Following a complaint investigation survey, the Centers for Medicare and Medicaid Services (CMS) found Cumberland Hall to be out of compliance with the conditions of Medicare participation pertaining to nursing services and patients’ rights to a safe care setting. CMS found that failures in performing routine patient searches (upon admission and following visitation) and in monitoring patients placed under 1:1 observation “placed patients at risk for injury, harm, impairment or death.” The cited deficiencies relate to an incident in which a patient with a previous history of attempted suicide engaged in another attempt with smuggled contraband. The patient (who wore an insulin pump) refused be searched upon admission and after visitation and was able to smuggle a vial of insulin and two syringes into the facility. The patient’s search refusal upon admission was not reported to the nurse on the unit and the “Admissions Check List” erroneously indicated the search had been completed. Following the visitation, the patient was asked to change his/her bra because it contained an underwire. Even though the patient was placed on 1:1 observation and accompanied to the restroom by a MHT (mental health tech), he/she was able to successfully transfer the smuggled contraband while changing. That night, the patient attempted suicide by injecting himself/herself with insulin six times. The patient was then taken to an emergency department via ambulance. As a result of the incident, the facility was required to initiate corrective actions such as prohibiting employees from conducting searches until they successfully completed a two tier training and demonstrated competency.