summary: Licensing conducted an unannounced visit at the facility. The facility was cited 912.4 for an issue identified during the review.

raw_content:
521 Visit Compliance Report

Licensee: Perimeter of the Ozarks

Facility Number: 237

Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766

Licensing Specialist: Michele Sutton
Person In Charge:

Record Visit Date: 3/2/2023

Home Visit Date: 3/2/2023

Purpose of Visit: Monitor Visit;Self Report Visit

Regulations Out of Compliance:

Regulation Number: 9. 912. 4

_ ARK ANSEA S
) DEPARTMENT OF

)}-7 HUMAN
~ “ai SERVICES
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550

Regulation Description: The bathroom shall be clean and sanitary.

Findings Description:
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:

Unannounced licensing visit completed this date. Licensing specialist verified that current safety plan
precautions are documented and being observed for residents [J and [J- Resident obtained staffing
sheet documentation which showed 9 MHTs working today. One MHT was assigned to 1:1 with resident
Licensing specialist observed staff member in the comfort room with this resident working on schoolwork.
CEO reported that resident was in comfort room with staff due to disruptive behaviors on the unit and in the
classroom. She is currently programming separately and is being taken outside separately for breaks and
recreation. A referral to acute care for this resident was made on Monday but resident was not accepted into
acute care setting. Licensing specialist looked at foam padding in the comfort room during visit. Foam
padding is intact with no loose or broken pieces. The padding is too shallow to represent a trip hazard.
Licensing specialist believes that the foam padding falls within acceptable standards under regulation 911.6 at
this time. Licensing specialist viewed bathroom near comfort room. The bathroom was reasonably clean,
supplied with soap and toilet paper, and did not have foul odors at time of visit.

Licensing specialist viewed toilet in bathroom 301 and observed that the box that the toilet is in has trash,
debris, and space for contraband on either side of the toilet. The facility stated that they plan to place foam in
the area, let it protrude, and then cut and seal it.Facility will be cited for standard 912.4 for this issue:
please ensure that this maintenance is completed by3/15/2023.

Licensing specialist viewed camera footage for self-reported incident involving ) | taking an outlet off of
the wall. The incident happened mostly in a camera blind spot. However, specialist could observe that staff
was aware that fj | | was in the corner out of camera view. For most of the hour that was viewed, one staff
member was in the corner with her. When staff would occasionally leave her to complete other tasks on the
unit, they circled back around to check on her within 5 minutes each time. There are no identified licensing
issues regarding supervision related to this incident. Licensing specialist checked corner of the unit during
walk through today to ensure that there were no loose or poorly fitted outlets on the wall.

Licensing specialist viewed camera footage for self-reported incident involving a suicide attempt for resident
BB Camera footage showed a staff member processing with resident 1:1 from 11:31 to 11:39 until other
residents arrive d on the unit for quiet/reflection time. Resident enters room around 11:40 A.M. and camera
footage shows that staff members respond to her attempt (tying a sweatshirt around her neck) at approx.
11:41.5. There are no identified licensing issues regarding supervision related to this incident.

Licensing specialist viewed environment of care maintenance logs for facility per CAA agreement. Log
showed documentation of daily walk throughs and lists of facility maintenance items that are being completed
every day.

Per facility, there were no new hires in the month of February.Please ensure that new H.R. director attends
the regulatory unit regulatory check training on 04/26/2023 per CCA requirements.

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

Licensing specialist followed up on a report from DSPQA IOC team that mail that shows resident names had
been left outside unsecured at the time of their visit. CEO Cassie stated that she is in contact with the USPS to
explore options for securing mail.Please ensure that there is a corrective action in place for this issue by
03/31/2023.This licensing specialist has never observed unsecure mail outside of facility.

Ratio:

Cafeteria 2:11 and 1:1
Isolation Room: 1:1
Orange unit: 2:11
Milieu: 1:3

Provider Comments:

CCL Staff Signature : Date: 3/2/2023
Provider Signature : Date: 3/2/2023
www.arkansas.gov/dhs

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


state: AR

facility_name: Perimeter Behavioral of the Ozarks

summary: A resident self-harmed with her fingers.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 3/1/2023
Date Received by DCCECE: 3/2/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Client
was in quiet room due to previous maladaptive behavior. Staff was present due to current
LOS. Client became escalated while in the quiet room and began self harm with her fingers.
Staff intervened using physical management in order to prevent client from harming herself.
Due to the inability to regain a state of calm, emergency medication was administered per
practitioner ordered. After, client began to calm as verbally assisted by therapist. As client
began to calm and have a willingness to display safe behavior, client was released from the
physical hold. Client continued on 1:1 LOS for safety.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Resident was on 1:1 constant LOS precaution at time of visit today per
safety plan. She is currently programming separately due to severity of her behaviors. The
facility has made several acute care referrals for resident with no accepting facility as of this
date.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

doc_type: Notice of Incident


summary: A resident was found with a piece of material tied around her neck.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 3/1/2023
Date Received by DCCECE: 3/1/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: , DOB: 1 , Guardian:
Mother: Notified On 3/1/23 at approximately 1040, RN spoke to client while RN was
cleansing her arms from picking scabs. Client appeared extremely calm, but flat affect. No
issues/concerns or suicidal ideations were noted by client. Client was on standard Q15
observation due to no recent self-harm behavior. This client then returned to the unit and
went to room for quiet time as did the entire milieu. Room changes had been made due to
maladaptive behaviors and this client did have a room change. At approximately 11:39, staff
unlocked client?s door and client preceded to walk inside. Staff continued to walk down the
hallway, unlocking other bedroom doors for quiet time. Other peers continued to walk by
client?s door, then go into their individual rooms. Approximately 1 minute, 15 seconds later,
staff returned down the hallway and looked into the client?s room as client was laying in the
floor. Staff immediately approached the bedroom and called for nursing and staff support
via walkie. It was found, client tied a piece of material around her neck. After nursing
arrived, she immediately left to get scissors to assist in the rapid removal of material.
However, staff were successful in removing the material with their hands before RN
returned. Once RN re-entered room, resident was seen to be breathing, conscious, and
tearful, but refused to verbally process. Client did have a red area on neck where material
had been tied with no breathing difficulty or speaking noted. At this time, therapist came in
to attempt to process. Rn confirmed that during this event on both entries into the bedroom,
resident did not have loss of consciousness. Corrective Action Plan includes 1:1 level of
supervision during wake hours while wearing paper scrubs. Client will sleep in the day room
area for optimal supervision/safety. Therapist will continue to process and communicate
with medical team regarding issues/concerns. Individualized safety plan will be developed
with therapist as client continues to stabilize.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Licensing specialist viewed camera footage of this incident. Resident
can be seen processing 1:1 with a staff member from 11:31 to 11:39 A.M. At 11:39 A.M. other
residents and staff enter unit for quiet/reflective time and staff begin opening doors for
residents. Resident enters room around 11:40 A.M. and is discovered by staff at around
11:41.5 . Staff reported she used an intact sweatshirt to self-harm during this incident.
Resident was observed in the cafeteria at time of visit 1:1 with an MHT. No need for
additional licensing follow up at this time.


summary: A resident self-harmed by picking scabs.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/28/2023
Date Received by DCCECE: 3/1/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: DOB: Notified: Mylea White
(DHS, AR) On 02/28/2023 at approximately 2100, H was noted to be picking scabs on her
left forearm. One scab she picked resulted in minor bleeding which was cleaned. She then
attempted to attack a peer who verbalized that she was going to pull the fire alarm. In the
process of trying to get to the peer, pushed a staff member. is currently on 1:1
observation as a result of increased self-harm behaviors and aggression.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Unannounced visit to facility this date. Acute care referral was made for
this resident on Monday, 2/27, but she was not accepted by facility due to not enough staff
to manage her 1:1 needs. Facility was observing 1:1 at time of visit. Resident is currently
programming separately from other residents due to the severity of her behaviors. She was
completing schoolwork in the comfort room at time of visit. CEO stated she is being taken
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

outside separately for breaks and recreation. No additional licensing follow up needed at
this time.


