Riveredge Hospital was cited by the Centers for Medicare and Medicaid Services (CMS) for deficiencies related to training of core staff on the pediatric unit regarding interventions for patients who act out sexually. Two 8-year-old male patients who were ordered to be placed on “sexual acting out” precautions were in the day room without any staff for a 17-minute period and subsequently reported sexual activity. CMS found that even though a nurse had visual and verbal contact with the patients from the nursing station, clinical judgment would have warranted a staff member to be physically present in the room. In another incident, a patient was allegedly sexually assaulted by another patient. CMS found the hospital failed to timely adjust the attacker patient’s observation precautions, thus placing 13 patients on the unit at risk for assault.