summary: A resident was sent to Forrest City Medical Center for evaluation of right knuckle swelling after punching a chair.

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: 8/24/2023
Date Received by DCCECE: 8/25/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: DOB: Date of Incident: 8/24/23 Nurse was
notified to come and check on resident who had punched the chair with his hand after
feeling overwhelmed. Upon assessment the right knuckle was slightly swollen and
reddened. Action taken: APRN notified and an order was obtained to send resident to
FCMC for further evaluation and treatment. Results: Right hand contusion, PRN Ibuprofen
ordered for pain. Proper notifications were made. Guardianship: Faith Guide, AR DHS
Interim Action Narrative: Resident was assessed by the nurse, APRN notified, and resident
ordered to FCMC for further evaluation/treatment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


state: AR

facility_name: Perimeter Behavioral of Forrest City

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

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: 8/24/2023
Date Received by DCCECE: 8/25/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: DOB: Date of Incident: 08/24/23 Resident
presented to nurses' station complaining of swallowing a lego and complaining of pain on
the left side of his chest. Upon assessment B/P 110/74, Oxygen level 97%, Heart Rate 74,
Respiration 20. APRN notified and an order was obtained to send client to FCMC for
further evaluation and treatment. Results: Foreign Body (leg0) of alimentary tract, part
unspecified, follow-up as needed. Proper notifications were made. Guardianship: Kassie
Sauer, TX DFPS
Interim Action Narrative: Resident was assessed by the nurse, APRN notified, and resident
ordered to FCMC for further evaluation/treatment.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist inquired if resident was placed on any precautions. Licensing
Specialist informed that resident reported was trying to break the pieces apart and
accidently swallowed one.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was sent to Forrest City Medical Center for an x-ray of his face after a physical altercation with a peer.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/22/2023
Date Received by DCCECE: 8/23/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident 08/22/23 @ 12:52 PM
Resident was in a physical altercation with a peer. Per staff, resident was hit multiple times
on the left side of his face. APRN notified and an order was obtained to send client to
FCMC for X-ray of Face. No acute facial fracture or dislocation. The visualized paranasal
sinuses are clear. No air fluid levels are present. The mandible and temporomandibular
joints are intact. Proper notifications were made. Guardianship: Kimberlic Malatek, TX DPS
Interim Action Narrative: Resident was assessed by nursing and sent to FCMC for further
evaluation. Residents were placed on assaultive precautions and peer restriction.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire about camera footage and ratio. Licensing
Specialist reviewed camera footage.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for assessment after complaining of pain after fainting in the dining room.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/20/2023
Date Received by DCCECE: 8/21/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 8/20/23-
17:20 Resident fainted in the dining room during dinner time as observed by staff and was
taken to the nurse?s station. There was not as visible observation why fainted
when resident came to, he was not able to identify why he fainted either. did
complain of pain in his right knee from the fall when he fainted. Corrective Actions Taken:
Resident was assessed and checked by nurse. The nurse consulted with APRN who
recommended that be sent to Forrest City Medical Center for assessment and for
X-Ray of his knee. The diagnosis at Forrest City Medical Center was syncope and collapse,
contusion of right knee. The physician ordered a follow up appt for further diagnostic work
up and recheck and monitoring of today?s complaints with continuance of care. Additional
Information: None currently. Guardian Notified: Grandmother
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
8/22/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Specialist inquired about follow-up appointment for further diagnostic work up.
Resident is scheduled to follow-up with the APRN at the end of the week.


summary: A resident was sent to Forrest City Medical Center for evaluation due to nausea and vomiting.

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: 8/20/2023
Date Received by DCCECE: 8/21/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 8/20/23-
10:30 Resident was sent out to Forrest City Medical Center for nausea and vomiting.
Corrective Actions Taken: Resident was assessed and checked by nurse. The nurse
consulted with APRN who recommended that be sent to Forrest City Medical
Center for assessment. The diagnosis at Forrest City Medical Center was nausea with
vomiting unspecified, fever unspecified, noninfective gastroenteritis and colitis unspecified.
Resident was not able to identify with nurse or hospital staff the cause of nausea and
vomiting either. Additional Information: None currently. Guardian Notified: Nicole
Netherton, DCFS worker
Interim Action Narrative: Resident was assessed by the nurse and the APRN referred
resident to APRN for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/20/2023
Date Received by DCCECE: 8/21/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 8/20/23-09:00
Resident continued to complain of elbow pain previously reported on 8-18-23 but resident
was not able to go because he was elopement precautions for his verbalization of planning
to elopement when he was sent out for ?his elbow.? Corrective Actions Taken: Resident was
assessed and checked by nurse. Resident was offered Ibuprofen for pain which he refused to
take. The nurse consulted with APRN who recommended that be sent to Forrest City
Medical Center for assessment and for X-Ray of his elbow. The diagnosis at Forrest City
Medical Center was a 1.5 mm calcification at the anterior tip of the coronoid process of the
ulna is probably tiny developmental unfused apophysis, less likely would be an avulsion
injury, correlate history of trauma. No significant bony arthritic deformities. No lytic
lesions. However, there is evidence of a small elbow joint effusion. Prominent soft tissue
edema at the posterior and medical elbow, which could be due to trauma or cellulitis. No
soft tissue emphysema. No radiopaque foreign bodies are seen in the soft tissues. Resident
sent back to the facility with orders of ibuprofen 3x daily and to see an orthopedic specialist
by appointment. Resident placed on activity restriction until further notice by APRN or
Nurse per medical assessment. Additional Information: None currently. Guardian Notified:
Madison Lee Case Manager DHS
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
8/22/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about resident's orthopedic specialist appointment.
8/24/2023, Licensing Specialist informed that due to resident having out of state insurance
the process could take one to two weeks.


summary: Officers were dispatched in response to a resident running away from the facility.

raw_content:
CES - Command Log Printed on August 25, 2023
eT AUS 9 CUES

CFS # CFS2334943
Call Taker VICTORIA MCCLINTOCK
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)

Location Details
Primary Incident Code RUNAWAY : Runaway

Mod Report Needed
Priority 1
Use Caution No
Primary Disposition —_ Handled By Officer / Deputy
Beat
Zone Forrest City Police Department
Call Time 08/20/23 12:48:36
Completed Time 08/20/23 13:11:09
Reporters |
Unknown (Initial Reporter)
Sex
DOB
Address

Report Time 08/20/23 12:48:36
How Reported

From Phone

Contact Phone (870) 816-5168
Comments

Other Names

Vehicles
Responders
531” 531-VOUDREN, SEAN —_-FCPD (Primary)
532 (Primary) 532 - POWERS, JAKE FCPD (Primary)
535 FCPD (Primary)

_ Response Times

Assigned 08/20/23 12:49:34 *
Enroute 08/20/23 12:49:34
Arrived 08/20/23 12:53:24
Leaving

Arrived At

Completed 08/20/23 13:11:09

-IR/ External Agency Numbers
So  — ae _ . RS cemereeeereenereeeerermennmennmenecmmennsisitcutie

| Officer Addenda

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown
08/20/23 12:48:36 | MCCLINTOCK, VICTORIA | New CFS

Page 1 of 2

08/20/23 12:49:34 | MCCLINTOCK, VICTORIA | 532 | Enroute

08/20/23 12:50:07 | MCCLINTOCK, VICTORIA | A JUVENILE HAS LEFT THE BUILDING LAST SEEN ON KITTLE
UNKNOWN DIRECTION OF TRAVEL

08/20/25 12:53:24 | GRAVES, ANN | 531 | On Scene

08/20/23 12:54:45 | GRAVES, ANN | 532, 535 | On Scene

08/20/23 12:54:54 | GRAVES, ANN | 532 ADV HE IS GOING TO BE OUT WITH THE JUVENILE

08/20/23 12:57:32 | MCCLINTOCK, VICTORIA | BLACK MALE WEARING A WHITE T-SHIRT AND BLUE JOGGING
PANTS.

