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Based on observation, record review and interview the hospital failed to provide care in a safe setting as evidenced by failure to prevent unsupervised patient access of restricted items in 10 (a-j) of 16 (a-p) rooms observed with assigned patients. Of the 10 rooms, 7 (#R1-#R7) of these patients were on suicidal precautions and/or aggressive/assault precautions.
Findings:

Review of hospital policy provided by S1CNO titled "Control of Contraband and Dress Code", last revised 3/21/2018, revealed in part: "Policy: Beacon Behavioral Hospital is committed to providing a safe, secure, therapeutic environment. As part of this endeavor, clinical staff have identified items that are considered a risk to safety and/or are counter-therapeutic. Such items are considered "contraband." At Beacon Behavioral Hospital there are three categories of Contraband, in part: (1) Restricted: Items that are secured away from patient access but may be used by the patient with staff supervision and/or at scheduled times. Contraband: 1. Restricted items: This category includes any items that a patient will be permitted to access during his hospitalization on a limited basis or with supervision. Items may be secured in a designated locked room or in the nurses' station. Generally included in this category are: a. Toiletries: Toothpaste, Toothbrush, Deodorant (stick or roll-on), Shampoo, Conditioner, Chap stick (unmedicated), Shaving cream (non-aerosol), Shower gel, Hairbrush, and Comb."

On 04/23/2025 at 2:14 PM observation of patient rooms revealed the following with contraband:

'a': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel.
'b': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel.
'c': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel.
'd': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table.
'e': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table
'f': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table
'g': deodorant on bedside table.
'h': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table
'i': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash, large comb, and shower gel on bedside table
'j': bin with toothpaste, toothbrush, deodorant, shampoo, conditioner, mouthwash and shower gel on bedside table

Review of Patient Bed Board dated 04/23/2025 revealed Patient #R1 was assigned to room 'a' and on suicide precautions and assault / aggression precautions.
Review of Patient Bed Board dated 04/23/2025 revealed Patient #R2 was assigned to room 'b' and on suicide precautions.
Review of Patient Bed Board dated 04/23/2025 revealed Patient #R3 was assigned to room 'd' and on suicide precautions.
Review of Patient Bed Board dated 04/23/2025 revealed Patient #R4 was assigned to room 'e' and on suicide precautions.
Review of Patient Bed Board dated 04/23/2025 revealed Patient #R5 was assigned to room 'h' and assault / aggression precautions.
Review of Patient Bed Board dated 04/23/2025 revealed Patient #R6 was assigned to room 'i' and assault / aggression precautions.
Review of Patient Bed Board dated 04/23/2025 revealed Patient #R7 was assigned to room 'j' and on suicide precautions.

During an interview on 04/23/2025 at 2:16 PM, S2DC confirmed the restricted products were not secured away from patient access as above per hospital policy and should be picked up after shower time and placed in the locked patient belonging room until next scheduled use.

Based on record review and interview, the facility failed to ensure routine maintenance was performed at the offsite location. The deficient practice is evidenced by 1) non-working light bulbs; 2) stained and damaged ceiling tiles; 3) missing laminate covering on restroom doors; and 4) dirty window coverings throughout the facility.
Findings:

1)Non-working light blubs
Tour of the off-site facility on 04/23/2025 between 1:45 PM and 2:20 PM revealed one non-working light bulb in room A, 1 non-working light in room B, 2 non-working light bulbs in room C, 3 non-working light bulbs in room G, 5 non-working light bulbs in room L, and 3 non-working light bulbs in room P.

2) Stained and damaged ceiling tiles
Tour of the off-site facility on 04/23/2025 between 1:45 AM and 2:20 PM revealed a partially down tiles in rooms E, G, H, K, and Q. Stained ceiling tiles in rooms D, K, M and Q and a hole in ceiling tile in room N.

3) Missing laminate covering on restroom doors
Tour of the off-site facility on 04/23/2025 between 1:45 PM and 2:20 PM revealed the laminate had been removed from the edge of the both stall doors in room B and room C and the laminate was also missing along the inside edge of the door frame exposing the particle board.

4) Dirty window coverings
Tour of the off-site facility on 04/23/2025 between 1:45 PM and 2:20 PM revealed fine granular grey material on the blinds and window ledges located in rooms F, G, H, K, and L.

During the tour at the time of discovery, S3RDOO, S4RVP, and S5PD verified the above findings.