Based on review of facility documentation, observation and staff interview it was determined that the facility failed to ensure that the residents received appropriate treatment and services to correct assessed problems associated to an event of self-harm for one of two residents reviewed (Resident R1) resulting in actual harm, transfer to the hospital (Resident R1); and the investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services, resulting in an Immediate Jeopardy situation for one of 108 residents (Resident R1). …
F742 citations in Pennsylvania
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
Pennsylvania cites F742 more often than its own record predicts
1.88 times the share F742 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F742 findings written in Pennsylvania, 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 clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to prevent physical and verbal behaviors, and/or failed to develop and implement new interventions to address ongoing physical and verbal behaviors for two of 44 residents reviewed (Residents 8, 68) resulting in psychosocial harm for one resident (Resident 68). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 31, 2026, indicated that the resident was severely cognitively impaired, had verbal behaviors directed at others 1-3 days, and had diagnoses that included dementia. …
Based on clinical record review and staff and resident interviews, it was determined the facility failed to provide or arrange individualized treatment and services to address identified mental and psychosocial needs for one of 13 residents reviewed (Resident 12). Findings include: A clinical record review revealed Resident 12 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and chronic kidney disease (gradual loss of kidney function). …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.10% | 0.86× |
| 2024 | 0.14% | 1.15× |
| 2025 | 0.23% | 1.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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