08/20/23 12:58:32 | MCCLINTOCK, VICTORIA | GIVEN THE JUVENILE A RIDE BACK TO THE FACILITY
BEGINNING MILEAGE 28769 @12:57P AND ENDING MILEAGE IS 28769 @12:58PM

08/20/23 12:59:04 | MCCLINTOCK, VICTORIA | 531 | Clear Alarms

08/20/23 13:01:15 | MCCLINTOCK, VICTORIA | 532 | Clear Alarms

08/20/23 13:01:17 | MCCLINTOCK, VICTORIA | 535 | Clear Alarms

08/20/23 13:11:05 | MCCLINTOCK, VICTORIA | JUVENILE HAS BEEN RETURNED

08/20/23 13:11:09 | MCCLINTOCK, VICTORIA | 531, 532, 535 | Complete

CLQ
Requested At
Sent To
Status
Received At

Location '
Accuracy

so

Page 2 of 2

doc_type: Police Report


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

raw_content:
CFS - Command Log Printed on August 25, 2023

CFS # CFS2334674
Call Taker VICTORIA MCCLINTOCK
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)

Location Details
Primary Incident Code HARTHREAT : Harassment/Threats

Mod Report Needed
Priority 1
Use Caution No
Primary Disposition Handled By Officer / Deputy
Beat
Zone Forrest City Police Department
Call Time 08/18/23 17:42:47
Completed Time 08/18/23 18:04:16
Reporters
LISA (Initial Reporter)
Sex
DOB
Address

Report Time 08/18/23 17:42:47
How Reported

From Phone

Contact Phone (870) 630-4589
Comments

Other Names

Vehicles

_ Responders

522 ~522- HALLMARK, FCPD (Primary)
BRIANNA

534 (Primary) 534 -PEOPLES, MASON _ FCPD (Primary)

Response Times
Assigned 08/18/23 17:45:03 *
Enroute 08/18/23 17:45:03
Arrived 08/18/23 17:52:40
Leaving
Arrived At
Completed 08/18/23 18:04:16

IR / External Agency Numbers
na seen . oe una neene nner

Officer Addenda

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown
08/18/23 17:42:47 | MCCLINTOCK, VICTORIA | New CFS /

Page 1 of 2

08/18/23 17:45:03 | MCCLINTOCK, VICTORIA | 534 | Enroute

08/18/23 17:46:10 | MCCLINTOCK, VICTORIA | CALLER ADVISED THAT ONE OF THE LITTLE BOYS HAS
THREATEN TO SHANK HER AND HE HAD THREE SHANKS

08/18/23 17:52:40 | MCCLINTOCK, VICTORIA | 522 | On Scene

08/18/23 17:53:06 | MCCLINTOCK, VICTORIA | 534 | Off Duty

08/18/23 17:53:18 | MCCLINTOCK, VICTORIA | 522 | Enroute

08/18/23 17:56:36 | GRAVES, ANN | 522 | On Scene

08/18/23 17:57:55 | GRAVES, ANN | 522 | Check Status (Time (minutes): 15)

08/18/23 18:04:08 | MCCLINTOCK, VICTORIA | 522 ADVISED THAT SHE IS CHECKING BACK IN AND NEGATIVE
CONTACT IF THE CALLER CALLS BACK THEN RECALL HER AGAIM

08/18/23 18:04:11 | MCCLINTOCK, VICTORIA | AGAIN

08/18/23 18:04:16 | MCCLINTOCK, VICTORIA | 522 | Complete

Requested At
Sent To

Status
Received At
Location ‘
Accuracy

Page 2 of 2


summary: A resident was sent to Forrest City Medical Center for an x-ray after twisting his ankle 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: 8/16/2023
Date Received by DCCECE: 8/21/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 8-15unknown
reported on 8-16-23-23 Resident came the nurses station reporting that he twisted his ankle
on 8-15-23 while playing basketball in the gym. When asked why he didn?t come on 8-15-23
for assistance he stated that it didn?t hurt that bad and he didn?t want to go on activity
restrictions. Resident had pain and swelling that was observed by the Nurse. Corrective
Actions Taken: Resident was assessed and checked by nurse. The nurse consulted with
APRN who recommended that be sent to Forrest City Medical Center for X-Ray and
assessment. Forrest City Medical Center completed an X-Ray and assessment. No
significant findings were noted and were sent back to the facility. Nurses gave Tylenol for
pain and offered an ice pack. Additional Information: None currently. Guardian Notified:
Mother
Interim Action Narrative: Resident was assessed by the nurse and consulted with APRN.
Resident was referred to FCMC for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
Licensing Specialist informed that provider reported incident was late due to computer
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

issues. 8/21/2023, Licensing Specialist reviewed provider reported incident for licensing
concerns.


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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/16/2023
Home Visit Date: 8/16/2023
Purpose of Visit: Subsequent Building and Grounds
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 11:00 am to 2:15 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Census: 58
Licensing Specialist completed buildings and grounds and observed the following areas: classroom hall, 100
hall, 200 hall (SRU), 300 hall, 400 hall, dining room, and gym.
Licensing Specialist was escorted by Mr. Clifton Williams, Program Director. Walking into the building,
Licensing Specialist observed parked cars on the lot with no debris and flowers in flowerpots by the door. The
abandoned house across has been cleaned of debris.
Classroom hall: Ms. Twana’s classroom, ratio 3:15. Residents were sitting at desks. Ms. Barnes’ classroom,
ratio 4:15. Residents were sitting at desks. Ms. Walkers’ classroom was empty, residents were at lunch. Mr.
Shane’s class was empty, residents were outside. Licensing Specialist observed clients’ rights and values on
the wall near the classroom hall. In the quiet rooms on the classroom hall, Licensing Specialist observed that
the flooring in the quiet rooms have been replaced.
Entering the hallway, Licensing Specialist smelled the aroma of cleaning products on the residential hallways
being cleaned. All bedrooms were organized, and bathrooms were cleaned. Licensing Specialist observed the
dayroom/s on each hall. 100 Hall will be having a celebration on 8/31/2023 for having zero write ups.
Licensing Specialist informed last fire drill was conducted in July 2023.
Residents and staff (ratio 2:11) were observed in the dining room area. Residents were having lunch.
Licensing Specialist observed residents and staff outside, ratio 3:12. Residents were playing basketball and
some were observed talking with staff.
Licensing Specialist reviewed the MAR’s on the residents listed below:
All initialed and up to date.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/16/2023
Home Visit Date: 8/16/2023
Purpose of Visit: Staff Record Review Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 11:00 am to 2:00 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 58
Licensing Specialists reviewed four (4) personnel files:
7/10/2023 Youth Care Worker/Mental Health Technician
2/21/2021 Youth Care Worker/Mental Health Technician
7/10/2023 Youth Care Worker/Mental Health Technician
12/18/2017 Youth Care Worker/Mental Health Technician
Personnel files reviewed complied with the minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/16/2023
Home Visit Date: 8/16/2023
Purpose of Visit: Child Record Review Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 11:00 am to 2:15 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 58
Licensing Specialist reviewed two (2) children files:
All children’s files reviewed complied with the minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2

doc_type: Compliance Report


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

raw_content:
AR KAN S A S&S
DEPARTMENT OF

+4 HUMAN
<a¥ SERVICES

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

Notice of Serious Incident

Date of Incident: 8/14/2023

Date Received by DCCECE: 8/14/2023

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

Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: ee State: FY Date/Time of incident: 8-11-23/07:30
Please give a description of the incident: The resident hit a wall last night and was
monitored by Nurses. During the next day pain and swelling persisted and the resident
could not bend his wrist per his report. Corrective Actions Taken: The resident was assessed
and checked by Nurse and then recommended by APRN to go to FCMC for a medical
examination and X-Ray. The resident was diagnosed with no acute findings after X-Ray and
an examination was performed and sent by to the facility for continued monitoring by
Nurses. Additional Information: None currently. Guardian Notified: Sheila Gale, DCFS
worker

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

Maltreatment Narrative:

Licensing Narrative: Licensing Specialist received provider reported incident via email.
8/15/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about resident hitting the wall. Licensing Specialist informed
that resident hits walls at will unprovoked.

