was already in effect for , his report, if valid, suggests
that he did not adhere to it.
Interim Action Narrative: For safety reasons, was relocated to Tiger Hall,
where he was separated from the alleged offender. The staff received training on the rules
that require patients under 1:1 staffing to always remain within arm?s length of their
caregivers.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/21/23 that client
reported that he was in his room in Magnolia Hall with his door shut, masturbating. It was
later determined that client reported this to staff 8/19/23. After review on 8/21/23, Chris
Butler of Millcreek notified the Hotline on 8/21/23. Patient
entered the room, grabbed hold of him, and started "jacking him off." stated that this
went on for about 5 minutes and then requested that stop. stopped and left the
room. Reported to the Mandated Reporter Portal. Reference ID: . No return
correspondence has been received at this time. Phone call made to Chris Butler of Millcreek
who stated that Hotline Maltreatment correspondence was received that
ref# was not accepted. Facility visited 8/22/23. Statement of client reviewed.
A/O interviewed. When asked, A/O stated that increased supervision means "eyes
on me 24/7". When asked if he is supervised 24/7, replied "most of the time". When
asked how long goes unsupervised "5 minutes". When asked what does during
those 5 minutes, replied "talk to other kids...make noodles in the kitchen". For
clarification, Chris Butler of Millcreek stated that supervision means that he is not
allowed out of arm's length of and is to be in constant line of sight of staff. Inservice was
provided to staff 8/19/23 who are in contact with which reiterated this. Staff
who only works weekends, was asked by Chris Butler of Millcreek if allegation was
possible. stated to Chris Butler, she was supervising client at all times and
never went in client 's room. provided an email to Millcreek as follows:
asked permission to go to his room. Door was unlocked and went into s room.
and myself told to get out and that he is not supposed to be in the room.
Relocked the door. Initial allegation made by client stated that client entered client
s room when incident took place. Licensing in not prepared to make a finding at this
time. 8/22/2023- Hotline was called again for concerns regarding possible lack
of supervision given the alleged offenders previous true finding of maltreatment against
another peer. The hotline call was screened out (see attachment in the notes section of the
attached inspection). Consultation held with licensing supervisor 9/12/23. No
determination could be made regarding if the events occurred, or the resident was ever left
unattended. The facility will continue with the current safety plan for .

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/22/2023
Home Visit Date: 8/22/2023
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Licensing received facility report 8/21/23 that client reported that he was in his room in Magnolia Hall
with his door shut, masturbating. Patient entered the room, grabbed hold of him, and started "jacking him
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

off." stated that this went on for about 5 minutes and then requested that stop. stopped and left the
room.It was later determined that client reported this to staff 8/19/23. After review on 8/21/23,
of Millcreek notified the Hotline on 8/21/23.
Facility visited 8/22/23. Statement of client reviewed. A/O interviewed. When asked, A/O stated
that increased supervision means "eyes on me 24/7". When asked if he is supervised 24/7, replied "most of
the time". When asked how long goes unsupervised "5 minutes". When asked what does during those
5 minutes, replied "talk to other kids...make noodles in the kitchen". For clarification, of
Millcreek stated that supervision means that he is not allowed out of arm's length of and is to be in
constant line of sight of staff. Inservice was provided to staff 8/19/23 who are in contact with which
reiterated this. Staff , who only works weekends, was asked by of Millcreek if
allegation was possible. stated to , she was supervising client at all times and
never went in client room. provided an email to Millcreek as follows: asked permission
to go to his room. Door was unlocked and went into room. and myself told to get out
and that he is not supposed to be in the room. Relocked the door-end email. Initial allegation made by client
stated that client entered client room when incident took place.
For clarification on why this incident was not immediately reported to the Hotline.
of Millcreek stated that report did not meet criteria for sexual abuse, maltreatment. For transparency and
compliance with Corrective Action Agreement, report was made 8/21/23.
Licensing in not prepared to make a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 8/23/2023
Provider Signature : Date: 8/23/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Licensing conducted a monitoring visit at the facility. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/16/2023
Home Visit Date: 8/16/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Monitor visit conducted 8/16/23. Census: 158. Ratios checked today.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Classroom A6 staff/client ratio: 3:15
Outdoor area staff/client ratio: 6:31
Outdoor area staff/client ratio: 4:18
Cafeteria staff/client ratio: 9:32. Cafeteria was sanitary, safe, clean and in good repair.