summary: A resident picked at scabs from previous self-harm attempts and attempted to self-harm with contraband she acquired from tampering with power outlets.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/27/2023
Date Received by DCCECE: 2/27/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: Notified: Mylea White
(DHS, AR) On 02/27/2023 at approximately 0841, resident pulled an outlet out of the wall to
obtain contraband to self-harm with. Staff were able to keep resident from tampering with
the outlet until it could be repaired. She then continued to try to obtain contraband to self-
harm from other areas around the unit. She sat in a corner to be out of sight so she could
pick at her scabs that are existing from previous self-harm. RN and staff had to physically
remove contraband from her hand that she was attempting to self-harm with. Staff were able
to physically block resident for an extended period of time while therapy processed with
. After some time, due to continued attempts to self-harm, resident was placed in a
physical restraint during which circulation was checked periodically and therapist
communicated with resident to deescalate her. After the restraint was released, RN assessed
there were no abnormalities found on her. She then took her morning meds, a PRN
and processed with therapy. In relation to this, she will be on self-harm precautions with
constant line of sight.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative:Licensing specialist reviewed camera footage for this incident today.
The incident occurred in the corner of the day room in a camera blind spot. However,
licensing specialist could observe that staff was with her in the corner for most of the hour of
footage viewed. When staff left her to take care of other tasks on the unit, they always circled
back around to check on her within 5 minutes. Based on footage, there are no supervision
concerns related to this incident. Licensing specialist viewed corner area of orange unit
during visit. There were no loose or poorly fitted outlets observed in the area at time of visit.
No additional licensing follow up required at this time.


summary: A resident used her fingernails to reopen a wound from a previous self-harm attempt.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/27/2023
Date Received by DCCECE: 2/28/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: -
notified o Incident: On 02/27/23 @ approximately 2100, resident used nails to reopen an
area on their right cheek from a previous self-harm attempt. Minimal bleeding noted. Area
was cleaned and dried, left open to air. Resident to remain on self-harm precautions until
safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Licensing specialist was provided documentation that there is a current
self-harm safety plan in place for this resident. Resident was eating in the cafeteria and
interacting appropriately with peers at time of visit. No additional licensing follow up is
required at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used her nails to reopen areas from previous self-harm attempts.

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 S140, Little Rock, AR 72203-1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550

Notice of Serious Incident

Date of Incident: 2/26/2023
Date Received by DCCECE: 2/27/2023

Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential

Incident Type: Licensing

Report Description: Name: a. DOR. Guardian: a

notified o Incident: On 02/26/23 @ approximately 1834, resident used nails to reopen an
area on their left cheek from a previous self-harm attempt. Minimal bleeding noted. Area
was cleaned and dried, left open to air. Resident able to de-escalate and no further incidents
occurred. Resident to remain on self-harm precautions until safe behavior is observed.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Unannounced licensing visit today. Resident was in the cafeteria
engaging with other peers at her table at time of visit. Licensing specialist viewed
documentation that current safety plan with self-harm precautions is in place. No additional
licensing follow up needed at this time.

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


summary: Licensing performed an unannounced visit at the facility. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Michele Sutton
Person In Charge:
Record Visit Date: 2/23/2023
Home Visit Date: 2/23/2023
Purpose of Visit: Monitor Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Unannounced visit to facility today.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 3

Viewed all units-blue, orange, and green. Bedrooms in blue unit were clean and no contraband or dangerous
materials were observed at time of visit. Bedrooms in orange unit were clean and no contraband/dangerous
materials observed at time of visit. Ratio on green unit was 1:2--2 residents refusing school were in bed.
Residents' rooms were on opposite ends of the hall, and MHT was in the dayroom. Licensing specialist
viewed MHT Q15s to verify supervision in accordance with regulatory requirements--Q15s were
completed/current for both residents. Licensing specialist verified that neither resident was on a constant LOS
safety plan. Unit was clean and no dangerous items were identified.
Ratio-- 1st Classroom 3:10
2nd Classroom 3:14
Cafeteria: 2:3--2 MHTs were at a table working on schoolwork with 3 residents who were experiencing
behavioral issues in the classroom.
Viewed grounds--no safety hazards identified. Grounds are now open for use as the roofing project has been
completed.
Viewed 5 MARS--all MARS meet regulatory requirements.
- meets regulatory requirements
-meets regulatory requirements
-meets regulatory requirements
-meets regulatory requirements
-meets regulatory requirements
Reviewed all self-harm incidents with administrator and verified that all children who are on LOS precautions
have appropriate documentation. LOS was being observed for all children on constant LOS precautions.
Outings: residents went hiking this week, are going to have ice cream at the park today and went to the Blue
Zoo this week in Rogers. Facility plans to offer increased outings as incentives for positive behaviors.
Provider Comments:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 3

CCL Staff Signature : Date: 2/23/2023
Provider Signature : Date: 2/23/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 3

doc_type: Compliance Report


summary: A resident used her fingernails to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/21/2023
Date Received by DCCECE: 2/22/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: -
notified o Incident: On 02/21/23 @ approximately 1850, resident used nails to create a raw
reddened area on their left cheek. did not give an explanation as to what caused the self-
harm behavior. Until resident can be assessed by therapy, she will be placed on self-harm
precautions with constant line of sight for safety. Reddened area on lower right side on
cheek noted, no blood. No nursing care was rendered. Resident was instructed to wash area
with soap and water.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Unannounced licensing visit today. Licensing verified documentation
that self-harm precautions are currently in place. Resident was in the classroom at time of
visit and within LOS of staff. No additional licensing follow up is required at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident self-harmed by scratching her forearm and banging her head.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/19/2023
Date Received by DCCECE: 2/20/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (TX)-
notified o Incident: On 02/19/23 @ approximately 1800, staff called RN to the unit and
reported had been attempting to bang her head. When RN arrived, she was scratching
left forearm. RN was able to verbally de-escalate. Resident taken off unit to comfort room to
process. Patient returned to unit and no other issues reported. Patient noted to have a
quarter size knot on forehead. No complaints of pain. No signs of further injury on
arm/head.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Unannounced licensing visit completed this date. Resident was in the
classroom within LOS of staff at time of visit. Resident has not had any other attempted
self-harm episodes this week, and facility continues to address her behaviors using the
interventions on her individualized behavior management plan.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident reported that a peer had inappropriately touched her private area.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/18/2023
Date Received by DCCECE: 2/20/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: ? Allegation of sexual misconduct Residents Name/DOB:
Victim ? Perpetrator Date/Time of
incident: 2/17/2023, approximately 2100 On 2/18/23, reported to MHT staff that
had inappropriately touched her private area in their room on the night of 2/17/23.
Immediate Actions Taken: Corrective Action Plan includes: Therapeutic group to be
conducted by therapist on peer-to-peer boundaries, reeducate no touching by residents to
each other on the unit, residents separated units for safety, re-educate staff on appropriate
supervision throughout the night, resident impacted will process with their therapist.
Additional Information: ; report taken. Report Notified:
Guardian , CEO Erin Duvall APRN Madeline Spence, Therapist Crystal
Mapes, Therapist Felicia.Harris@dhs.arkansas.gov Kris Stewart & Reagan Stanford and
Ashlyn Whelchel Disability Rights of AR Chelsea Vardell and Kendra Rice DHS Rebecca
Thomas, Perimeter Arkansas abuse hotline
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative:Unannounced licensing visit completed this date. This allegation was
screened out by the child . The AO is now on "bed block" status--
meaning that currently no other children can share a room with her until facility clinical
staff determines safety. No additional licensing follow up is required at this time.