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


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

raw_content:
CFS - Command Lag Printed on August 25, 2023
2 CE I ES SES

CFS # CFS2333790
Call Taker ALLISON LAWS
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)

Location Details
Primary Incident Code DISTURBANCE/DOMESTIC : Domestic Disturbance

Mod
Priority 1
Use Caution No
Primary Disposition Handled By Officer / Deputy
Beat
Zone Forrest City Police Department
Call Time 08/13/23 13:36:24
Completed Time 08/13/23 14:44:03
“Reporters i
JENA WEBSTER (initial pépanan
Sex
DOB
Address

Report Time 08/13/23 13:36:24
How Reported

From Phone

Contact Phone (870) 633-3200
Comments

Other Names

Vehicles

“Responders
541 "541 - TODD, ADRIAN ~FCPD (Primary)
545 (Primary) 545 - ALBERT, TANESHA —_FCPD (Primary)

' Response Times i
Assigned 08/13/23 13:40:26 *
Enroute 08/13/23 13:40:26 *
Arrived 08/13/23 13:40:26
Leaving

Arrived At

Completed 08/13/23 14:44:03

_IR/ External Agency Numbers
| Officer Addenda

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

08/13/23 13:36:24. | LAWS, ALLISON | New CFS

08/13/23 13:39:00 | LAWS, ALLISON | CALLER ADVISED A MALE SUBJECT BY THE NAME OF

AGE 17, PHYSICALLY ASSAULTED A FEMALE EMPLOYEE JASMINE ROGERS AND THEY ARE NEEDING TO
Sn

Page 1 of 2

ADMINISTRATIVE DISCHARGE THE MALE AND ALSO FILE A REPORT
08/12/23 13:40:26 | LAWS, ALLISON | 545 | On Scene

08/13/23 13:41:30 | HOWTON, KILEY | 541 | Enroute

08/13/23 13:45:01 | HOWTON, KILEY | 541 | On Scene

08/13/23 14:44:03 | HOWTON, KILEY | 541, 545 | Complete

-CLQ
Requested At
Sent To
Status
Received At

Location :
Accuracy

Page 2 of 2

CES - Command Loy Printed on August 25, 2023

CFS # CFS2333808
Call Taker ALLISON LAWS
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)

Location Details
Primary Incident Code INFO: Info

Mod Transfer Non Emergency
Priority 4
Use Caution No
Primary Disposition Handled By Officer / Deputy
Beat
Zone Forrest City Police Department
Call Time 08/13/23 17:06:19
Completed Time 08/13/23 17:30:49

Reporters

545 ALBERT (Initial Reporter)
Sex

DOB

Address

Report Time 08/13/23 17:06:19
How Reported

From Phone

Contact Phone

Comments

_ Other Names

Vehicles
Responders
545 (Primary) ~~‘ 545-ALBERT, TANESHA___FCPD (Primary)

' Response Times
Assigned 08/13/23 17:06:22 *

Enroute 08/13/23 17:06:22

Arrived 08/13/23 17:09:10

Leaving

Arrived At

Completed 08/13/23 17:30:49

_IR/ External Agency Numbers
FCPD202308743.—~—*«~*«~t«*é
| Officer Addenda

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

08/13/23 17:06:19 |LAWS, ALLISON|NewCFS stst—s rs
08/13/23 17:06:22 | LAWS, ALLISON | 545 | Enroute

08/13/23 17:06:47 | LAWS, ALLISON | ADVISED SHE IS GOING TO GET MORE INFORMATION

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08/13/23 17:09:10 | LAWS, ALLISON | 545 | On Scene
08/13/23 17:30:49 | MORGAN, SYDNEY | 545 | Available

CLQ

Requested At
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Accuracy

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FORREST CITY Pxe 1 [Incident

POLICE DEPARTMENT incitent¥ 9308130007

FORREST CITY, AR. 72335

Crime / Incident (Primary, Secondary, Tertiary) a Sct) ae | = =

5-13-202 BATTERY 2ND DEGREE | On or Fron} 08/13/2023 | 17:06 | Sun |
Cl [re |osrazoas [| sun

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Location of Incident 1521 ALBERT, FORREST CITY, AR
Cross Street PERIMETER
"Vv" = Victim "RP" = Reporting Party "W" = Witness "S" = Suspect
Last, First, Middle (Firm if Business)

RODGERS, JAZZALYN NICOLE

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| sex | Ace | HT | Wr [Hair] Eyes _| Home Phone

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City, State, Zip Code Local ID # Cell Phone

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City, State, Zip Code —— Local ID # State # FBI | | Phone

Synopsis

Continuation PropertyList
Attached | Attached Property Damage $ $0.00
Press Domestic Violence
ver 04D
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Pursuit [| Child Abuse [|

Solvability fy Pang ST FRA Disposition OR

Points

Connecting Case #

CADICFS Event # 2308130007

<H-r-o>r<cron

Report Complete/Ready for Review

Assigned To Date

Reviewed By Approved Date
Officer ID KINNEY, CODY Sgt. Adrian Todd 08/16/2023

Z22222222222

Printed By/On: 412 / 08/25/2023 10:51:33
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page 2 Incident conta
POLICE DEPARTMENT incident # 2308130007
Crime / Incident (Primary) Attempt] Type
[sien sarrenvawoecees |
Item # Tag # Article Brand Serial No. (or Drug Type)
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0

Description in Stolen Value , LC] Evidence Value
PHOTO OF INJURY |] Recovered Value [_] Safekeeping Value 0

Owner Owner Address

FORREST CITY AR 72335
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Serial No. (or Drug Type)
Description

in Stolen Value C] Evidence Value
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Location D d= Val
7 Reviewed By : Approved: | Date:
Officer ID: KINNEY, CODY 561 Sgt. Adrian Todd 08/16/2023

Printed By/On: 412 / 08/25/2023 10:51:34
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page = 3 Incident cont'd
POLICE DEPARTMENT

225 N. ROSSER ST

FORREST CITY, AR. 72335 Property Photos Incident # 2308130007

Date : 08/13/2023
Item # : onl
Tag #
Article : PHOTO

Brand

Model

Date : 08/13/2023
Item # : ol
Tag #

Article : PHOTO

CCOLL_000514
2023/08/1313:27:50 Brand

Model

Date
Item #
Tag #
Article
Brand

Model

Printed By/On: 412 / 08/25/2023 10:51:37
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT

FORREST CITY Page Incident cont'd
POLICE DEPARTMENT Narrative
ame tines amen 43-202 BATTERY 2ND DEGREE

On 08/13/2023 dispatch received a call for a physical disturbance at 1521 Albert
involving a female healthcare working and a male residence of the facility.

Officers were dispatched to the scene upon their arrival they were notified that
the female healthcare worker had already left the scene to receive medical care.

I Officer Kinney went to the Forrest City medical center to speak with the
female later identified as Jazzalyn Rodgers. Rodgers stated that residence of
the facility were playing competative basketball which they are not allowed to
do, Rodgers and another female employee told the residents to stop and to line
up. Rodgers then stated that one of the male identified as MM became
irrate and began cussing Rodgers and the other employee. Rodger then stated that
the other female employee was standing between her and a, «EN ten charged
the other female pushing her into Rodgers causing both females to fall into a
bench.

Rodgers stated that when she was trying to get up from the ground J the
struck her in the nose with his fist.

Rodgers received two small laserations and slight swelling of the nose and right
eye, Rodgers stated that her glasses were broken during the incident.

Rodgers was informed of the affidavit process and stated that she did want to
press charges on]. Rodgers then came to the Forrest City police department
and gave a written statement and filed an affidavit.

