Millcreek Behavioral Health / Habilitation Center, Inc.

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at rstanford@disabilityrightsar.org

Location: Fordyce, AR                   Population Served: Youth ages 6-17

# of residents per unit: Up to 20 Residents per room: 2-3

Capacity: 162 (111 Arkansas Medicaid PRTF beds, 51 Residential beds used for out-of-state resident PRTF placement or AR contract beds).

Contact with family (Calls and visit schedule): Family visits vary on a case-by-case basis. Phone Calls are allowed on 4 days of each week and are limited to 10 minutes unless otherwise specified.

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? Yes

Treatment Components:

Clinical Director: LPC                    Therapists:8 full-time therapists (LPC-S, 5 LPC, 1 LCSW, 1 LMSW)

Treatment modalities offered: 1 EMDR, TF-CBT

# of individual therapy sessions/week: 1

# of group therapy sessions led by a licensed mental health professional/week: 3

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PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

Buildings & Grounds conducted for Deerfield and School buildings. Pine Ridge and Rock Hill currently under remodel, to be followed by Deerfield next.

Deerfield building clean, safe, and in good repair except baseboard trim purposely removed from sleeping areas due to upcoming paint job. Client rights observed. Bathrooms clean and sanitary with functioning sinks, showers, and toilets. Grounds clean and free of safety hazards.

School clean, safe, and in good repair. Classroom ratios: 4:14, 4:10, 2:7, 5:16, and 5:15. Staff seen escorting clients across campus. Staff/client ratio 2:0. MARS checked. All initialed and up to date.

PRLU or OLTC

Medical, Notice of Incident

Client complained of right hip and leg pain. Client stated that it’s been hurting since before arrival at Millcreek, but it’s gotten worse. Client was taken to the Dallas County Medical Center on 4.30.2024, for x-rays of right hip and femur. No fractures or dislocations found.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was outside playing football in the field behind the barn and stepped on a nail. Client was taken to Dallas County Medical Center to receive a tetanus shot. There has been no recent construction in the area. Maintenance is running a magnet through the field to check for any other objects that might have washed up during the recent rainstorms.

Police Report

Abuse

Officer was dispatched to Millcreek in reference to a parent filing a complaint against a staff member. COO of Millcreek, Chris Butler, stated that the resident’s father informed him that he would be removing the resident from the facility. Day shift manager Mrs. Edwards, stated she was informed that a staff member had called the resident a “faggot” and a “nigger”.

Officer made contact with the resident’s mother who stated that the resident told her about the incident when she arrived for a visit. The resident stated that the staff member called him a “faggot” and a “nigger”, slammed him on the ground, and threw him across the room. Resident stated he tried to leave the room and call for help, but the staff member pulled him back inside the room. The resident’s mother stated she requested a statement be filed regarding the situation, but the statement had not yet been filed. Resident’s mother stated that when she did a full body audit on her child, she observed a blood spot under the skin on his right eye.

Officer made contact with accused staff member. He stated he did nothing wrong and was putting the resident in time out for acting up. Staff member said resident was screaming, cussing, and threatening to kill people.

Staff member was suspended pending an internal investigation into the incident.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Resident was having an on-campus visit with his mother on 4.13.24 and reported to his mother that a staff member called him a “faggot” and a “nigger”. Resident also stated that he was having an episode of physical aggression and that the staff member physically escorted him away from the situation and brought him to his room. The resident reports that when he arrived to his room, the staff member “threw him around.” The events allegedly happened on 4.12.2024. The mother reported these events to Millcreek staff and informed them that she would discharge the resident from the facility. She filed a police report with the Fordyce Police Department. Officers arrived on Campus and took statements from both the mother and the resident concerning the allegations. A Child Abuse Hotline report was made and accepted for investigation.

Licensing Specialist: Clayton DeBoer

Facility visited 4/15/24. Staff member was placed on administrative leave pending investigation. There is no video footage of this incident. There are no documented incidents (4/12/24) of this nature in the client’s file. Resident was discharged from Millcreek.

CACD investigation and licensing complaint determined to be unfounded.

PRLU or OLTC

Medical, Notice of Incident

Resident was sent to Dallas County Medical Center ER for assessment of a possible allergic reaction. Client was assessed at DCMC and given Benadryl before being discharged.

Facility stated the following “It was determined that she did have a minor allergic reaction. She did have a rash, but was found to be in no acute distress. Vitals all normal. She was admitted to ER at 1715 and discharged at 1745. The assumption was contact with bananas.”

PRLU or OLTC

Accidental Injury, Notice of Incident

Resident fell on the gym floor while playing basketball, injuring her right ankle. She was taken to Dallas County Medical Center for an x-ray. X-ray revealed no fractures.

PRLU or OLTC

Notice of Incident, Self-Harm

Resident kicked a wall during a behavior, and was taken to Dallas County Medical Center on 04/9/2024 for an x-ray on her 3rd toe on the right foot due to pain. X-ray revealed no fractures.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was playing basketball when he fell and hurt his left great toe. Client was transported to Dallas County Medical Center for an x-ray. He was found to have a nondisplaced fracture in the distal metadiaphyseal region of proximal phalanx of the first digit.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer

After hours visit conducted at 6:00 AM. Staff/client ratio: 2:10.