summary: A resident self-harmed with a comb and by biting her hands.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/18/2023
Date Received by DCCECE: 2/20/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: DOB: 9, Guardian: DHS (TX)-
notified o Incident: On 02/18/23 @ approximately 2200, attempted to self-harm with a
comb. The comb was removed from the unit. then walked with staff to the comfort
room. She began to bite her hands. No skin broken. She then rubbed off her scabs on her
left arm causing them to bleed. She then processed with staff. Her picked scabs were
covered and cleaned. She was given her PRN anxiety medication. Self-harm precautions
initiated for 7 days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Licensing specialist Sutton completed an unannounced licensing visit
to facility today. Resident was receiving individualized help with her schoolwork in the
cafeteria area due to behavioral issues in the classroom today. She was within close
proximity and LOS of 2 MHTs at a small table. Verified that she has current LOS safety
plan documentation in place. No additional licensing follow up is required at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: Deficiencies were noted in the Inspection of Care conducted on 2/6/2023.

raw_content:
Inspection of Care Summary
Facility Tour:
Upon arrival to facility, AFMC staff noted two men sitting on sidewalk of facility smoking cigarettes within
25 feet of the main entrance. AFMC staff also noted a large pile of mail sitting unattended on sidewalk at
the front door. Mail labels included client’s names. AFMC staff was promptly greeted at the main entrance
by a Woodridge of the Ozarks staff member. AFMC was immediately taken to an office on the
administrative hallway where they were met by the Director of Clinical Services. AFMC staff was given
the completed and signed consent form listing approval for access to the AFMC portal.
This IOC visit was upon request of DPSQA to follow up on a recent IOC inspection conducted on
October 6, 2022, and December 5, 2022. A tour of the facility was completed with the Director of Clinical
Services. Group activities and educational classes were in session. All staff members were observed
interacting calmly and therapeutically with clients throughout the facility. Staff were able to answer
questions regarding the facility.
The areas that were toured included three client units, the seclusion room area, the school unit,
gymnasium, outside grounds, and cafeteria. The following is a list of environmental observations noted
during the facility tour.
• The three client units toured included Blue Unit, Orange Unit, and Green Unit.
o Units appeared to be much cleaner than the past IOC visits. All client’s beds were made,
and the rooms did not have excessive trash and clutter which has been a problem noted
on previous inspections.
o Multiple walls and doors that previous had an excessive amount of profanity carved into
the paint have been repainted recently.
o The unit floors have been recently waxed and stripped and looked very clean.
o As noted on previous inspections, each unit had missing floor tiles in the main hallways.
o As noted on previous inspections, the client toilets in each room have a wooden covering
with openings around the bottom of the toilet and the flush handle to provide anti-ligature
safety for the clients. Clients have stuck trash, personal items such as socks and
underwear, used feminine products in these openings in every client bathroom. These
openings are difficult to clean which provides an area to harbor germs, biohazard waste,
as well as contraband.
o The client’s shower floors had recently been concreted or had plastic shower floor inserts
placed to prevent injury or self-harm from sharp edges from the broken shower tiles or
peeling epoxy. This was implemented due to a recent DHS Division of Child Care and
Early Childhood Education visit on January 24, 2023.
• As noted on previous inspections, the rubber flooring outside of the seclusion room was
overlapping causing a trip hazard.
• The client restroom outside of the seclusion room had excessive spills dried on the floor, the trash
was overflowing, and there was a foul odor noted.
• Two classrooms were toured. There were twelve clients with three staff members and one teacher
noted per class. Staff were calmly interacting with clients and providing a therapeutic
environment that was conducive for learning and treatment therapies.
• Per the clinical director the outdoor area is not being utilized at the time due to the metal roof
being replaced, which is causing the presence of sharp pieces of metal, screws, and other
hazardous objects on the ground. Due to clients picking up scattered pieces of debris from the
roof replacement and using it as contraband, staff decided to close the outside area until project is
completed. Maintenance staff are going out frequently with a magnet to help keep area as clean as
possible for safety of clients and staff.
Woodridge of the Ozarks—Springdale, Arkansas—IOC Report 2 | P ag e

• There were no issues noted in the gymnasium. It was noted that this area is shared with an
adolescent outpatient day treatment provider that is housed next door and this facility was
currently utilizing gymnasium as AFMC staff toured. There are two side doors in the gymnasium
that open to the above mentioned outside area that is closed due to the metal roof being replaced.
These gymnasium outside access doors must remain unlocked due to fire safety code, so currently
the residential patients of Woodridge of the Ozarks have not accessed the gymnasium area in
several weeks. The CEO did state later during the inspection that she has implemented an
exercise plan that is being done on each unit at this time.
• There were no concerns noted in the cafeteria.
AFMC staff noted that while working in the office space provided on the administration hallway
throughout the day, that the offices and hallways had a lot of staff traffic, and that privacy was lacking.
Staff had multiple personal and inappropriate conversations that could be heard. The CEO conducted an
interview with a Director of Nursing candidate that was also not private to the surrounding offices in that
area.
Facility Review-Policies and Procedures:
Upon review of the site’s policies and procedures, the following deficiencies were noted:
Rule Deficiency Statement Reviewer Notes
Medicaid IP Sec. 2: The facility has not complied with The provider had a reportable
221.801; 42 CFR Medicaid, state, and federal incident that occurred after-hours on
482.130, 483.376 reporting requirements of death, January 31, 2023, however it was not
serious injury, or attempted suicide. reported until February 3, 2023. The
provider also had a documented 521
visit from the Division of Child Care
and Early Childhood Education.
Personnel Records- Licenses, Certifications, Training:
There were fourteen personnel records requested, two (25%) professional staff and twelve (27%)
paraprofessional staff. During the review of the personnel records, no deficiencies were noted.
Clinical Summary
As a part of the Quality of Care survey of the IOC, an active Fee for Service (FFS) Medicaid client list
was requested, client and/or guardian interviews were conducted, and a clinical record review was
completed. There was no active FFS Medicaid clients at the time of the inspection.
Client/Guardian Interviews:
No active FFS Medicaid clients currently admitted at the time of IOC. Therefore, there were no client
interviews were conducted.
Clinical Record Review Deficiencies:
No active FFS Medicaid clients currently admitted at the time of IOC. Therefore, there were no clinical
records reviewed.
Program Activity/Service Milieu Observation:
Staff and residents were in the classroom setting and on the units. Staff were calmly interacting with
clients and providing a therapeutic environment that was conducive for learning and treatment therapies.
Medication Pass:
No FFS Medicaid clients received medications during medication pass. Due to the observation of non-
Medicaid clients not being complaint with the HIPAA minimal necessary rule, no medication pass was
observed. AFMC RN visited with a Woodridge of the Ozarks medication nurse who was able to show
Woodridge of the Ozarks—Springdale, Arkansas—IOC Report 3 | P ag e

AFMC RN the facility policies and procedures regarding medication administration, narcotic
count/reconciliation/handling, and medication discrepancies. Tour of medication room completed with the
medication nurse and no discrepancies with medication storage, cleanliness of medication room, and
knowledge of medication dispensing found.
AFMC staff did note that the hinge on narcotic box was found to be bent causing the narcotic box to not
close properly. Narcotic box was still able to be locked but there was a small gap between the lid and side.
This was reported to the Assistant Director of Nursing who stated they were already aware of the issue
with the narcotic box and had she had been informed by someone that if the box could be locked, and the
medication room door was locked the box was fine as this would be considered double locked.
Corrective Action Plan:
The CAP must be completed within 30 calendar days of the date of the email notice of the IOC report
available for review. The IOC Report and Request for Corrective Action can be accessed through the link
to AccessPoint, provided via email.
*For more details on the individual related deficiencies, please log into the portal.
Respectfully,
AFMC Inspection Team
InspectionTeam@afmc.org
1020 W. 4TH ST., SUITE 300
LITTLE ROCK, AR 72201 • afmc.org
Woodridge of the Ozarks—Springdale, Arkansas—IOC Report 4 | P ag e

doc_type: IOC Report


summary: Licensing visited the facility to review children’s records and personnel records. The facility was cited for multiple deficiencies as a result of the review.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 2/15/2023
Home Visit Date: 2/15/2023
Purpose of Visit: Personnel Records
Regulations Out of Compliance:
Regulation Number: 1. 105. 3
Regulation Description: Child caring staff shall complete pre-service training prior to being counted in the
staff/child ratio. This training may be counted toward training hours for the first year. This applies to personnel
employed on or after January 1, 2011.
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 105. 13
Regulation Description: Documentation verifying annual training shall include the date, number of hours, the
name of the source, and the topic/title.
Findings Description:
Action Due Date:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 4

Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 107. 4
Regulation Description: The agency shall document that all staff have been made aware of the need to protect
the confidentiality of children in the use of social media.
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 103. 2 .a
Regulation Description: The following persons in a child welfare agency shall be checked with the Child
Maltreatment Central Registry in his state of residence, if available, and any state of residence in which the person
has lived for the past five (5) years, and in the person’s state of employment, if different, for reports of child
maltreatment:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Number: 1. 105. 15 .h
Regulation Description: The agency shall maintain a personnel file for each employee, which shall include:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
Regulation Number: 1. 105. 15 .c
Regulation Description: The agency shall maintain a personnel file for each employee, which shall include:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 4

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Licensing Specialist Michele Sutton and Program Coordinator Chelsea Vardell reviewed personnel records for
11 staff to include
The facility will be cited for the following issues:
105.3- All pre-service documentation was not documented in all 11 personnel records.
105.13- Training documentation shall include the date, hours, topic, and source. Training records for all 11
personnel only contained the date and topic of the training. Please ensure that the source and hours for each
training are clearly documented in the files.
105.10- Each personnel shall have 10 hours of psychiatric specific training before being counted in the
staff/child ratio. All 11 personnel records viewed today did not have 10 hours of psychiatric training
documented.
107.4- Personnel records should include documentation that they have been made aware of the need to protect
the confidentiality of children in the use of social media. The documentation was only found in 1 of the 11
personnel files viewed today. Please ensure that documentation of the personnel's education of the social
media policy is in the personnel files.
103.2- Personnel AR Child Maltreatment regulatory check was not initiated within ten days of hire.
(CEO Cassie Sowder reports that this was likely due to the termination of the facility's HR Director 1/9/23).
105.15.h- 10 of the 11 personnel records viewed today did not have three references from non-relatives in the
personnel file.
The facility received Technical Assistance for the following issues:
105.15.c- T/A- Please ensure that all personnel have some form of verification of their qualifications. For
example, high school diploma, GED, or college diploma.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 3 of 4

Provider Comments:
CCL Staff Signature : Date: 2/15/2023
Provider Signature : Date: 2/15/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 4 of 4


summary: A resident self-harmed by biting herself.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/14/2023
Date Received by DCCECE: 2/15/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: Guardian: -
notified o Incident: On 02/14/23 at approximately 2000, RN was called to the unit because
was reportedly biting her hand. No injury noted on either hand. When RN arrived,
resident was in the corner sitting with her head on her knees. I offered her an exit due to the
unit peers being loud. She accepted and spent approx. 30 minutes sitting in the quiet room
regulating emotions. Resident placed self-harm precautions for the next 7 days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:Licensing specialist Sutton completed an unannounced visit to facility
this date. Resident safety plan ended on Tuesday 2/21/2023 and there have been no
additional self-harm incidents, therefore, it was not extended. Resident was in the classroom
at time of visit and was within LOS of staff. No additional licensing follow up needed at this
time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used a clip from a walkie talkie to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/13/2023
Date Received by DCCECE: 2/13/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: DOB: Guardian: DHS (TX) -
Notified On 2/13/23 at approximately 0900, became upset about having to move units
and stole a staff member's walkie. She broke the clip and went down the hall and began
attempting to self-harm her arms/legs. She was blocked by staff when she was attempting
to self-harm and eventually placed the contraband in her pants. willingly walked out of
the unit to comfort room per direction of staff. While in the comfort room, began
attempting to use the contraband in her pocket to self-harm her legs. A physical hold was
initiated to maintain safety per Dr. Froman. Contraband was retrieved by RN. Once safe
behavior was exhibited, was released from hold. She sat in the comfort room and talked
with staff about her frustrations about moving units. While doing so, she became
dysregulated again and took another walkie from the milieu and placed it in her pants. She
refused to give the walkie back to the staff and again, attempted to use walkie to self-harm.
She was placed in a second brief physical hold to retrieve contraband. Once safe behavior
and calm demeanor was observed, resident was released. She walked over to her new unit
willingly. A little while later while on her unit, she began trying to climb wall to get to the
fire alarm on the ceiling but was unsuccessful due to staff intervention. This evening, she
grabbed a staff's keys from around their neck stating she was going to attempt to escape the
unit. The keys were retrieved by staff promptly. Resident was eventually able to regulate
emotions by processing with staff. Resident assessed by RN and no injuries were sustained
from any events listed above. Resident placed on self-harm precautions with constant line of
sight, as well as assault and property destruction precautions as a result of these events.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: Discussed this series of incidents with Cassie Sowder CEO. She stated
that resident became escalated due to a room change. She stole a walkie from a staff
member to self-harm and later stole a key from around a staff member's neck by breaking
the lanyard. The second time she obtained a walkie happened shortly after she was released
from restraint after demonstrating calm behaviors. Staff had taken walkies off in order to
complete the restraint. She grabbed one off of the milieu counter and it was quickly
retrieved. She has been placed on a self-harm precaution plan and an assault and property
destruction precaution plan. Staff reports that her behaviors have stabilized since incident,
and she has expressed to CEO that she likes her new unit better than she thought that she
would.


summary: A resident self-harmed by punching herself repeatedly in the face.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/13/2023
Date Received by DCCECE: 2/14/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: -
notified o Incident: On 02/13/23 at approximately 1830, while in the bathroom,
repeatedly punched herself in the face causing minimal bleeding from nose. Resident was
physically blocked by staff while she continued to attempt to cause injury. She was able to
regulate her emotions by talking with several different staff members. No continued
bleeding was noted, nor outside visible injury, and face was washed with soap and water.
No first aid required. A self-harm precaution safety plan is in place with constant line of
sight until safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident became escalated and tied a shirt around her neck in an effort to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/12/2023
Date Received by DCCECE: 2/13/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (AR) - notified
o Incident: On 02/12/23 @ approximately 0900, became agitated when she was
informed that she could not take the ?comfort sock? body suit into the cafeteria, along with
other triggers occurring at once. She became escalated and used her shirt to tie around her
neck. The shirt was quickly removed by RN and resident was taken back to her unit so that
she could be monitored closer. There were no injuries involved in the incident. Resident
scored low risk on C-SSRS, stating her action was out of "frustration." will be placed on
suicide precautions for the next 7 days as a result of her initial action of tying the shirt
around her neck to ensure safety.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton completed a full review of child's record this date.
Resident has a current, updated safety plan in file to address recent self-harm behaviors.
Resident has an updated treatment plan that reflects her treatment goals and progress.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used a staple she found on the unit to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/12/2023
Date Received by DCCECE: 2/13/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (TX) -
notified o Incident: On 02/12/23, became triggered when a peer was attempting to hit
their head on the wall next to her. She obtained a staple on the unit and was using it to
make superficial horizontal abrasions on her right forearm. RN and staff had to remove the
staple from ?s hand. She agreed to come with RN to the nursing station to allow the
areas to be cleansed. Upon assessment there was minimal blood and very superficial marks
on her right forearms. No bandages needed. will be on self-harm precautions for 7 days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Per in-person conversation with Cassie Sowder, CEO, resident is
currently on a self-harm precaution safety plan due to recent incidents.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident began self-harming by biting herself and trying to hit herself in the face.