Reviewed By Approved Date
OficerID KINNEY, CODY 561 Sgt. Adrian Todd YES 08/16/2023
Printed By/On: 412 / 08/25/2023 10:51:37
CrimeStar® Law Enforcement Records Management System
Licensed to: FORREST CITY AR POLICE DEPARTMENT


summary: A resident was transported to JDC by Forrest City Police for assaulting a staff member who redirected him.

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: 8/13/2023
Date Received by DCCECE: 8/14/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: X Police was called to the facility Residents Name/DOB:
State: Date/Time of incident: 8-13/13:15 & 8-14/12:27 Please give a
description of the incident: Resident assaulted staff who redirected him
causing injury and her nose to bleed. Corrective Actions Taken: was detained by
the Forrest City Police on 8-14-23 with the plan to transport and process him to a Juvenile
Detention Locked Facility in Yell County Arkansas. Youth was detained after
assaulted a female staff on 8-13-23 hitting her in her face and breaking her glasses and
fracturing her nose/face. He also came onto the 400 hallway threatening to fight a male staff
and began threatening any staff with bodily harm that attempted to process with him,
picked up a box fan on 400 hall threw it, and broke it then came to 300 hall and picked up a
box fan threw it and broke it, took staffs clipboard threw it and broke it, picked up staffs cup
and threw it and then he picked up staffs chair threw it breaking a light fixture. The police
were called, and was released back to Perimeter after he was handcuffed.
was placed on Unit Precautions and Assault Precautions until Arkansas Detention services
was able to find placement in a Juvenile detention facility on 8-14-23. As of this morning
continued to make threats to harm staff and hurt them. A 24-hour emergency
discharge is being requested because unfortunately will not be allowed back to the
facility due not only to hitting staff but also fracturing her nose. After several therapeutic
interventions including medication changes (see attached), several interventions and
strategies of Therapist and the Treatment Team continues violent and assaultive
behaviors. (Additional information) After staff redirected him, he threw a basketball at her
and proceeded to assault her. ?s verbal threats of harm to staff have been frequent
and escalated over the past few weeks. Treatment Team at Perimeter discussed on 8-11-23
going to acute, but he did not meet criteria. Another request from the Clinical
Director on 8-13-23 was sent out again to assess for acute after the adverse incident
and was denied admission to acute care. has hit staff before (please see
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

attached) and was not detained to attempt to treat his explosive and violent outbursts.
frequently threatened harm to staff as well (see attached. (Also see pictures
attached of assault by to staff on 8-13-23). Call was made to on 8-14-
23 the Report ID# A report was called in to Arkansas as well the results and
number of that report are TBD the report was done by Alyssa to 1-800-482-5964. Staff who
was assaulted also made a police report, and the number is . Additional
Information: None currently. Guardian Notified: Micheal Cervantes Texas DFPS
Interim Action Narrative: Resident was placed on unit and assault precautions. FCPD were
called and resident was detained. Call to TX made and call accepted. AR
was called.
Maltreatment Narrative:
Licensing Narrative: 8/14/2023, Licensing Specialist received complaint via email.
8/15/2023, Licensing Specialist reviewed complaint for licensing concerns. Licensing
Specialist inquired about resident's DOB and camera footage. 8/16/2023, Licensing
Specialist observed pictures of the staff member's injuries. There is no camera footage of
this incident. Licensing Specialist informed that resident was still detained. During the
buildings and grounds, Licensing Specialist observed where the light fixtures have been
repaired on the 300 Hall near the nurse's station that resident damaged. 8/18/2023,
Licensing Specialist will inquire if incident was accepted by AR 8/21/2023,
Licensing Specialist informed call was screened out by AR Licensing Specialist
followed-up with facility to see if any allegations were made against staff. Licensing
Specialist informed that resident did not make any allegations toward staff. Resident was
angry because a female staff member redirected from playing rough and gave him the
option of changing the game or ending the gym time. 8/22/2023- Program Coordinator
completed a FOIA request for the police report to the Forrest City Police Department.


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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 8/8/2023
Date Received by DCCECE: 8/9/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Type of Incident: Serious injury requiring outside medical attention
Residents Name/DOB: State: Date/Time of incident:
8-8-23/10:05 Name of Facility: Perimeter Behavioral of Forrest City Phone Number: 870-
633-3200 Street Address, City, State, Zip: 1521 Albert St, Forrest City, AR 72335 The resident
reported to the nurse that he had stomach pain and discomfort origin of the pain not known
and the resident said he did not know why he waited so long to ask for help. The resident
reported to the nurse that his stomach has been hurting for the past four days. Corrective
Actions Taken: The resident was assessed and checked by the nurse, after consultation with
the staff APRN, the resident was taken to Forrest City Medical Center for examination. The
resident was diagnosed with . The resident was prescribed for
the next 7 days and for the next 3 days. The resident returned
back to the facility for continued monitoring by nurses. Additional Information: None
currently. Guardian Notified: Mother
Interim Action Narrative: Resident assessed by nurse. APRN referred resident to FCMC for
further evaluation.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
8/10/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of hand pain from recent property destruction and an 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: 8/8/2023
Date Received by DCCECE: 8/9/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Type if incident x Serious injury requiring outside medical attention
Residents Name/DOB: State: Date/Time of incident: 8-8-
23/10:20 Please give a description of the incident: The resident reported to the nurse that he
had hand pain and swelling to his right hand. The resident was examined by Staff APRN.
Resident rated pain a 7 out of 10. This pain and swelling has most likely come from frequent
past incidents of property destruction and physical altercation where the resident has been
advised by staff not to use or further injure his hand. Corrective Actions Taken: The resident
was assessed and checked by APRN who recommended going to FCMC for a medical
examination and X-Ray. The resident was diagnosed with a Hand Contusion and was given
Ibuprofen and prescribed to take every 8 hours as needed. The resident returned to the
facility for further monitoring by Nurses. Resident continues to be on activity restrictions
until he has able to stop injuring his hand/body and is cleared by Doctor, Nurse, or APRN.
Additional Information: None currently. Guardian Notified: Sheila Gale, DCFS worker
Interim Action Narrative: Resident was assessed by the APRN and referred to FCMC for
further evaluation.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
8/10/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.


summary: Two residents were sent to Forrest City Medical Center for evaluation after a physical altercation.

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: 8/7/2023
Date Received by DCCECE: 8/8/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: s Date/Time of incident: 8-7-23/14:45
Name of Perimeter Staff Making Notification Date Time Name of Person Notified Antoine
T. Jackson LPC Clinical Director 8/8/2023 Signature and title of staff completing this form
Date: Name of Facility: Perimeter Behavioral of Forrest City Phone Number: 870-633-3200
Street Address, City, State, Zip: 1521 Albert St, Forrest City, AR 72335 Please give a
description of the incident: The resident injured foot after attacking a peer in a physical
altercation. Resident complained of pain, swelling and was able to put full weight on his
right foot. Swelling was noted in the foot. Corrective Actions Taken: The resident was
assessed and checked by a nurse, after consultation with the staff APRN, the resident was
taken to Forrest City Medical Center for examination. RICE Therapy with bandage was
given to the resident. When returned to the facility bandage was taken for safety, continued
monitoring, and RICE Therapy. Resident placed on Activities Restriction for safety until
cleared by Doctor and/or APRN. Additional Information: None currently. Guardian
Notified: Shaneka Guidry, CPS Worker
Interim Action Narrative: Resident was assessed by nurse. APRN ordered for resident to go
to FCMC for examination. Resident placed on assaultive precautions.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist was informed of provider reported incident via
email. 8/9/2023, Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist inquired and reviewed camera footage. Licensing Specialist
informed that resident jumped in the physical altercation. Licensing Specialist reviewed
camera footage.

