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. …
F742 citations in North Carolina
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 — 2023
North Carolina cites F742 less often than its own record predicts
0.43 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina in 2023, 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 North Carolina surveyors wrote
F742 findings written in North Carolina, 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, record review, and interviews with resident, Psychiatric Nurse Practitioner (PNP), psychotherapist, and staff, the facility failed to promptly obtain psychotherapy services as ordered by the PNP for a resident (Resident #4) with a [DIAGNOSES REDACTED]. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of nursing notes dated 7/13/18 indicated Resident #4 had frequent episodes of crying and made statement he didn ' t want to live any more. The physician was notified, and an order was obtained for a psychiatric consultation and for [MEDICATION NAME] (antidepressant medication). Resident #4 was placed on suicide precautions with hourly checks conducted by nursing staff. …
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). …
What else North Carolina surveyors cite →
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