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: 2/11/2023

Date Received by DCCECE: 2/13/2023

Facility Name: Perimeter of the Ozarks
Facility Number: 237

Facility Type: Residential

Incident Type: Licensing

Report Description: Name: a. DOB gammy. Guardian: PY -
notified o Incident: On 02/11/23 at approximately 0940, it was reported to this RN that
came back to her unit after an exit agitated. She went with a staff to the end of the hallway
and began attempting to self-harm by biting herself and trying to hit herself in the face.
When staff intervened, she bit the staff member, not breaking skin was able to be
regulated emotions with the help of staff and a lead giving her another exit. There were no
breaks in the skin on and therefore, no blood. No first aid required. Hwill continue to
be on self-harm precautions for 7 days and will be on assault precautions for 7 days as a
result of biting staff.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Specialist Sutton was at the facility today completing a record review
visit. Spoke to Cassie Sowder, CEO, who confirmed that resident is on a current self-harm
safety plan. Facility continues to monitor her for safety until behaviors stabilize.

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


summary: A resident self-harmed by punching themselves in the face.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/10/2023
Date Received by DCCECE: 2/13/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB , Guardian: -
notified o Incident: On 02/10/23 at approximately 1915, staff support was called to blue unit.
Resident was in the bathroom repeatedly punching themselves in the face. Resident was
escorted off unit to comfort room where a physical hold was initiated per Dr. Froman to
maintain safety. Resident was released from physical hold when safe behaviors were
exhibited. RN noted that resident had a slight nosebleed prior to physical hold that required
no first aid, no other injuries noted. Resident washed nose and processed with staff post
restraint until emotions were regulated. Resident was placed on a self-harm precaution
safety plan with constant line of sight as a result of this event.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton was at facility this date for a record review visit.
Spoke with CEO Cassie Sowder who confirmed that this resident is on a self-harm safety
precaution plan and facility continue to monitor for safety at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/9/2023
Date Received by DCCECE: 2/10/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (WI) -
notified o Incident: On 02/09/23 at approximately 2215, resident was observed scratching at
left forearm with fingernails. Staff was able to intervene with physical blocking while RN
responded to unit. Resident was able to regulate emotions once they were able to process
event 1:1. Superficial scratch noted on L. forearm requiring no first aid. Resident placed on
self-harm precautions with constant line of sight for 7 days as a result of this event.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing specialist Sutton completed a record review visit this date.
Resident record contained a current, updated safety plan to address self-harm behaviors and
a current treatment plan with updated treatment goals.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident self-harmed by punching herself in the face.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/9/2023
Date Received by DCCECE: 2/10/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB , Guardian: DHS (TX) -
notified o Incident: On 02/9/23 at approximately 1400, it was reported to RN that was
observed sitting on the floor attempting to injure herself by punching herself in the face.
Physical blocking techniques were used by staff to maintain safety until resident was taken
to comfort room to reduce stimuli. Resident processed with staff until emotions were
regulated. Minimal swelling noted on L. side of nose, ice pack applied. Resident to continue
on current self-harm precaution safety plan until safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton completed a complete review of resident record this
date. Resident has a current, updated self-harm safety plan to address her recent self-harm
incidents.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident self-harmed by biting themselves.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/9/2023
Date Received by DCCECE: 2/10/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: DOB: Guardian: DHS (TX) -
notified o Incident: On 02/09/23, it was reported to RN that resident had been biting
themselves. In response to this, staff used physical blocking techniques to prevent any
injury. Resident did not break skin, nor did they draw blood. No first aid required upon
assessment. Resident will continue to be on current self-harm precautions with constant line
of sight until safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing specialist Sutton completed a full review of resident's record
this date. There is a current, updated self-harm safety plan in resident file along with a
current, updated treatment plan that reflects treatment goals and progress.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used a piece of a broken light bulb to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/9/2023
Date Received by DCCECE: 2/10/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian:
- notified o Incident: On 02/09/23 at approximately 1945, had to be physically
restrained after breaking one of the light bulbs in the ceiling and holding on to glass from
the broken bulb. sustained two small cuts, one on each palm. Both cuts were cleaned
and covered, no first aid required. Once restrained, began to calm, glass from the bulb
was removed from hands, and the unit was swept clean. was released to process with
staff in the comfort room without issue. has been placed on Self-Harm safety
precautions for 7 days as a result of this incident.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing specialist Sutton completed a full review of child's record
this date. Resident has a current, updated safety plan to address her recent self-harm
incidents. Facility has documented restraint per regulatory requirements and had the
appropriate order to initiate.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident self-harmed by using her fingernails and hitting herself.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/7/2023
Date Received by DCCECE: 2/8/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: DOB: , Guardian: -
notified o Incident: 02/7/23 at approximately 1230, resident became escalated and began to
attempt to self-ham with her fingernails on her left forearm. When she was physically
blocked by staff, she then began to attempt to bang her head on the wall. When RN arrived,
staff were physically blocking to prevent her from self-harming. RN was able to verbally
deescalated resident enough to get her to come to the comfort room. While she was there,
she paced from seclusion to comfort room and shut herself in the bathroom. She then began
to attempt to hit herself in the face, punch the wall and bang her head all which were
physically blocked by staff. RN and staff were able to finally deescalate resident. No injuries
noted. PRN cold pack provided for discomfort in knuckle from punching the wall. Current
self-harm precaution safety plan to be continued until safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Specialist Sutton completed a record review visit at facility today.
Spoke with CEO Cassie Sowder who confirmed that resident is on a self-harm safety plan
and assault precautions due to recent behavioral disturbances resulting in incidents. Facility
continues to monitor progress and needs.


summary: A resident used her fingernails to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/7/2023
Date Received by DCCECE: 2/8/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (AR) -
notified o Incident: 02/07/23 approximately 1145 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 02/07/23 at approximately 1145, resident
became escalated related to a trigger that was not apparent to staff and began to use her
nails to pick scabs off her old self harm wounds. This caused some bleeding that quickly
ceased, and wounds were cleaned and cover them to prevent any further picking. Resident
states that increased sound level on unit may be the culprit. Earbuds will be offered to
attempt to reduced noise stimuli. Resident will remain on her current self-harm precaution
safety plan with constant line of sight until safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing specialist completed a record review visit to facility this
date. Spoke with facility CEO Cassie Sowder regarding this resident. Cassie confirmed that
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

resident remains on a safety plan and an individualized safety contract to address her self-
harm behaviors and reports that the therapist has noted progress, but it is up and down.


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/7/2023
Date Received by DCCECE: 2/8/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (TX) -
notified o Incident: On 02/7/23 at approximately 1930, it was reported to RN that was
observed sitting on the floor attempting to injure herself by punching herself in the face.
Physical blocking techniques used by staff to maintain safety until RN arrived. Resident
was taken to comfort room to reduce stimuli. No injury noted to face caused by incident per
RN report. Resident processed with staff until emotions were regulated. PM meds provided.
Resident returned to unit with no further incidents.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton completed a record review at facility this date.
Reviewed resident's complete record. Resident record contained an updated, current safety
plan to address her self-harm behaviors.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was observed attempting to place her hands around her neck in an attempt to self-harm. The resident began to scratch herself using her fingernails.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/6/2023
Date Received by DCCECE: 2/7/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: -
notified o Incident: 02/06/23 at approximately 1440, was observed attempting to place
her hands around her neck in the hallway to education. She continued to do this despite
verbal redirection and physical blocking. Resident was escorted to the comfort room to give
her a chance to regulate her own emotions. Resident then began to scratch her left forearm
with her nails and state that she did not want to talk to anyone that is currently here right
now. Resident processed with a new staff member from 2nd shift and was able to self-
regulated. There are superficial vertical scratches on left forearm from nails with minimal
blood. No first aid required; Resident instructed to clean area and leave open to air.
Resident will remain on current self-harm precaution safety plan until safe behavior is
observed.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Unannounced visit to facility today. Facility provided current safety
plan/self-harm precaution plan to licensing specialist. Precautions were being observed at
time of facility visit.