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: 8/7/2023
Date Received by DCCECE: 8/8/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 8-7-23/14:45
Name of Perimeter Staff Making Notification Date Time Name of Person Notified Antoine
T. Jackson LPC Clinical Director 8/8/2023 Signature and title of staff completing this form
Date: Name of Facility: Perimeter Behavioral of Forrest City Phone Number: 870-633-3200
Street Address, City, State, Zip: 1521 Albert St, Forrest City, AR 72335 Please give a
description of the incident: Resident got bitten by a peer during a physical altercation with a
peer. The bite was to the left thumb, the skin was broken, and the wound was bleeding.
Corrective Actions Taken: The resident was assessed and checked by the nurse, the wound
was cleaned, and triple antibiotic ointment with dressing was applied to the thumb. After
consultation with the staff APRN, the resident was taken to Forrest City Medical Center for
examination and X-ray. After examination was given an X-ray there were no broken bones
and antibiotic was given and prescribed to the resident. The resident was sent back to the
facility with wound to be monitored by the nurse. Additional Information: None currently.
Guardian Notified: Kassie Sauer, CPS Worker
Interim Action Narrative: Resident was assessed by the nurse. APRN ordered for resident to
be examined and x-rayed at FCMC. Resident placed on assaultive precautions.
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing Specialist was informed of provider reported incident via
email. 8/9/2023, Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist inquired and reviewed camera footage. Licensing Specialist
reviewed camera footage.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/9/2023
Home Visit Date: 8/10/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 10:30 am to 1:30 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing Specialist spoke with Ms. Charlotte Lockert, CEO, Antione Jackson, Clinical Director, and Clifton
Williams, Program Director, regarding ELS Cases #015431 and 015429. This incident happened on the 300
Hall in the dayroom. Licensing Specialist reviewed camera footage on 8/9/2023 for the provider reported
incident.
Licensing Specialist observed residents playing cards at a table, sitting in chairs around the television, walking
around the room, and horseplaying, ratio 2:12. Resident was observed walking around the room talking to
different residents.
At 14:51, resident was observed pushing his peer. Licensing Specialist observed the two residents begin to
fight. Staff was observed separating the residents. Licensing Specialist observed a peer jump in the
physical altercation. Licensing Specialist observed the peer that got into a physical altercation with resident
being escorted out of the room.
Due to staff members and residents around the physical altercation, Licensing Specialist was unable to see the
resident being bitten and peer hurting his foot. Licensing Specialist did observe peer limping away
from the area of the physical altercation.
Licensing Specialist informed that both resident and peer were placed on assaultive precautions.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was left unattended on his hall while staff and other residents transitioned to the day room then outside. Two staff members were terminated as a result of this incident. The facility was cited 907.2 for supervision issues.

raw_content:
Maltreatment Narrative: Staff left a resident alone on the unit for 45mins-one hour
unattended. The resident has a history of self-harming, but when the resident was found no
injuries were noted.
Licensing Narrative: Licensing Specialist informed of complaint via email. Licensing
Specialist informed facility that camera footage will need to be reviewed. 8/8/2023,
Licensing Specialist reviewed complaint for licensing concerns. Licensing Specialist will
inquire about the ICA for the staff members involved. Licensing Specialist will contact the
investigator for permission to reach out to the facility. Licensing Specialist received
permission to contact the facility. Investigator informed Licensing Specialist that resident
discharged on 8/7/2023. CEO informed Licensing Specialist that staff members were sent
home and instructed to return on 8/8/2023 and will be terminated. Licensing Specialist will
follow-up with facility on 8/9/2023. 8/9/2023, Licensing Specialist reviewed camera footage
and received documentation of terminations. 9/5/2023, Licensing Specialist contacted
investigator for an update. 9/7/2023, Licensing Specialist reached out to investigator for an
update. Licensing Specialist informed that AOs agreed to meet with investigator on
9/8/2023. 9/21/2023, Licensing Specialist contacted investigator for an update. Investigator
McFarland informed Licensing Specialist case found unsubstantiated.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/9/2023
Home Visit Date: 8/10/2023
Purpose of Visit: Complaint 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 members left resident on hall in his bedroom unsupervised.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Regulations Not Correctable:
Narrative:
Time of visit: 10:30 am to 1:30 pm
Census: 57
Licensing received a complaint on 8/4/2023 for ELS Case #015412.
Licensing Specialist reviewed camera footage for reported complaint on 8/9/2023 for ELS Case #015412. The
incident took place on the 100 Hall. Before the incident, residents were in the hallway preparing to go to the
gym.
At 15:46, Licensing Specialist observed resident kick his door open and enter his bedroom while a staff
member was distracted by some residents horseplaying. There were two (2) female staff members on the hall.
However, the other staff member walked pass the other staff member off the hallway and then returned to the
hallway.
At 15:47, Licensing Specialist observed staff members checking and locking the bedrooms. Both staff
members were observed walking by the resident’s bedroom and neither staff member checked or locked his
bedroom. At 15:48, Licensing Specialist observed staff members and residents leave the hall.
At 16:36, Licensing Specialist observed resident’s bedroom cracked. Resident went and stood at the front
entrance door of the hall. At 16:39, a peer saw resident standing in the window of the door. Licensing
Specialist observed the peer talking with a male staff member. The male staff member was observed opening
the door to allow the resident to enter where the other residents were located.
Facility will be cited for R907.2 due to the two female staff members leaving the resident on the hallway
unsupervised.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3


summary: A resident was sent to Forrest City Medical Center for evaluation after presenting with crossed eyes and informing nursing he could not close his eyes.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Arkansas Date/Time of incident: 8-4-23/18:00
Name of Perimeter Staff Making Notification Date Time Name of Person Notified Antoine
T. Jackson LPC Clinical Director 8/7/2023 Signature and title of staff completing this form
Date: Name of Facility: Perimeter Behavioral of Forrest City Phone Number: 870-633-3200
Street Address, City, State, Zip: 1521 Albert St, Forrest City, AR 72335 Please give a
description of the incident: Resident came to the nurse's station with his eyes open and
appeared to be cross stating to the nurse that he could not open his eyes. When nurses
asked him what made his eyes get to the point where he could not open them, he stated that
he did not know but asked to come to the nurses? station when he realized that he could not
close his eyes while staring at the ceiling. was also experiencing anxiety as well that
may have induced his eyes to feel like they were stuck. The skin was noted to be cool and
dry and did not look distressed or broken. Corrective Actions Taken: The resident was
assessed and checked by the nurse for eye discomfort and injury. After consultation with the
staff APRN, the resident was taken to Forrest City Medical Center for examination. After
the medical screening exam at the ER, it was determined that the encounter for screening
was unspecified. The resident returned from ER and was able to respond to eye commands
given by the nurse. Additional Information: None currently. Guardian Notified:
Mother
Interim Action Narrative: Resident was assessed by nursing. APRN ordered for resident to
be taken to FCMC for further evaluation.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of multiple nosebleeds and vomiting.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: x Serious injury requiring outside medical attention Residents
Name/DOB: State: Date/Time of incident: 8-4-
23/20:30 Name of Perimeter Staff Making Notification Date Time Name of Person Notified
Antoine T. Jackson LPC Clinical Director 8/7/2023 Signature and title of staff completing
this form Date: Name of Facility: Perimeter Behavioral of Forrest City Phone Number: 870-
633-3200 Street Address, City, State, Zip: 1521 Albert St, Forrest City, AR 72335 Please give a
description of the incident: Resident came out of the shower with a nosebleed. Within the
next three hours after that nosebleed was brought under control by the nurse, he had three
additional nose bleeds in addition to vomiting. Origin or cause of nose bleeds after medical
assessment is unknown. Corrective Actions Taken: The resident was assessed and checked
by the nurse after the first nosebleed and additional nose bleeds including vomiting. After
consultation with the staff APRN, the resident was taken to Forrest City Medical Center for
examination. The resident was given an X-ray, and general assault edema was diagnosed.
Received oxymetazoline intranasal drops (0.05%) in spray and Norco P) 5/325 1 tablet oral
during visit and assessment at ER. Sent back to Nurses for monitoring if symptoms return
or worsen further diagnostic workup was recommended. The resident did not complain of
pain, swelling, or further complications. Symptoms appeared to reduce and go away after
the ER visit. Additional Information: None currently. Guardian Notified:
Grandmother
Interim Action Narrative: Resident was assessed by nursing and referred to FCMC for
further evaluation and treatment.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident. 8/8/2023,
Licensing Specialist reviewed provider reported incident. Licensing Specialist inquired
about incident due to the resident's diagnosis. 8/9/2023, Licensing Specialist informed that
resident caused trauma to his nose by picking in his nose.