Provider Comments:
CCL Staff Signature : Date: 8/23/2023
Provider Signature : Date: 8/23/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for an x-ray after complaining of back pain to her PCP.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/15/2023
Date Received by DCCECE: 8/16/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , DHHR custody, DOB: was sent to
Dallas County Medical Center for an outpatient x-ray. She reported back pain to PCP and
received an order for an x-ray of her spine. x-ray report indicates a normal-appearing lumbar
spine. She was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/16/23 that on 8/15/23 client
was sent to Dallas County Medical Center for an outpatient x-ray. She reported back
pain to PCP and received an order for an x-ray of her spine. x-ray report indicates a normal-
appearing lumbar spine. She was released to return to the facility. No licensing concerns
noted in this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an ultrasound of his gallbladder after reporting digestive tract concerns to nursing.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/12/2023
Date Received by DCCECE: 8/14/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , DCBS Custody, DOB: was sent to
Dallas County Medical Center for an ultrasound of his gallbladder. He reported digestive
track concerns to on-site nursing. His PCP referred him for the ultrasound. The results
came back as normal. He was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/14/23 that on 8/12/23 client
was sent to Dallas County Medical Center for an ultrasound of his gallbladder. He
reported digestive track concerns to on-site nursing. His PCP referred him for the
ultrasound. The results came back as normal. He was released to return to the facility. No
licensing concerns noted from this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray after being struck in the hand by a ball during recreation time.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/11/2023
Date Received by DCCECE: 8/14/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Adoptive Parent Custody, DOB: ) was
sent to Dallas County Medical Center for outpatient x-ray. PCP referred him after reporting
pain to on-site nursing after being struck in the hand by a ball during recreation time. X-ray
report indicated that there were no fractures present.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/14/23 that on 8/11/23 client
was sent to Dallas County Medical Center for outpatient x-ray. PCP referred him
after reporting pain to on-site nursing after being struck in the hand by a ball during
recreation time. X-ray report indicated that there were no fractures present. No licensing
concerns noted from this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/6/2023
Date Received by DCCECE: 8/7/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , Parent Custody, DOB: ) was sent to Dallas
County Medical Center for outpatient x-ray after an incident where she became upset and
punched a metal door. On-site nursing assessed her and noted swelling to the right hand. X-
ray report indicates that there are no fractures or dislocations. She was released to return to
the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/7/23 that on 8/6/23 client
was sent to Dallas County Medical Center for outpatient x-ray after an incident
where she became upset and punched a metal door. On-site nursing assessed her and noted
swelling to the right hand. X-ray report indicates that there are no fractures or dislocations.
She was released to return to the facility. No licensing concerns noted from this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray after reporting continued pain in his jaw from accidently striking his jaw on a peer’s head while sliding down a water slide.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/4/2023
Date Received by DCCECE: 8/7/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Parent Custody, DOB: ) was sent to
Dallas County Medical Center for outpatient x-ray after reporting continued pain in his jaw.
The injury occurred when he unintentionally struck his jaw against another patient's head
while sliding down a water slide on 07.28.23. The x-ray report indicates that there is no
fracture. He was released to return to the facility.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/7/23 that on 8/4/23 client
was sent to Dallas County Medical Center for outpatient x-ray after reporting
continued pain in his jaw. The injury occurred when he unintentionally struck his jaw
against another patient's head while sliding down a water slide on 07.28.23. The x-ray report
indicates that there is no fracture. He was released to return to the facility. No licensing
concerns noted from this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for an x-ray after reporting pain and swelling to his hand from punching a metal pole.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/4/2023
Date Received by DCCECE: 8/7/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , parent custody, DOB: ) was sent to
Dallas County Medical Center for outpatient x-ray. He reported pain and swelling in his
right hand after an incident where he punched a metal pole that supports a walkway
awning. X-ray report indicates an acute non-displaced minimally angulated right small
finger metacarpal neck fracture. He is being referred to his PCP for further treatment.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received facility report 8/7/23 that on 8/4/23 client
was sent to Dallas County Medical Center for outpatient x-ray. He
reported pain and swelling in his right hand after an incident where he punched a metal
pole that supports a walkway awning. X-ray report indicates an acute non-displaced
minimally angulated right small finger metacarpal neck fracture. He is being referred to his
PCP for further treatment. No licensing concerns noted in this incident.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for treatment of a head laceration after he was pushed out of a chair by a peer.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/2/2023
Date Received by DCCECE: 8/3/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: Location Millcreek of Arkansas ? Rock Hill ? PRTF On 08/02/23
, , Parent Custody, DOB ) was sitting down in a chair near the
water cooler when a peer ran up and pushed out of his chair and causing him
to obtain a laceration to the left side of his head. The staff intervened and separated the
patients. The supervisor and nurse were notified. The staff will continue to monitor. The
nursing report indicated pain and the injury was a 2cm laceration to the left side of the
scalp. was sent to the Dallas County Medical Center and received staples to
his head and released back to Millcreek of Arkansas. will follow up with his
PCP. Dallas County Medical has not released the medical report.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received incident report from facility 8/3/23 that on 8/2/23
client was sitting down in a chair near the water cooler when a peer ran up and
pushed out of his chair and causing him to obtain a laceration to the left side
of his head. The staff intervened and separated the patients. The supervisor and nurse were
notified. The staff will continue to monitor. The nursing report indicated pain and the injury
was a 2cm laceration to the left side of the scalp. was sent to the Dallas County
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Medical Center and received staples to his head and released back to Millcreek of Arkansas.