Staff seen through window awake prior to arrival. Staff answered the door immediately. Nightly visual checks roster produced with appropriate time initialed. All clients were reportedly asleep. Day/living areas observed to be clean, safe, and in good repair. Grounds clean and free of safety hazards. Bathrooms and sleeping areas not observed during after hours as to not disrupt clients’ routine.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Facility visited in follow up to attempted elopement of client in January 2024. Per staff, police were notified per elopement protocol, but no arrests were made. The police department did not show up for this call. Staff reported client would converse with staff, run ahead, then converse with staff, and so on. Client eventually returned to the facility without need of physical intervention.

Background checks for 99 staff were reviewed during this visit. All checks were completed.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

On 3/19/24, client reported that a staff member hit him in the mouth and nose during an attempted elopement and physical restraint that occurred on 3/17/24. A report was made to the Arkansas Child Abuse Hotline (accepted).

Staff reported there is no video of alleged incident as it was reported to have occurred in a transit vehicle. Client attempted to elope but never made it off campus. Staff drove a facility vehicle to the edge of the road and located client, and client got in the transit vehicle where the incident allegedly occurred. Staff has been placed on administrative leave pending investigation.

Licensing Specialist: Clayton DeBoer.

3/20/24-Facility visited. Nursing note reviewed for 3/17 which does indicate that client had “abrasion to inner lip”. Facility investigation yields that alleged incident happened in transit vehicle, Shakaila Edwards driving, staff Mantrell Neal and the accused staff member riding.

The 2 staff that were also present in the transit vehicle reported that at no time did they see the accused staff member punch or hit the client. Staff Neal reported that client was restrained by the accused staff member while in the vehicle. Staff Neal did say that he saw the client spit blood, but at no time saw any staff do anything during the incident that would cause client to spit blood.

Client interviewed. Client stated that he was going to elope but stopped in the road and let staff catch him. Client stated that staff grabbed him by his hoodie with both hands and while restraining him (in transit vehicle), staff punched him “once in the nose and twice in the mouth”. When asked if any staff were present, client indicated that staff Shakaila and Mantrell were present. When asked if either of these staff saw the accused staff member hit him, client replied “I don’t know”. Client had no outwardly visible scarring or bruising on his face today but did show a healing cut on the inside of his lip.

CACD investigation was unsubstantiated. Licensing complaint unfounded.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was sent for an outpatient x-ray at Dallas County Medical Center following a visit with his PCP. He complained of continued pain resulting from a fall during a recreational basketball game. X-ray report indicates a greenstick fracture distal radius and a buckle fracture distal ulna. He has been provided a splint and will follow his PCP directives for treatment of the injury.

PRLU or OLTC

Maltreatment, Notice of Incident, Visit Compliance Report

Client was placed in a physical restraint following an extended period of verbal and physical aggression and property destruction. The restraint was initiated for safety after he directed his aggression toward staff members, pushing and biting them. On 3/9/24, client made the verbal statement that a staff member had choked him while initiating the physical restraint. The nurse’s notes following the restraint indicate scratches on the left side of the neck. A report was made to the Arkansas Child Abuse Hotline (accepted). The staff member was placed on administrative leave pending the investigation.

Licensing Specialist: Clayton DeBoer.

Facility reported there was no video of this incident. Witness statements reviewed.

Of note, a supervisor’s witness statement states “during the restraint at no time did I see staff [redacted] choke patient”. Witness statement continues to state that after the restraint was over, at no time did patient mention being choked. Nursing note from the day after, 3/9/24, states that client had abrasion like scratches to left side neck and base of throat and reported being choked during restraint. Client interviewed. Client stated that during the restraint, staff put his right hand around his neck, while client was lying on the ground face up. Client stated he heard another staff say “don’t choke him”. Client stated that after the restraint he did not mention being choked because of fear of retaliation from peers. Licensing attempted to contact the involved staff member by phone (no answer). Client did have a 3″ scratch to left side of neck during today’s visit.

CACD investigation was unsubstantiated. Licensing complaint unfounded.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Personnel Records Review conducted for staff. All items accounted for. Background check file reviews also conducted for 33 additional staff.

PRLU or OLTC

Accidental Injury, Notice of Incident

Client was sent to Dallas County Medical Center for an outpatient x-ray for a complaint of continued thumb pain, reported after losing his balance and catching himself. X-ray report indicates no fracture present. He was released to return to the facility without restriction.

PRLU or OLTC

Elopement, Notice of Incident

Patient eloped from the property. Patient was found within 200 yards of facility. Emergency protocol was initiated and followed. Patient returned to facility with no injuries.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Buildings and Grounds conducted from 9:45am – 11:30am. Census: 159. Pebble Creek and Pine Ridge viewed. MARs checked for 5 residents. Background checks reviewed for 99 staff.

Facility cited 911.6: Pine Ridge room 4 closet had graffiti, bathroom 4 had a missing bolt on toilet lid and baseboards were missing for entire unit (baseboards have been intentionally removed and are awaiting remodel).

