Following a complaint investigation survey, the Centers for Medicare and Medicaid Services (CMS) determined that Cumberland Hospital was out of compliance with the Medicare condition of participation for nursing services. CMS found that “the facility failed to ensure adequate nursing staff were available to maintain staff to patient ratio as prescribed, care as prescribed and the safety of patients.” CMS surveyors found that the facility’s neurobehavioral unit was not adequately staffed for the required number of staff to patients after conducting staff interviews and touring the unit. A CMS interview with a staff member (staff #1) revealed that the unit was not adequately staffed and “‘[t]hat’s a problem when you have a mix of kids (patients) on a unit..chronic illness, brain injury…and they go to difference classes.'” Staff #1 went on to report that “there was not a coordination of staff to ensure that the adequate number of staff was maintained at certain times of the day” and that the Unit coordinator would probably not be contacted about the issue “until the situation was out of control.” CMS surveyors also found other instances when the facility failed to provide adequate nursing staff to ensure patient safety. For example, CMS surveyors observed a reshaped metal wire hanger in the room of a patient being treated for anger management and impulse control. Separately, a CMS interview with a patient’s family also revealed safety concerns. The family voiced concerns about the safety of their relative after a certain male patient made several attempts to enter her room. On the fourth attempt, the male patient entered her room and physically struck one of her family members. In order to address the cited deficiencies, the facility submitted a plan of correction which included, among other actions, modifying its deficient nursing service policies and initiating staff training.