will follow up with his PCP. Dallas County Medical has not released the
medical report. Phone call made to Chris Butler of Millcreek who stated there is no camera
footage of this incident. Visit scheduled for 8/4/23. Facility visited 8/4/23 in response to
facility reported incident that client was pushed by a peer requiring emergency medical
attention, staples to head. No video was available of this incident. was interviewed.
stated that client pushed him out of a chair for no reason and that he had to go to the
hospital and get staples. showed staples on the back of his head. stated that client
picks on him sometimes. stated that it took "about 5 seconds" for staff to make sure he
was ok. When 5 seconds was demonstrated to , he replied "quicker than that...right
away...Mr. Bruce made sure I was ok". stated that he feels safe at Millcreek and feels
comfortable speaking to staff if he feels unsafe. stated he felt that staff do everything they
can to keep him safe. Millcreek Staff Kelly O'Brien, Supervisor over Rock Hill where the
incident occurred consulted. Ms. O'Brien stated that other living units house older, larger
males who could be a threat to . Close Observation of client was discussed. CEO Ben
Beasley stated that client would be placed on Close Observation. It was determined that
client should remain at Rock Hill cottage for optimum safety.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge: Ben Beasley
Record Visit Date: 8/4/2023
Home Visit Date: 8/4/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 8/4/23 in response to facility reported incident that client was pushed by a peer requiring emergency
medical attention, staples to head. No video was available of this incident. was interviewed. stated that client
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

pushed him out of a chair for no reason and that he had to go to the hospital and get staples. showed staples on the back of
his head. stated that client picks on him sometimes. stated that it took "about 5 seconds" for staff to make sure he
was ok. When 5 seconds was demonstrated to , he replied "quicker than that...right away... made sure I was ok".
stated that he feels safe at Millcreek and feels comfortable speaking to staff if he feels unsafe. stated he felt that staff do
everything they can to keep him safe.
Millcreek Staff , Supervisor over Rock Hill where the incident occurred consulted. stated that other
living units house older, larger males who could be a threat to Close Observation of client was discussed. CEO
stated that client would be placed on Close Observation. It was determined that client should remain at Rock
Hill cottage for optimum safety.
Provider Comments:
CCL Staff Signature : Date: 8/23/2023
Provider Signature : Date: 8/23/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for an x-ray due to complaint of pain after punching a peer in the face.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/1/2023
Date Received by DCCECE: 8/2/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: On 07.31.23, , (AR, Parent Custody, DOB: 1 )
was involved with a peer in a recreational game of basketball. He became upset and
punched a peer in the face. Initial nursing report indicated pain and swelling. After visit
with PCP on 08.01.23, he was referred to Dallas County Medical Center for outpatient x-ray.
X-ray report received on 08.02.23 indicated a
. He will follow up with Ortho Arkansas for further treatment.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received incident report from facility that on 8/1/23 client
was involved with a peer in a recreational game of basketball. He became
upset and punched a peer in the face. Initial nursing report indicated pain and swelling.