PRLU or OLTC

Accidental Injury, Notice of Incident

Client injured his ankle while playing a recreational game of kickball. He complained of pain during nursing assessment. He was referred to Dallas County Medical Center for outpatient x-ray. X-ray report reveals no fracture present. He was released to return to the facility without restrictions.

PRLU or OLTC

Notice of Incident, Peer Sexual Contact, Visit Compliance Report

During an interview with DHS Licensing regarding a separate matter, Client 2 reported Client 1 coerced him into permitting Client 1 to engage in non-consensual sexual contact. A report was made to the Arkansas Child Abuse Hotline (accepted).

Licensing Specialist: Clayton DeBoer.

This allegation was made during a facility visit on 2/12/24 (interviews were being conducted for allegations made on 2/9/24 by Client 1).

Client 1 stated that two incidents occurred, one in the dayroom in which Client 2 asked Client 1 to touch his privates, and one in his room, in which Client 2 flashed him. Client 1 stated staff were present in the cottage when these incidents occurred, and both took less than 5 minutes.

Client 2 was then interviewed, who reported that Client 1 “put his privates in me” and that Client 1 physically forced this to happen. Client 2 reported this occurred in Client 1’s room, the same evening Client 2 flashed Client 1. After interviews, staff reported the residents will be assigned different cottages and remain on close observation.

CACD investigation was unsubstantiated. Licensing complaint was unfounded.

PRLU or OLTC

Notice of Incident, Self-Harm

Client was sent to Dallas County Medical Center for an outpatient x-ray after reporting hand pain. His report was made during the examination by nursing staff after client punched a cinderblock wall. The x-ray report indicates that no acute fracture or injury was present. He was released to return to the facility without restriction.

PRLU or OLTC

Notice of Incident, Peer Sexual Contact, Visit Compliance Report

Client 1 reported to his therapist that he was forced to inappropriately touch Client 2’s penis. A report was made to the Arkansas Child Abuse Hotline (accepted).

Licensing Specialist: Clayton DeBoer.

Facility visited 2/12/24 and residents interviewed. Client 1 stated that two incidents occurred, one in the dayroom in which Client 2 asked Client 1 to touch his privates, and one in his room, in which Client 2 flashed him. Client 1 stated staff were present in the cottage when these incidents occurred, and both took less than 5 minutes.

Client 2 was then interviewed, who reported that Client 1 “put his privates in me” and that Client 1 physically forced this to happen. Client 2 reported this occurred in Client 1’s room, the same evening Client 2 flashed Client 1. After interviews, staff reported the residents will be assigned different cottages and remain on close observation. Staff reported a new maltreatment report will be made regarding this allegation.

CACD investigation was unsubstantiated. Licensing complaint was unfounded.

PRLU or OLTC

Maltreatment, Notice of Incident, Peer Altercation, Visit Compliance Report

Client exhibited emotional distress and confrontational behavior towards other patients and staff members in her classroom setting, leading to several patients trying to initiate physical altercations with her. A review of the surveillance footage revealed that during the incident, a staff member physically assaulted client by slapping her twice on the back of the head and, while standing, yanked her legs out from under her, causing her to fall to the floor. A report to the Arkansas Child Abuse Hotline was made (accepted). The staff member involved was terminated from employment immediately. Nursing assessment revealed no injury from the incident.

Licensing Specialist: Clayton DeBoer.

Facility visited 2/12/24 and camera footage reviewed which clearly shows staff take client’s legs out from under her causing her to fall to the floor landing on her buttocks. Staff can be seen slapping the top of client’s head twice. Staff/client ratio in video 2:9. Facility cited 109.1g and 905.4g: Staff can be seen on video causing physical harm to client.

An in-service training will conducted on Therapeutic Crisis Intervention De-escalation techniques with the staff member also in the room. A campus-wide in-service will be conducted on the usage of announcing “CODE GREEN” on the walkie talkie communication, requesting additional assistance for de-escalation.

Licensing complaint is founded. 4/29/24 – CACD investigation was unfounded.

PRLU or OLTC

Visit Compliance Report

Licensing Specialist: Clayton DeBoer.

Background checks reviewed for 72 staff. No licensing concerns noted.

PRLU or OLTC

Notice of Incident, Suicide Attempt, Visit Compliance Report

Client was assisting the Activities Director with cleaning and activity preparation in her office. After returning to her living unit, client reported to the supervisor that she had taken a bottle of Ibuprofen from the Activity Director’s desk drawer and swallowed all of the pills. She stated that she regretted her actions immediately after taking them. The bottle was estimated to be ¼ to ½ full (approx. 30-50 pills). She was taken to Dallas County Medical Center ER where she received activated charcoal and fluids. She was placed on 1:1 staffing ratio upon her discharge from the hospital. A safety plan is currently being created.

Licensing Specialist: Clayton DeBoer.

Facility visited 2/8/24 and video was reviewed.

  • Facility cited 908.4: Staff member left Ibuprofen in an unlocked desk drawer. Staff member involved was counseled on the importance of keeping all medications on campus locked up.