Old Vineyard Behavioral Health was cited by the Division of Health Service Regulation for failing to maintain line-of-sight monitoring of residents on a unit where all patients had histories of sexual offenses and aggressive behaviors. Two male residents, one 12 years old and the other 13 years old, were found engaging in oral sex and masturbation in the unit’s day room while other patients were at lunch. An RN was responsible for monitoring the patients, but was also simultaneously responsible for dispensing medications and watching two other patients, one of whom was on another unit. When interviewed, the nurse said, “I was watching (all 4 of the residents – 3 on Phoenix 12 and 1 on Phoenix 9) from the med(ication) room. I was watching the dayroom the best I could.” In its plan of correction, the facility agreed to increase the number of direct care staff by two and create a position for a full time Assistant Director of Nursing. Old Vineyard was also cited for failures to properly document, observe and restrict the mobility of residents placed on Special Precaution Levels due to diagnoses and behavior. Two residents, one 15 years old and one 13 years old, were ordered to have progress notes on their status recorded every four hours, but their records showed numerous periods where no progress notes were recorded, with the longest period being over 26 hours long. Additionally, the facility did not ensure that residents placed on room restriction stayed on the unit, with some allowed to go to the cafeteria for lunch and leave the building for outside activities. In one instance, three residents who were on Room and Unit Restrictions were allowed to participate in an outside activity and managed to elope from the facility. The Mental Health Counselor in charge of the residents during the activity revealed in interviews he was not aware that the patients were on restricted status.