summary: The facility was cited 109.1.f for failure to comply with the current Corrective Action Agreement.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 2/6/2023
Home Visit Date: 2/8/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulation Number: 1. 109. 1 .f
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Due to the facilities failure to comply with the current corrective action agreement,
requiring all self-harm incident be reported to licensing by the next business day, the facility is being cited for a
violation of regulation 109.1.f.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No site visit conducted on this day.
Licensing received notification of a self-harm incident after business hours on 2/3/2023 that occurred on
1/31/2023.
Due to the facilities failure to comply with the current corrective action agreement, requiring all self-harm
incident be reported to licensing by the next business day, the facility is being cited for a violation of
regulation 109.1.f.
Provider Comments:
CCL Staff Signature : Date: 2/8/2023
Provider Signature : Date: 2/8/2023
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 of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 2/6/2023
Home Visit Date: 2/6/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulation Number: 1. 109. 1 .f
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Due to the facilities failure to comply with the current corrective action agreement,
requiring all self-harm incident be reported to licensing by the next business day, the facility is being cited for a
violation of regulation 109.1.f.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No site visit conducted on this day.
Licensing received notification of a self-harm incident after business hours on 2/3/2023 that occurred on
1/31/2023.
Due to the facilities failure to comply with the current corrective action agreement, requiring all self-harm
incident be reported to licensing by the next business day, the facility is being cited for a violation of
regulation 109.1.f.
Provider Comments:
CCL Staff Signature : Date: 2/6/2023
Provider Signature : Date: 2/6/2023
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 of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Chelsea Vardell
Person In Charge:
Record Visit Date: 2/6/2023
Home Visit Date: 2/6/2023
Purpose of Visit: Self Report Visit
Regulations Out of Compliance:
Regulation Number: 1. 109. 1 .f
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description: Due to the facilities failure to comply with the current corrective action agreement,
requiring all self-harm incident be reported to licensing by the next business day, the facility is being cited for a
violation of regulation 109.1.f.
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulations Needing Technical Assistance:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
No site visit conducted on this day.
Licensing received notification of a self-harm incident after business hours on 2/3/2023 that occurred on
1/31/2023.
Due to the facilities failure to comply with the current corrective action agreement, requiring all self-harm
incident be reported to licensing by the next business day, the facility is being cited for a violation of
regulation 109.1.f.
Provider Comments:
CCL Staff Signature : Date: 2/6/2023
Provider Signature : Date: 2/6/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/6/2023
Date Received by DCCECE: 2/7/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (TX) -
notified o Incident: On 02/06/23, it was reported to RN that resident has been biting
themselves of several occasions throughout the day. In response to this staff has been
physically blocking resident to prevent any injury. Resident was successful in biting self but
did not break skin nor did they draw blood. No first aid required upon assessment. Resident
does not tell staff why they are doing this. Will continue to monitor and resident will be on
self-harm precautions with constant line of sight for 7 days.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton completed an unannounced licensing visit this date.
Facility provided current safety plan for this resident. It was being observed at time of visit.
Facility continues to utilize and individualized behavior management plan with resident.
The number of incidents for this resident has decreased so far since this has been
implemented. No additional licensing follow up required at this time.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident self-harmed by hitting themselves in the nose.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/6/2023
Date Received by DCCECE: 2/7/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (TX) -
notified o Incident: 02/06/23 approximately 2130 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 02/06/23 at approximately 2130, RN was
called to orange unit because resident had hit their nose with their hand causing it to bleed.
Nursing processed with the resident alongside staff allowing the resident to calm self
without escalating the intervention needed. The resident was taken to nurses' station where
nose was treated and cleaned. No evidence of swelling or bruising at this time and no first
aid required, as blood had begun to clot, stopping the nosebleed. Current self-harm
precautions to remain in place until resident can show safe behavior.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton completed an unannounced licensing visit this date.
Facility provided a current safety plan for resident that is in response to this incident. Safety
plan was being observed at time of licensing visit.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used a paint brush to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/4/2023
Date Received by DCCECE: 2/4/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian:
- notified o Incident: 02/04/23 approximately at 1310 o
Precaution safety plan: Self-Harm, Constant LOS o Police were called: N/A o On 2/4/2023
at approximately 1310, was discovered in the bathroom on the unit using a small piece
of a paint brush to cause injury to her left forearm. Staff intervened and called RN to unit.
Small laceration noted on the top of the lower forearm. Resident was taken off unit to the
nurses station where cut was cleaned and covered. No first aid required. Contraband
retrieved. Resident placed on a self-harm precaution safety plan with constant line of sight
for 7 days as a result of this event.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Specialist Sutton completed an unannounced visit this date. Facility
provided a copy of the current self-harm safety plan for resident. Precautions were being
observed at time of visit.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used their fingernails to self-harm and placed their hands around their neck while dysregulated.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/4/2023
Date Received by DCCECE: 2/4/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB:1 , Guardian: -
notified o Incident: 02/04/2023 approximately at 1600 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 2/4/2023 at approximately 0900, became
dysregulated on the unit and placed hands around neck and began scratching inner
forearms with fingernails. RN intervened and took to comfort room to process and
regulate emotions. Nails were trimmed and filed. Superficial scratch noted on left inner
forearm. Scratch was cleaned and covered; no first aid required. will remain on current
self-harm precautions with constant line of sight until safe behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: Licensing specialist Sutton completed an unannounced visit to facility
today. Facility staff provided a current self-harm safety plan for review. Current safety plan
was being observed at time of visit.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident was found with a sweatshirt tied around their neck. Once the sweatshirt was removed by staff, the resident began hitting their head on the bathroom wall.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 2/3/2023
Date Received by DCCECE: 2/6/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: o Name: , DOB: Guardian: DHS (TX) -
notified o Incident: 02/03/23 approximately 1545 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 02/03/23 at approximately 1545, SP went into
a bathroom on her unit and was discovered by staff with a sweatshirt tied around her neck.
The sweatshirt was removed promptly by staff. Once the sweatshirt was removed from
around the neck, the resident began hitting their head on the wall of the bathroom and was
assisted out to the dayroom. was taken off the unit to process event with staff and was
given an intervention phone call to help regulate emotions. She was able to de-escalate, and
no further incidents occurred. Since this incident, there has been no redness/bruising on
the neck noted, and resident has not complained of any pain in the area. C-SSRS scale
placed resident on low risk for suicide. She verbalized she was just feeling ?very impulsive
and overwhelmed in the moment and not suicidal at all?. Per the therapist, resident will be
placed on a 3-day suicide precaution safety plan as a result of this event.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Reviewed camera footage for incident this date. Facility was cited for
standard 907.2--see inspection 059120.


summary: A resident began hitting themselves in the face and placed their hands around their neck in an attempt to self-harm.

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: 2/3/2023

Date Received by DCCECE: 2/4/2023

Facility Name: Perimeter of the Ozarks
Facility Number: 237

Facility Type: Residential

Incident Type: Licensing

Report Description: Name: a. DOB gammy. Guardian: -
notified o Incident: 01/31/23 approximately at 1600 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 2/3/2023 at approximately 1600, | went to
the end of the hallway on her unit after becoming dysregulated and began hitting
themselves in the face and placing their hands around their neck in attempts to cause injury
to self. Staff intervened by using blocking techniques and verbal de-escalation. Eventually,
|| agreed to go to comfort room with RN to process and regulate emotions. Mild redness
noted around neck requiring no first aid/medical attention. [J was placed on a self-harm
precaution safety plan with constant line of sight for 7 days as a result of this event.

Interim Action Narrative:

Maltreatment Narrative:

Licensing Narrative: Licensing specialist Sutton completed an unannounced visit to facility
today. Facility staff provided a current self-harm safety plan for review. Current safety plan
was being observed at time of visit.