After visit with PCP on 08.01.23, he was referred to Dallas County Medical Center for
outpatient x-ray. X-ray report received on 08.02.23 indicated a fracture to the 3rd metacarpal
with a slight apex dorsal angulation. He will follow up with Ortho Arkansas for further
treatment.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Dallas County Medical Center for assessment after a physical altercation with a peer.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 7/29/2023
Date Received by DCCECE: Millcreek of Arkansas PRTF
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: was sent to
Dallas County Medical Center ER for assessment following a physical confrontation he
initiated with a peer. He was assessed for concussion and diagnosed with two fractured
teeth. He was released to return to the facility with orders to follow up with a dentist. Dental
appointment is scheduled for Wednesday, August 2nd. returned to a different
living unit, in order to separate him from the peers involved in the confrontation.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received incident report 7/31/23 that on 7/29/23 client
was sent to Dallas County Medical Center ER for assessment
following a physical confrontation he initiated with a peer. He was assessed for concussion
and diagnosed with two fractured teeth. He was released to return to the facility with orders
to follow up with a dentist. Dental appointment is scheduled for Wednesday, August 2nd.
returned to a different living unit, in order to separate him from the peers involved
in the confrontation. Per phone call 7/31/23 with Chris Butler of Millcreek this incident
occurred at Magnolia Hall where there is no video footage. Facility visited 8/2/23 in
response to 7/29/23 incident in which client was in an altercation with peer
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

resulting in being sent to Emergency Room. Nursing note reviewed. Safety plan client
was moved to Tiger Hall from Magnolia Hall where incident took place and
resides, upon return from ER visit. Client was at the dental appointment during today's
visit. Client interviewed. stated that he and had been bickering earlier in the
day. Client stated that client "hit me from behind so I hit him back". Client
stated that the altercation took "about 15 seconds". When asked if he, felt that staff
broke the fight up as soon as possible "no". When asked what staff were present during the
altercation " ... ". When asked if he ( could think of any reason
staff did not immediately intervene, indicated that he felt staff let him retaliate for being
attacked by ( ) was not present during today's visit.
( ) was present and was interviewed. interviewed who
stated that he was, for the most part, continuously attempting to intervene between and
bickering for the earlier part of the day. stated that he believed the
altercation to be over when client hit from behind. stated he was right
there and did his best, using the least amount of force he could whilst attempting to
separate the clients and deescalate clients around him. Without video of incident, licensing
cannot determine for certain if there was a supervision issue or not as of 8/2/23. Follow up
visit conducted 8/9/23. interviewed. stated that "called me names so I hit
him". stated that it took "3 minutes" for the fight to be broken up. stated that it
took "1 minute, 30 seconds" for staff to attempt to intervene during this altercation. When
asked if staff were aware the fight was happening during the 1 minute, 30 seconds,
replied "I don't know". When asked if he ( could think of any reason staff would not
intervene right away "maybe they were on the radio or something". When asked if
liked his new cottage assignment "no... can I go back...me and aren't friends, but we
shook hands afterwards". When asked what did not like about his new cottage "staff
are always nitpicking". was explained by Chris Butler of Millcreek that he would need
to remain in his current cottage for his safety. Without video of incident, licensing cannot
determine for certain if there was a supervision issue or not as of 8/9/23.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/2/2023
Home Visit Date: 8/2/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Facility visited 8/2/23 in response to 7/29/23 incident in which client was in an altercation with peer resulting in
being sent to Emergency Room. Nursing note reviewed. Safety plan client was moved to Tiger Hall from Magnolia Hall
where incident took place and resides, upon return from ER visit.
Client was at the dental appointment during today's visit. Client interviewed. stated that he and had been
bickering earlier in the day. Client stated that client "hit me from behind so I hit him back". Client stated that the
altercation took "about 15 seconds". When asked if he, , felt that staff broke the fight up as soon as possible "no". When
asked what staff were present during the altercation " ". When asked if he ( ) could think of any
reason staff did not immediately intervene, indicated that he felt staff let him retaliate for being attacked by .
was not present during today's visit. was present and was
interviewed. interviewed who stated that he was, for the most part, continuously attempting to intervene between
and bickering for the earlier part of the day. stated that he believed the altercation to be over when
client hit from behind. stated he was right there and did his best, using the least amount of force he
could whilst attempting to separate the clients and deescalate clients around him.
Without video of incident, licensing cannot make a finding at this time.
Provider Comments:
CCL Staff Signature : Date: 8/22/2023
Provider Signature : Date: 8/22/2023
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: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/2/2023
Home Visit Date: 8/2/2023
Purpose of Visit: Revisit Complaint
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Follow up visit conducted 8/2/23 of Magnolia Hall to verify client sleeping area. bedroom is Room
2 of Magnolia Hall. Three beds present, with only one furnished. Room appears as though one client occupies
it.