summary: A resident was sent to Forrest City Medical Center for an x-ray due to lower back pain from a recreational activity.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident sent to the FCMC for xray due to lower
back pain from recreational actvity
Interim Action Narrative: Resident referred to FCMC for an x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received provider reported incident via email.
8/4/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about guardianship and more details on reported incident.
8/9/2023, Licensing Specialist informed that upon admission it was disclosed that resident
has back issues that flare up from time to time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for removal of an object he had lodged in his ear.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident was sent to FCMC to get an object that he lodged
in his ear out.
Interim Action Narrative: Resident referred to FCMC to have object removed.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received provider reported incident via email.
8/4/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about guardianship and lodged object. Clinical Director
informed Licensing Specialist that the object was a piece of paper.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after injuring his finger 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: 8/2/2023
Date Received by DCCECE: 8/3/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident injured his right finger from playing
basketball and was sent to FCMC for an exam and Xray.
Interim Action Narrative: Resident referred to FCMC for an x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received provider reported incident via email.
8/4/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about guardianship.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Resident sent to FCMC for xray and exam due to neck
pain from recreational activity
Interim Action Narrative: Resident referred to FCMC for an x-ray.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received provider reported incident via email.
8/4/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist inquired about guardianship and more details on reported incident.
8/9/2023, Licensing Specialist informed that on admission it was disclosed that resident has
a nodule in his neck.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of a swollen area on the left side of his neck and a sore throat.

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: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date and time of Incident: 8/1/23 @ 1800 PM
Resident presented to nurses' station complaining that he found a swollen area on the left
side of his neck and that his throat felt a little sore earlier. Actions Taken: APRN notified,
and an order was obtained to send to FCMC for further evaluation and treatment. Results:
Enlarged Lymph node (lymphadenopathy). Proper notifications were made. Guardianship:
Michael Brewster, CPS,
Interim Action Narrative: Resident was assessed. APRN notified and ordered for resident to
have further evaluation and treatment at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident. 8/2/2023,
Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of left ankle pain, swelling, and bruising from banging his foot on the side of the bed.

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: 7/30/2023
Date Received by DCCECE: 8/1/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident: 7/30/23 @ 0905 AM
Resident presented to nurses' station stating that he woke up this morning (7/30) and his
left ankle was hurting, swollen and bruised. He denied any injuries to his left ankle. Upon
further questioning by the CEO, he reported that he had a dream that he was onfire so he
jumped up and banged his foot on the side of the bed to put out the fire. Actions taken:
APRN notified and an order was obtained to send client to FCMC for z-ray of left ankle.
Results: No acute fracture or dislocation. The ankle mortise is intact. Soft tissues are grossly
unremarkable. Proper notifications were made. Guardianship: , mother
Interim Action Narrative: Resident was assessed and APRN order obtained for resident to
have an x-ray of his left ankle.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was notified of provider reported incident.
8/1/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of pain and bumps in the groin and buttock areas.

raw_content:
ARK ANS A S&S
DEPARTMENT OF

+4 HUMAN
<a\ SERVICES

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

Notice of Serious Incident

Date of Incident: 7/29/2023

Date Received by DCCECE: 8/1/2023

Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142

Incident Type: Licensing
Report Description: ee > 2t</ Time of Incident: 7/29/23 @ 2130 PM

Resident presented to nurses' station complaining of pain and bumps in the groin area and
buttocks. Actions taken: APRN notified and an order was obtained to send client to FCMC

for further evaluation and treatment. Results: ee

days). Proper notifications were made. Guardianship: gg, DHS

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

Maltreatment Narrative:

Licensing Narrative: Licensing Specialist notified of provider reported incident. 8/1/2023,
Licensing Specialist reviewed provider reported incident for licensing concerns.

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


summary: A resident was sent to Forrest City Medical Center for an x-ray after complaining of hand pain from playing in the gym.

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: 8/1/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident: 7/28/23 @ 1330 PM
Per client report, he hurt his hand 2 weeks ago and hurt it again playing in the gym on
7/28/23. Action taken: Nurse Assessment: no bruising, no swelling noted, capillary refill
less than 2 seconds, skin warm and dry to touch, non-tender upon palpation. APRN notified
and order for x-ray at FCMC obtained. Results: No acute fracture or dislocation (normal
right hand). Proper notifications were made. Guardianship: , mother
Interim Action Narrative: Resident was assessed and referred to FCMC for further
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received notification of provider reported
incident. 8/1/2023, Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray after jamming his finger 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: 7/28/2023
Date Received by DCCECE: 8/1/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date and Time of Incident: 7/28/23 @
1330 PM Per client report, he sated he hurt right hand playing basketball 2 weeks ago ( he
has an appointment with Jonesboro Sports Medicine on 8/18/23 for that incident). He
presented on 7/28 and stated he jammed his finger while at the gym playing basketball.
Action taken: Order obtained from APRN for transport to FCMC for x-ray of right hand.
Results: There has been healing of the mid-fourth metacarpal fracture now with mild
intervening callus formation present. Bony alignment is well maintained. There is an old,
healed fracture of the fifth metacarpal. There is no adverse change (healing fourth
metacarpal fracture). Proper notifications were made. Guardianship:
, Grandparents
Interim Action Narrative: Resident was assessed and APRN ordered for resident to FCMC
for further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist notified of provider reported incident. 8/1/2023,
Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after complaining of vomiting and nosebleed.

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: 8/1/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time if Incident: 7/28/23 @ 1915 PM Client
reported to staff he did not feel good and asked if he could go to the restroom. Client came
to nurses' station and reported that he had vomited and had a nosebleed at the same time.
Action Taken: APRN notified, and an order was obtained to send client to FCMC for further
evaluation and treatment. Results: Nausea with vomiting, unspecified. Proper notifications
were made. Guardianship: , Caseworker-Florida
Interim Action Narrative: Resident was assessed. APRN notified and order obtained for
resident to have further evaluation at FCMC.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist notified of provider reported incident via email.
8/1/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for evaluation after he was hit in the forehead 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: 7/28/2023
Date Received by DCCECE: 8/1/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident 7/28/23 Resident was in
n ESI for physical aggression towards staff. While in the ESI, resident was hit in the
forehead by a peer and has a hematoma on the right side of his forehead. Action taken:
Order obtained from APRN for transport to FCMC for evaluation and treatment. Results:
Assault by unspecified means: Contusion of unspecified part of head. Proper notifications
were made. Guardianship: , DHS
Interim Action Narrative: Resident was assessed and referred to FCMC for further
evaluation. Peer was placed on assaultive precautions.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was informed of provider reported incident.
8/1/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist will follow-up with facility regarding camera footage and safety
precautions. Licensing Specialist informed camera footage is available and peer was placed
on assaultive precautions, Licensing Specialist will schedule a day and time to review
camera footage. 8/9/2023, Licensing Specialist reviewed camera footage.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/9/2023
Home Visit Date: 8/10/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 10:30 am to 1:30 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing Specialist spoke with Ms. Charlotte Lockert, CEO, Antione Jackson, Clinical Director, and Clifton
Williams, Program Director, regarding ELS Case #015309.
Licensing Specialist informed before the incident, resident was being disruptive, throwing chairs, and
disrespectful toward staff. It was reported that resident’s peer felt that resident was being disrespectful and
that was a trigger to the peer. In return the resident’s peer hit the resident.
On Station 1 Hall, Licensing Specialist observed resident in a restraint against the wall, ratio 1:1. Licensing
Specialist observed four (4) and then five (5) staff members on Station 1. Licensing Specialist observed the
male staff member trying to observe what was going on across the hall. Licensing Specialist was unable to
observe what was taking place across the hall.
Licensing Specialist observed a male staff member move the resident down the hallway for a female staff
member to take over the restraint. Resident was observed to what appeared to be defiant toward being placed
in a restraint with the female staff member. While in a restraint with the female staff member, Licensing
Specialist observed a peer run up to resident and hit him, ratio 1:3. Licensing Specialist observed another staff
member enter the area and escort the peer away from the area.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 7/27/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident: 7/27/23 @ 1130
am Per client report, a peer accidently fell on his left foot causing pain, Actions Taken:
Order obtained from APRN for transport to FCMC for evaluation and treatment of left foot.
Results: No acute fracture. Soft tissues are grossly unremarkable. Proper notifications were
made. Guardianship: , TX - DFPS
Interim Action Narrative: Resident was assessed by APRN and referred to FCMC for further
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist informed of provider reported incident via email.
7/28/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Licensing visited the facility to conduct an annual review of policies and procedures.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Rebecca Thomas
Record Visit Date: 7/26/2023
Home Visit Date: 7/26/2023
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of visit: 11:00 am to 12:30 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 59
Licensing Specialist conducted an annual review of policies and procedures for Perimeter of Forrest City. Mr.
Antione Jackson, Clinical Director, assisted Licensing Specialist with the review.
Policies and procedures for Perimeter of Forrest City complied with minimum licensing standards.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Forrest City Medical Center for evaluation after landing wrong on his ankle while playing in the gym.