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


summary: Licensing visited the facility to conduct a buildings and grounds walkthrough. No deficiencies cited.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Michele Sutton
Person In Charge: Cassondra Sowder
Record Visit Date: 2/3/2023
Home Visit Date: 2/3/2023
Purpose of Visit: Self Report Visit;Subsequent Building and Grounds
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Completed buildings and grounds/self-report visit this date.
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

All units within ratio at time of visit, all residents were observed to be within LOS of staff members at time of
visit. Ratios: Green 2:9, Orange 2:10, Classroom 1 3:8. Licensing specialist viewed all bedrooms and
dayrooms on each unit and there were no safety hazards noted. The tiles in bathroom of room 205 have been
repaired, and the tiles in showers of room 305 have been repaired. The grounds remain out of use until the
roofing project is completed on the building due to the presence of contraband materials such as nails and
sharp sheet metal.
Licensing specialist observed classroom 1 engaged in an activity with the facility activity coordinator.
Monthly activity calendar not available at time of visit because activity director was out most of the week with
the inclement weather. However, facility provided a list of activities that were provided to residents this week
including exercise groups, therapy groups, arts and crafts, and team building exercises.
Facility provided a list of all new hires for month of January 2023 as per CAA requirements and confirmed
that they are no longer using temporary staffing agencies.
Licensing specialist followed up regarding recent facility self-reports of self-harm incidents: resident has
been placed on a detailed, individualized, signed, safety contract which outlines interventions and for
self-harm behaviors and incentives for safe behaviors that was developed with her input. Interventions include
1:1 while in the classroom, regular room searches, and processing using grounding activities. disclosed to
facility staff that she has been hiding contraband in a very narrow gap between her bed and the wall (bed is
bolted to the floor and does not move). The gap is too small for a hand to fit through, so she was sliding a
folder in the gap to retrieve items. Staff has used a rod to remove all contraband items from the gap and are
implementing regular room searches on the units. CEO is in process of training all staff on how to complete a
thorough room search. The other incidents of self-harm, which primarily involved fingernail scratches are
being addressed by staff re-training on de-escalation and continued programmatic changes to ensure residents
are engaged throughout the day. There is also a standing order to trim and cut resident fingernails as needed.
No citations in areas viewed.
Provider Comments:
CCL Staff Signature : Date: 2/3/2023
Provider Signature : Date: 2/3/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: Complaints #AR00029527 and #AR00029530 were in compliance.

raw_content:
ARKANSAS -
DEPARTMENT. OF

February: 10, 2023

Divislon of Provider Services
& Quality Assurance
P.O. Box 8059, Slot $404
Little Rock, AR 72203-8059

Derek Thompson, Administrator
Woodridge Of The Ozarks
2466 S 48th Street

Springdale, AR | 72762

Dear Mr. Thompson:

A Complaint Investigation survey was conducted on February 3, 2023. We are pleased to inform you
that no deficiencies were cited during the survey and that your facility was in compliance with the
requirements of 42 CFR Part 483, Subpart G, Requirements for Psychiatric Residential Treatment
Facilities. Your certification remains in effect unless terminated due to non-compliance with program
requirements or voluntary withdrawal from the program.

We have enclosed form CMS 2567, “Statement of Deficiencies and Plan of Correction” for the .
February 3, 2023, Complaint Investigation survey conducted at your facility for participation in the
Medicaid program. CMS 2567 is enclosed, indicating your facility's compliance status. Please sign
and date the 2567 and email to Theresa.Forrest@dhs.arkansas.goy,

If you have any questions, please contact your reviewer at 501-320-6235.

Sincerely,

DPSQA/Office of Long Term Care
Survey and Certification Section

tf

Derek Thompson - Woodridge Of The Ozarks - 02/08/2023- (AOLTC - PRTF No Def) Page 4]

ce: DRA

Derek Thompson ~ Woodridge Of The Ozarks ~ 02/08/2023- (AOLTC - PRTF No Def) Page 2]

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AN® PLAN OF CORRECTION IDENTIFICATION NUMBER:

04L120

NAME OF PROVIDER OR SUPPLIER

WOODRIDGE OF THE OZARKS

(x4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(BACH DEFICIENCY MUST 8E PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Initial Comments

Note: The CMS-2567 (Statement of Deficiencies)
is an official, legal document. All information must
remain unchanged except for entering the plan of
correction, correction dates, and the signature
space. Any discrepancy in the original deficiency
citation(s) will be reported to the Dallas Regional
Office (RO) for referral to the Office of the
Inspector General (OIG) for possible fraud. If
information is inadvertently changed by the
provider/supplier, the State Survey Agency (SA)
should be notified immediately.

‘| AR00029527 was in compliance.

AR00029530 was in compliance.

The facility was in compliance with §483, Subpart
G - Conditions of Participation for Psychiatric
Residential Treatment Center.

PRINTED: 02/10/2023
FORM APPROVED
OMB NO, 0938-0391-

(X2) MULTIPLE CONSTRUCTION (X) DATE SURVEY
A, BUILDING - COMPLETED
Cc

B. WING _____—_-———_____— 02/03/2023
STREET ADDRESS, CITY, STATE, ZIP CODE
2486 S 48TH STREET
SPRINGDALE, AR 72762
PROVIDER'S PLAN OF CORRECTION (x6)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION"

CROSS-REFERENCED TO’ THE APPROPRIATE DATE
DEFICIENCY) 7

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE _ X86) DATE

. .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that . an i

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
. following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correctlon are disclosable 14

days following the date these documents are made available to the facillty. If defictencles are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: C9UG11 Facility ID: 3017 if continuation sheet Page 1 of 1

doc_type: Complaint Survey


summary: Technical assistance for 109.1.f was provided to the facility.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Michele Sutton
Person In Charge: Sarah Kroon
Record Visit Date: 2/1/2023
Home Visit Date: 2/1/2023
Purpose of Visit: Technical Assistance Request Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Number: 1. 109. 1 .f
Regulation Description: Unprofessional conduct in the practice of child welfare activities shall include, but not
limited to the following:
Findings Description:
Action Due Date:
Action Due Description:
Comply Date:
Sub Regulation Description:
Regulation Not Applicable:
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 1 of 2

Regulations Not Correctable:
Narrative:
Per the corrective action agreement, licensing requires that all acts of self-harm, injuries/accidents requiring
emergency medical treatment, and maltreatment reports and complaints should be reported to the licensing
unit within one business day, and all maltreatment (e.g., peer-to-peer sexual touching, staff maltreatment)
should be called in to the child maltreatment hotline within one business day.
Several reports of self-harm incidents from the 27th and 26th were received on 01/31/2023. Technical
assistance is being provided to facility for standard 109.1.f,Failing to comply with any stipulation or agreement with
the Board involving probation or a settlement of any disciplinary matters.Facility did not receive copy of signed CAA
until 01/30/2023, and the ADON for the facility only recently (01/27/2023) became responsible for reporting
incidents. Moving forward, it is required that all incidents will be reported within one business day of
occurrence, and facility will be cited for any incidents that are not reported within the timeframes specified in
the corrective action agreement.
Provider Comments:
CCL Staff Signature : Date: 2/1/2023
Provider Signature : Date: 2/1/2023
www.arkansas.gov/dhs
Serving more than one million Arkansans each year Page 2 of 2