Provider Comments:
CCL Staff Signature : Date: 8/22/2023
Provider Signature : Date: 8/22/2023
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: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 8/9/2023
Home Visit Date: 8/9/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Follow up visit conducted 8/9/23 in response to facility report that client received emergency medical care following an
altercation with a peer. interviewed. stated that "called me names so I hit him". stated that it took "3
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

minutes" for the fight to be broken up. stated that it took "1 minute, 30 seconds" for staff to attempt to intervene during
this altercation. When asked if staff were aware the fight was happening during the 1 minute, 30 seconds, replied "I don't
know". When asked if he could think of any reason staff would not intervene right away "maybe they were on the radio
or something". When asked if liked his new cottage assignment "no... can I go back...me and aren't friends, but we
shook hands afterwards". When asked what did not like about his new cottage "staff are always nitpicking". was
explained by of Millcreek that he would need to remain in his current cottage for his safety.
Without video of incident, licensing cannot determine for certain if there was a supervision issue or not as of 8/9/23.
Provider Comments:
CCL Staff Signature : Date: 8/23/2023
Provider Signature : Date: 8/23/2023
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Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Dallas County Medical Center for treatment of a head laceration after colliding with a peer while on a water slide.

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: 7/28/2023
Date Received by DCCECE: 7/31/2023
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Licensing
Report Description: , DHHR Custody, DOB: ) was
sent to the Dallas County Medical Center ER following a recreation injury. He sustained a
laceration to the head from a collision with another patient while sliding on a water slide.
The ER doctor closed the laceration with surgical staples. He was released to return to the
facility. Follow up with PCP will occur.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing received report 7/31/23 that on 7/28/23 client
was sent to the Dallas County Medical Center ER following a recreation
injury. He sustained a laceration to the head from a collision with another patient while
sliding on a water slide. The ER doctor closed the laceration with surgical staples. He was
released to return to the facility. Follow up with PCP will occur.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported he sustained a bruise when a staff member grabbed his arm while trying to separate him and a peer who were engaged in a physical altercation. The facility received technical assistance for 905.9 and 110.10 as a result of the incident.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
R
Notice of Serious Incident
Date of Incident: 7/26/2023
Date Received by DCCECE: Millcreek of Arkansas PRTF
Facility Name: Millcreek of Arkansas PRTF
Facility Number: 233
Incident Type: Dual
Report Description: Mandated Reporter Portal: Patient reported a fading
bruise. When questioned on the origin of the bruise, he stated, " did it."
explained that last week (unable to give an exact date/time), he and a peer engaged in a
physical confrontation. picked up a chair to throw at the peer. Staff member
got the chair away from and stepped in between the two patients, grabbing
them on the upper part of the arm. continued to explain that the incident was over
once separated them. Nursing report indicates that has a brownish-green
bruising on his left bicep. The allegation was ACCEPTED for investigation by
Referral ID: Staff member was immediately placed on
administrative leave, pending the results of the investigation.
Interim Action Narrative: Staff member was immediately placed on
administrative leave, pending the results of the investigation.
Maltreatment Narrative: Patient reported a fading bruise. When
questioned on the origin of the bruise, he stated, " did it." explained that
last week (unable to give an exact date/time), he and a peer engaged in a physical
confrontation. picked up a chair to throw at the peer. Staff member
got the chair away from and stepped in between the two patients, grabbing them on
the upper part of the arm.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: 7/27/2023- Program Coordinator determined that no investigator with
has been assigned to this case yet. Licensing is unable to obtain permission
to contact the agency at this time. 7/27/23-Phone call made to Chris Butler of Millcreek
who stated there was no video of the incident. 7/27/23-Phone call made to Investigator
Tonyetta Flint who gave permission for licensing to interview A/V. Ms. Flint scheduled a
visit with licensing at Millcreek for 9AM 7/28/23. Facility visited 7/28/23 in response to
complaint that staff grabbed client arm causing a bruise. Licensing
attended interview with Investigator Tonyetta Flint and A/V reported that the
incident happened in the dayroom where he lives. reported that he and another client,
were fighting when " " broke them up. added that did not grab
but grabbed him ( and "dragged me to where I threw some keys". A green/brown
discolored bruise was noticed on both of arms during today's visit. indicated that
he got the bruise on his right arm from a peer and that he got the bruise on his left arm from
" ". stated that he does not remember saying anything when he
grabbed him. stated that he grabbed him hard to where it hurt adding "he was doing
pressure points". interviewed "he ( threw a shoe at me, so I hit him in his face".
reported that " " separated him and reported "he pulled me off" of
When asked, reported that when pulled him off of it did not hurt.
reported that he does not remember anything other than being pulled off of Witness
statements from staff ( ) and client reviewed. Neither indicated
unprofessional behavior on the part of staff. Licensing is not prepared to make a finding at
this time, 7/28/23. 7/31/23. T/A for licensing regulation 905.9: Physical restraints shall be
performed using minimal force and time necessary. Physical restraint means the application
of physical force without the use of any device for the purposes of restraining the free
movement of a resident's body. Briefly holding a child without undue force in order to calm
or comfort or holding a hand to safely escort a child from one area to another, is not
considered a physical restraint. Client reported receiving bruise on his left arm from
being grabbed by staff ( ). Staff will be retrained on
the use of minimal force during restraint holds prior to returning to work with any residents.