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: 7/26/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of incident 7/26/23 @ 0800 am Per
client report, he landed wrong on his ankle while playing in the gym. Order obtained from
APRN for transport to FCMC for evaluation and treatment of right ankle. Results: Sprain of
tibiofibular ligament of the right ankle. Proper notifications were made. Guardianship: AR -
DHS
Interim Action Narrative: Resident was assessed and referred to FCMC for further
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received provider reported incident on 7/27/2023.
7/28/2023, Licensing Specialist reviewed provider reported incident or licensing concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


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

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 7/26/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/Time of Incident: 7/26/23 @ 0815 AM Per
client report, he woke up and his left elbow was hurting. Order obtained from APRN to
transport to FCMC for evaluation and treatment of left elbow. Results:
. Soft tissue swelling overlying the medial epicondyle noted. No
other acute fracture or dislocation. Upon return APRN made a referral to Orthopedic MD
for left elbow evaluation (appt set for 8/10/23 Jonesboro Sports Medicine Clinic. Proper
notifications were made. Guardianship: mother
Interim Action Narrative: Resident was assessed and APRN referred him to FCMC for
further evaluation. He is scheduled to see an orthopedic doctor on 8/10/2023.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist received provider reported incident via email.
7/28/2023, Licensing Specialist reviewed provider reported incident for licensing concerns.
Licensing Specialist will follow-up with facility after resident's appointment with the
orthopedic doctor on 8/10/2023. 8/11/2023, Licensing Specialist followed-up with facility on
resident's appointment with Jonesboro Sports Medicine Clinic. Licensing Specialist
informed that resident was placed in a splint and an ace wrap from elbow to his fingers.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Diagnosis: left elbow displaced medial epicondyle fracture. Dx with left elbow displaced
medial epicondyle fracture .


summary: Two residents eloped from the facility after one of the residents pulled a fire alarm that disabled the doors for safety.

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: 7/26/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Please describe the incident: On 7-26-23 Resident eloped
from the facility at @17:44 from Station One after a peer pulled a fire alarm that disabled the
doors for safety. Resident returned with staff after he responded to staff?s verbal de-
escalation and processing on his own. Actions Taken: Police were notified, and the resident
was returned to the facility at @17:52 When he was returned to the facility there were no
injuries that were apparent. The psychiatrist and AOC were notified as well. The resident
was placed on Elopement Precautions.
Interim Action Narrative: Staff provided verbal de-escalation and the police were called.
Resident was assessed and placed on elopement precautions. Psychiatrist and AOC were
notified.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was informed of provider reported incident via
email. 7/28/2023, Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire about camera footage. 7/31/2023, Licensing
Specialist followed-up on camera footage. 8/2/2023, Licensing Specialist unable to review
camera footage due to Clinical Director conducting a training. 8/9/2023, Licensing
Specialist reviewed camera footage.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 7/26/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Please describe the incident: On 7-26-23 Resident eloped
from the facility at @17:44 from Station One by pulling a fire alarm that disabled the doors
for safety. Resident returned without struggle per police escort. Actions Taken: Police were
notified, and the resident was returned to the facility at @18:10. When he was returned to the
facility there were no injuries that were apparent. The psychiatrist and AOC were notified as
well. The resident was placed on Elopement Precautions.
Interim Action Narrative: The police called. Resident was assessed and placed on
elopement precautions. Psychiatrist and AOC were notified.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was informed of provider reported incident via
email. 7/28/2023, Licensing Specialist reviewed provider reported incident for licensing
concerns. Licensing Specialist will inquire about camera footage. 7/31/2023, Licensing
Specialist followed-up on camera footage. 8/2/2023, Licensing Specialist unable to review
camera footage due to Clinical Director conducting a training. 8/9/2023, Licensing
Specialist reviewed camera footage.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 7/26/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Please describe the incident: On 7-26-23 Resident eloped
from the facility @17:44. Resident returned on his own after verbal escalation with staff and
processing with staff at @17:52 body check and cheek check were performed it did not
appear that resident had any injury. The resident then ran out of the building again as staff
were working with the door company to get the doors back online at @18:10. Police had to
escort the resident back to the facility @ 18:15. Actions Taken: Staff were able to convince
to return to the facility on his own after the first elopement through processing and
verbal de-escalation. Per the second elopement, police escorted back to the facility,
and the resident was returned to the facility at @18:15. When he was returned to the facility
there were no injuries that were apparent. The psychiatrist and AOC were notified as well.
was administered per doctor?s order for agitation, a 2nd body check was
performed and there were no injuries noted or observed.
Interim Action Narrative: The police were called. Staff provided verbal de-escalation.
Resident was assessed. Psychiatrist and AOC were notified.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist was notified of provider reported incident on
7/27/2023. 7/28/2023, Licensing Specialist reviewed provider reported incident for
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

licensing concerns. Licensing Specialist will inquire about camera footage and safety
precautions. 7/31/2023, Licensing Specialist followed-up on camera footage. 8/2/2023,
Licensing Specialist unable to review camera footage due to Clinical Director conducting a
training. 8/9/2023, Licensing Specialist reviewed camera footage.

Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter Behavioral of Forrest City
Facility Number: 142
Licensee Address: 603 KITTLE ROAD
FORREST CITY AR 72335
Licensing Specialist: Kendra Rice
Person In Charge: Charlotte Lockhart
Record Visit Date: 8/9/2023
Home Visit Date: 8/10/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Time of Visit: 10:30 am to 1:30 pm
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Census: 57
Licensing Specialist spoke with Ms. Charlotte Lockert, CEO, Antione Jackson, Clinical Director, and Clifton
Williams, Program Director, regarding ELS Cases #015267, #015268, and #015269.
Licensing Specialist reviewed camera footage of provider reported incidents on Station 1 Hall. Licensing
Specialist observed staff and residents in the hallway, ratio 3:3. One resident was standing at the by the
hallway exit door. Residents were observed walking up and down the hallway, in and out of the dayroom, and
moving the drink (water) dispenser. Licensing Specialist did not observe residents in the dayroom or shower.
Resident was observed jumping up by the exit door with his hand in the air by the exit sign. He then
pushed the door open and ran off the hallway. Licensing Specialist observed a nurse run after the resident.
Two residents and were observed bypassing staff, come out of the dayroom, and running off the
hall. The other residents remained in the dayroom.
Licensing Specialist observed a staff member on a walkie come down the hallway and return to her location.
Staff member was unable to go after the residents due to having residents in the shower. Staff member that
was by the dayroom was unable to go after the residents due to having a resident on line of sight. Nurse was
observed returning to the hall.
Residents and returned with staff. It was reported that staff was able to process (verbal de-escalate)
and convince the residents to return to the facility.
Provider Comments:
CCL Staff Signature : Date: 8/18/2023
Provider Signature : Date: 8/18/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident was sent to Forrest City Medical Center, then to Baptist Memorial Hospital for treatment after complaining of pain from having a Lego in his ear.