summary: A resident began to self-harm by biting herself.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 1/31/2023
Date Received by DCCECE: 2/3/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB , Guardian: DHS (TX) -
notified o Incident: 01/31/23 approximately at 2030 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 1/31/23 at approximately 2030, began
biting herself on her hand in the corner of the dayroom. This left a superficial opening on
the top of the skin that was cleaned by the RN and left open to air to heal. Resident was
given an exit and processed event with staff. Self-harm precautions with constant line of
sight initiated for the next 7 days as a result of this event.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 2/6/23- Licensing issued a 521 to the agency citing for 109.1.f due to a
failure to comply with the stipulations set forth in the current Corrective Action Agreement.
02/09/2023-unannounced licensing visit completed by specialist Sutton this date. Facility
provided a copy of the current safety plan for resident for review. Resident
was within LOS of staff members at time of visit.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident began to self-harm by reopening previous self-harm injuries.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 1/31/2023
Date Received by DCCECE: 2/3/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (AR) -
notified o Incident: 01/31/23 approximately at 2100 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 1/31/23 at approximately 2100, began
picking and opening previous self-harm scabs. She was taken to nurses' station where her
arms were cleaned and left open to air to heal. No first aid required. Because of this event,
resident will remain on current self-harm precautions with constant line of sight until safe
behavior is observed.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 2/6/23- Licensing issued a 521 to the agency citing for 109.1.f due to a
failure to comply with the stipulations set forth in the current Corrective Action Agreement.
02/09/2023 Specialist Sutton completed an unannounced visit to facility this date. Facility
provided a copy of resident's current safety plan. Safety plan was being observed at time of
visit.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident became dysregulated and put their hands around their neck in an attempt to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 1/31/2023
Date Received by DCCECE: 2/3/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , DOB: , Guardian: DHS (AR) - notified
o Incident: 01/31/23 approximately at 2000 o Precaution safety plan: Self-Harm, Constant
LOS o Police were called: N/A o On 1/31/23 at approximately 2000, resident became
dysregulated after arguing with peers and placed their hands around their neck. Resident
taken off unit to comfort room where they eventually deescalated after taking PM meds and
processed with staff. Resident placed on a self-harm precaution safety plan with constant
line of sight for 7 days as a result of this event.
Interim Action Narrative:
Maltreatment Narrative:
Licensing Narrative: 2/6/23- Licensing issued a 521 to the agency citing for 109.1.f due to a
failure to comply with the stipulations set forth in the current Corrective Action Agreement.
02/09/2023--Specialist Sutton completed an unannounced licensing visit to facility this date.
Resident was within LOS of staff during visit, although she is no longer on a self-harm
safety plan for this incident that occurred on 01/31/23.
We Care. We Act. We Change Lives.
humanservices.arkansas.gov


summary: A resident used a piece of metal from a clipboard to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 1/30/2023
Date Received by DCCECE: 1/31/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: Name: , , Guardian: DHS (AR) -
notified o Incident: 01/30/23 approximately at 1530 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 1/30/23 at approximately 1530, retrieved
a metal piece of contraband from a clipboard and used it as a means to scratch herself on
her left forearm. During event, verbal redirection and blocking techniques from the staff
were unsuccessful and refused to give staff the contraband. Resident was placed in a
brief physical hold until contraband was retrieved from hand to maintain safety. After being
released, resident handed staff a second piece of contraband. Body and room search was
preformed, paper scrubs provided. RN noted small superficial scratch on left wrist with
minimal bleeding and opening of scabs from previous self-harm episodes. No first aid
required. Arm/wrist was cleaned and covered. 's current safety plan with constant line
of sight for self-harm to be extended until safe behaviors are exhibited.
Interim Action Narrative:
Maltreatment Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Licensing Narrative: Licensing specialist completed a buildings and grounds visit this date.
Resident was in line in the hallway within LOS of staff. Facility reported that resident
disclosed that she has been collecting and hiding contraband in the narrow gap between her
bedframe and the wall of her room and using a folder to retrieve items. The bed is bolted to
the floor and does not move, and the gap is too narrow to fit a hand inside. Staff used a rod
to remove contraband from this area and placed resident on a signed, individualized safety
contract that lists the following interventions: regular room searches, 1:1 when in the
classroom (source of most contraband items), "chicken fingers" when upset, grounding
activities with staff assist, and incentives for safe behavior.


summary: A resident used their fingernails to self-harm.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203‐1437
P: 501.682.8590 F: 501.683.6060 TDD: 501.682.1550
Notice of Serious Incident
Date of Incident: 1/27/2023
Date Received by DCCECE: 1/31/2023
Facility Name: Perimeter of the Ozarks
Facility Number: 237
Facility Type: Residential
Incident Type: Licensing
Report Description: o Name: , DOB: 7, Guardian: DHS (TX) -
notified o Incident: 01/27/23 approximately at 1807 o Precaution safety plan: Self-Harm,
Constant LOS o Police were called: N/A o On 1/27/23, was seen self-harming by using
their fingernails to scratch away the scab and skin on their left forearm from their previous
self-harm injury. Staff attempted to communicate with , but they were not responding.
Staff attempted to use blocking techniques to prevent injury and became agitated and
began punching themselves in the head and face. The resident attempted to bite and kick
the staff member that was using blocking techniques. Additional staff and this RN
responded to the unit and attempted to communicate with but they would not respond.
Other residents were becoming dysregulated on the unit so was removed from the unit
and brought to the milieu. continued to attempt to kick and bite staff. A physical hold
was initiated to maintain the safety of herself and staff and was released when agreed to
safe behaviors towards self and staff. Afterwards, RN noted that had reopened their
previous fingernail-scratching-abrasion-injury to their left forearm. Resident refused to have
it cleaned/covered; no first aid required. Alternative staff member was brought in to process
the incident with the patient. will remain on their current self-harm precaution safety
plan with constant line of sight until safe behaviors are observed.
Interim Action Narrative:
We Care. We Act. We Change Lives.
humanservices.arkansas.gov

Maltreatment Narrative:
Licensing Narrative: 2/1/23- Program Coordinator spoke to the CEO, Cassie Sowder, and
discussed why the incident was reported late to the licensing unit per the current Corrective
Action Agreement. The CEO reported that a floor nurse quit without notice so the ADON,
who typically reports incidents, had to work the floor and was unable to report the incident
in a timely manner. The Program Coordinator informed the CEO that licensing will be
issuing a technical assistance for 109.1.f for all six incidents reported to us on 1/31/23 but
moving forward any reports that do not meet the requirements of the corrective action
agreement will be cited. Inspection # 058831 02/3/23--Licensing specialist Sutton
completed a buildings and grounds visit at facility. Resident was observed within LOS of
staff in the hallway. She has processed with therapist about this incident. Standing order to
cut and trim resident's fingernails as needed. CEO stated that facility is in the process of
educating staff about different de-escalation interventions and is continuing to work on
programmatic changes to keep residents engaged during the day.


summary: Licensing visited the facility to review the Corrective Action Agreement.

raw_content:
Division of Child Care & Early Childhood Education
P.O. Box 1437, Slot S140, Little Rock, AR 72203-1437
P: 501.508.8910 F: 501.683.6060 TDD: 501.682.1550
521 Visit Compliance Report
Licensee: Perimeter of the Ozarks
Facility Number: 237
Licensee Address: 2466 SOUTH 48TH STREET
SPRINGDALE AR 72766
Licensing Specialist: Michele Sutton
Person In Charge: Cassondra Sowder
Record Visit Date: 1/27/2023
Home Visit Date: 1/27/2023
Purpose of Visit: Special Visit
Regulations Out of Compliance:
Regulations Needing Technical Assistance:
Regulation Not Applicable:
Regulations Not Correctable:
Narrative:
Program manager Sharra Singleton-Litzey and licensing specialist Michele Sutton met in-person with
administrator Cassondra Sowers to review the corrective action agreement. Regional CEO Art Hickman and
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Serving more than one million Arkansans each year Page 1 of 2

Regional QA director Rebecca Thomas were present via video conference. Program manager reviewed the
requirements of the corrective action agreement with all present.
After the corrective action agreement review, facility CEO Cassondra Sowers and ADON Sarah Kroon were
provided instruction on reporting requirements for incidents. A copy of the CAA will be sent to the facility on
Monday, 01/30/23, for signature.
Provider Comments:
CCL Staff Signature : Date: 1/27/2023
Provider Signature : Date: 1/27/2023
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Serving more than one million Arkansans each year Page 2 of 2