8/31/23-Maltreatmnt Report closed as unsubstantiated. 8/31/23: Maltreatment Report for
Case#015254 closed as unsubstantiated. Staff suspended 7/26/23 immediately
following incident. Received email 9/1/23 from Chris Butler of Millcreek that staff
is still employed at Millcreek and received "Restraint Training (breaking up fights with
minimal force)" 8/10/23 and was returned to work 8/10/23. This was not approved by
Licensing. Facility visited 9/5/23 and finding 521 issued. Chris Butler of Millcreek
reminded of Licensing Regulation 110.10: If a complaint of child maltreatment is filed
against any owner, operator, employee, foster parent, volunteer, or other person in a child
welfare agency, the agency administration shall evaluate the risk to children and determine
the suitability of the person(s) to supervise, be left alone with children, have disciplinary
control over children, or remain in the child welfare agency until the allegations are
determined to be true or unsubstantiated. Any interim action measures shall be approved by
the Licensing Unit. T/A noted for regulation 110.10.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 7/28/2023
Home Visit Date: 7/28/2023
Purpose of Visit: Complaint Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Facility visited 7/28/23 in response to complaint that staff grabbed client arm causing a
bruise. Licensing attended interview with Investigator and A/V . reported that the
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Serving more than one million Arkansans each year Page 1 of 2

incident happened in the dayroom where he lives. reported that he and another client, , were fighting
when " " broke them up. added that did not grab , but grabbed him and
"dragged me to where I threw some keys". A green/brown discolored bruise was noticed on both of arms
during today's visit. indicated that he got the bruise on his right arm from a peer and that he got the bruise
on his left arm from " ". stated that he does not remember saying anything when he
grabbed him. stated that he grabbed him hard to where it hurt adding "he was doing pressure points".
interviewed "he threw a shoe at me, so I hit him in his face". reported that separated him
and . reported "he pulled me off" of . When asked, reported that when pulled him off
of , it did not hurt. reported that he does not remember anything other than being pulled off of .
Witness statements from staff and client reviewed. Neither indicated
unprofessional behavior on the part of staff.
Licensing is not prepared to make a finding at this time, 7/28/23.
Provider Comments:
CCL Staff Signature : Date: 8/22/2023
Provider Signature : Date: 8/22/2023
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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: Millcreek of Arkansas PRTF
Facility Number: 233
Licensee Address: 1828 INDUSTRIAL DRIVE
FORDYCE AR 71742
Licensing Specialist: Clayton DeBoer
Person In Charge:
Record Visit Date: 7/31/2023
Home Visit Date: 7/31/2023
Purpose of Visit: Revisit Complaint
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 9. 905. 9
Regulation Description: Physical restraints shall be performed using minimal force and time necessary. Physical
restraint means the application of physical force without the use of any device, for the purposes of restraining the
free movement of a resident's body. Briefly holding a child without undue force in order to calm or comfort, or
holding a hand to safely escort a child from one area to another, is not considered a physical restraint.
Findings Description: Client reported that staff bruised his arm during a restraint.
Action Due Date: 8/31/2023
Action Due Description: Staff will complete retraining on minimal force during restraint holds prior
to returning to work with any residents.
Comply Date:
Sub Regulation Description:
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Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
7/31/23. T/A for licensing regulation 905.9: Physical restraints shall be performed using minimal force and
time necessary. Physical restraint means the application of physical force without the use of any device for the
purposes of restraining the free movement of a resident's body. Briefly holding a child without undue force in
order to calm or comfort or holding a hand to safely escort a child from one area to another, is not considered
a physical restraint.
Client reported receiving bruise on his left arm from being grabbed by staff
Staff will be retrained on the use of minimal force during restraint holds prior to returning to
work with any residents.
Provider Comments:
CCL Staff Signature : Date: 8/22/2023
Provider Signature : Date: 8/22/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2