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: 7/26/2023
Date Received by DCCECE: 7/27/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date of incident: 7/26/23 time: 0140 am Per
staff report, resident presented to nurses' station complaining of pain in his left ear.
Resident stated he had a lego in his ear. Resident was noted to have a red foreign object in
his left ear. Referral obtained from APRN for transport to FCMC. FCMC was unable to
retrieve object from his ear and referred him to an ENT specialist. Resident was later
transported to Baptist Memorial Hospital for treatment/evaluation of foreign object in left
ear at which time the foreign object was removed without complication. All proper
notifications were made. Guardianship: AR-DHS
Interim Action Narrative: Resident was assessed and referred to FCMC for further
evaluation. FCMC referred resident to ENT Specialist.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Officers were dispatched in response to a report of a runaway resident.

raw_content:
CFS - Command Log Printed an August 25, 2023

CFS # CFS2330813

Call Taker NATALIE SPAIN

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

Location Details

Primary Incident Code ALRE : Fire Alarm

Additional Incident Code(s) RUNAWAY : Runaway

Mod Emergency Fire/Medical

Priority 5

Use Caution No

Primary Disposition Handled By Officer / Deputy

Beat

Zone Forrest City Police Department

Call Time 07/26/23 17:44:15

Completed Time 07/26/23 17:48:57

| Reporters

1191 (Initial Reporter)

Sex

DOB

Address

Report Time 07/26/23 17:44:15
How Reported Phone

From Phone = (866) 858-8950
Contact Phone

Comments

_ Other Names
Vehicles

Responders
CALL1 (Primary) — ; FCFD (Primary)
_ Response Times
Assigned 07/26/23 17:44:45
Enroute 07/26/23 17:48:57 *
Arrived 07/26/23 17:48:57 *
Leaving
Arrived At
Completed 07/26/23 17:48:57

' IR / External Agency Numbers

Officer Addenda

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

07/26/23 17:44:15 | SPAIN, NATALIE|NewCFS
07/26/23 17:44:45 | SPAIN, NATALIE | CALL1 | Assign

Page 1 of 2

07/26/23 17:45:17 | SPAIN, NATALIE | NURSE 1 HALL AND GENERAL MOTION

07/26/23 17:46:39 | SPAIN, NATALIE | 3 KIDS RAN AWAY FROM THE FACILITY

07/26/23 17:48:34 | SPAIN, NATALIE | ALARM COMPANY ADVISED THE FIRE DEPARTMENT COULD 10.22
07/26/23 17:48:57 | SPAIN, NATALIE | CALL1 | Complete

/CLQ
Requested At
Sent To
Status
Received At

Location ‘
Accuracy

Page 2 of 2


raw_content:
CFS - Command Log

Printed on August 25, 2023

CFS# CFS2330818
Call Taker ANN GRAVES
Location 1521 ALBERT ST, FORREST CITY, AR 72335 (WOODRIDGE BEHAVIORAL CENTER)

Location Details
Primary Incident Code RUNAWAY : Runaway

Mod Report Needed

Priority 1

Use Caution No

Primary Disposition Handled By Officer / Deputy
Beat

Zone Forrest City Police Department
Call Time 07/26/23 18:09:02
Completed Time 07/26/23 18:20:14

| Reporters

SPENCERI521 (Initial Reporter)

Sex

DOB

Address

Report Time 07/26/23 18:09:02
How Reported

From Phone

Contact Phone

Comments

Other Names

_ Vehicles

Responders

504 504-GRACEY, PRESTON FCPD (Primary)
506 506 - FORBES, JAMIE FCPD (Primary)
519 519 - ARCENEAUX, PAUL FCPD (Primary)
521 (Primary) 521 - SPENCER, BILLY FCPD (Primary)
522 522 - HALLMARK, FCPD (Primary)

BRIANNA
525 525 - DIXON, CORBIN FCPD (Primary)

» Response Times
Assigned 07/26/23 18:09:26
Enroute 07/26/23 18:09:31
Arrived 07/26/23 18:12:03
Leaving

Arrived At

Completed 07/26/23 18:20:14

-IR/ External Agency Numbers
FCPD202307963 a

| Officer Addenda

Page 1 of 2

Command Log Filter: All Commands | Details: Hidden | Units: All Units | Revised Entries: Shown
07/26/23 18:09:02 | GRAVES, ANN | New CFS
07/26/23 18:09:26 | GRAVES, ANN | 521, 522, 525 | Assign
07/26/23 18:09:31 | GRAVES, ANN | 521, 522, 525 | Enroute
07/26/23 18:11:03 | GRAVES, ANN | 521 ADV THEY JUST HAD ANOTHER ONE RUN FROM THE FACILITY IT ISA
BM WEARING LIGHT BLUE SHORTS GREY SHIRT HE IS RUNNING TOWARD KITTLE
07/26/23 18:11:10 | GRAVES, ANN | 504, 506 | Assign - IN AREA
07/26/23 18:11:47 | GRAVES, ANN | 521 ADV THEY HAVE THE SUBJECT AT ALBERT AND KITTLE
07/26/23 18:11:56 | GRAVES, ANN | 519 WILL BE ENROUTE BACK TO THE FACILITY WITH THE JUVENILE
07/26/23 18:12:03 | GRAVES, ANN | 519 | On Scene
07/26/23 18:12:42 | GRAVES, ANN | 522 | On Scene
07/26/23 18:13:09 | GRAVES, ANN | 519 ENROUTE BM AND EM 5501 06:12PM
07/26/23 18:13:20 | GRAVES, ANN | 504, 506, 521, 525 | Available
07/26/23 18:17:14 | MCCLINTOCK, VICTORIA | 519 | Clear Alarms
07/26/23 18:17:51 | MCCLINTOCK, VICTORIA | 522 | Clear Alarms
07/26/23 18:20:14 | GRAVES, ANN | 519, 522 | Complete

‘CLQ
Requested At

Sent To

Status

Received At
Location ,
Accuracy

EEE

Page 2 of 2


summary: A resident was sent to Forrest City Medical Center for an x-ray of his knee after he was pushed into a wall 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: 7/21/2023
Date Received by DCCECE: 7/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Per resident report, he was pushed into the gym wall by another peer,
he complained of right knee pain/swelling. The APRN made a referral for the resident to go
out to FCMC for X-ray of right knee. The resident findings were acute fracture or
dislocation noted; mild prepatellar tissue swelling noted. All proper notifications have been
made. Guardianship: , TX CPS
Interim Action Narrative: Resident was assessed and referred to FCMC by the APRN for
further evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was sent to Forrest City Medical Center for an x-ray of his hand after hitting 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: 7/21/2023
Date Received by DCCECE: 7/24/2023
Facility Name: Perimeter Behavioral of Forrest City
Facility Number: 142
Incident Type: Licensing
Report Description: Date/time of incident 7/21/23 @14:15 Per
staff, resident reported that he injured his right hand after hitting a door (small Hematoma
noted). APRN made a referral for the resident to go out to FCMC for an X-ray of his right
hand. The resident findings were no acute fracture or dislocation of the right hand. Remote
healed fracture of the distal right fifth metacarpal noted. All notifications have been made.
Guardianship: AR, DHS
Interim Action Narrative: Resident was assessed and referred to FCMC for further
evaluation.
Maltreatment Narrative:
Licensing Narrative: Licensing Specialist reviewed provider reported incident for licensing
concerns.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov