Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#7), with a known history of depression and suicidal ideation out of a total sample of 28 residents. Specifically, for Resident #7, the facility failed to implement and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation (SI). Findings include: Review of the facility policy titled Behavior Management, dated ,d+[DATE], indicated the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. …
F742 citations in Massachusetts
Quality of Life and Care Deficiencies
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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Massachusetts cites F742 more often than its own record predicts
1.92 times the share F742 takes of citations nationally.
Of every deficiency written in Massachusetts in 2025, this is the portion that was F742.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F742 findings written in Massachusetts, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interviews, and records reviewed for one Resident (#381) of 44 sampled residents, the facility failed to provide mental health services to a Resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). Specifically, for Resident #381 the facility failed to implement a physician's order for a psychiatric evaluation or develop a comprehensive plan of care, resulting in increased depression, thoughts of being better off dead, and an emergent hospital evaluation. …
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the facility with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation, the facility failed to ensure behavioral psychiatric services evaluated him/her in a timely manner, following episodes of suicidal behaviors. Findings include: Review of the Facility's policy, titled Consultant Services, dated April 2015, indicated the Facility will identify and facilitate consultant services to meet the residents' needs, to ensure optimum care for each resident/patient through consultant services. Resident #1 was admitted to the Facility in March 2025, diagnoses included suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.68× |
| 2024 | 0.27% | 2.20× |
| 2025 | 0.23% | 1.92× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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