Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
of F742 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025131
Every F742 citation surveyors wrote nationally that year.
Facilities cited128
Distinct nursing homes with at least one F742 finding.
The harm level
How severely F742 is cited
16.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J377.0%
K51.0%
L—
Actual harm
G387.2%
H40.8%
I—
No harm, potential for more than minimal
D40477.0%
E377.0%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F742 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F742 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedJune 23, 2026
Based on record review, staff, Medical Director, and family member interviews, the facility failed to ensure Resident #1 received a mental health evaluation and monitoring, failed to implement suicide precautions and failed to heighten awareness amongst all staff after Resident #1 had disclosed suicidal ideations. On 6/8/26 at 10:00pm, Resident #1 was found in his bed with the cord to the bed control wrapped around his neck tight with no breath or pulse. Nurse #2 called a code blue (a facility wide announcement that a resident was not breathing and without a pulse) and began Cardiopulmonary Resuscitation (CPR) while Nurse Aide (NA) #1 called for emergency medical services. …
Based on observations, interviews, and record review conducted during survey, the facility failed to ensure that each resident received necessary behavioral health care and services to attain the highest practicable mental and psychosocial well-being for one (Resident #5) of three residents reviewed for behavioral health. Specifically, upon readmission, the resident had a history of suicidal ideations and a self-harm attempt during a prior hospital stay and the facility failed to develop an individualized behavioral health care plan incorporating specific self-harm interventions. On 08/01/2026, Resident #5 verbalized self-harm statements and immediate protective interventions were not implemented which resulted in the resident causing a self-inflicted superficial cut to their left wrist. …
D · No harm, potential for more than minimal, isolatedSeptember 3, 2026
Based on record review, staff, Nurse Practitioner (NP) #2, On-Call NP, Medical Director, and Family Member #1 interviews, the facility failed to immediately implement a comprehensive plan to ensure highest practicable mental health and psychosocial well-being and failed to immediately notify Family Member #1 when Resident #9 voiced a suicidal ideation with a plan to Nurse Aide (NA) #1 on the 7:00 PM to 7:00 AM shift of 8/11/26-8/12/26. Resident #9 was seen by the Psychiatric NP on 8/11/26 due to his significant anxiety and depressive symptoms, his refusal of his anti-depressant medication and his request to have the medication discontinued. This deficient practice was for 1 of 1 resident reviewed for mental health services (Resident #9). …
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide and implement an infection prevention and control program.
Cited in the same inspection, not caused by one another.
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