Based on observation, interview and record review, the facility failed to ensure Resident #1, who had a history of [REDACTED]. This failure placed Resident #1 at risk of increased thoughts of self harm and potentially acting on them, thus causing self harm and/or death. The facility failed to acknowledge and assess the underlying causes of the ongoing expressions of emotional distress and/or suffering related to multiple factors including cyclical exacerbation of physical illness. Additionally, the facility did not have a system in place for collecting data of target behaviors in order to identify indicators of emotional distress, which are known to be contributing factors for self harm or suicidal thoughts. …
F742 citations in Washington
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
Washington cites F742 less often than its own record predicts
0.87 times the national share — cited less often here than elsewhere.
Of every deficiency written in Washington 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 Washington surveyors wrote
F742 findings written in Washington, 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, interview and record review, the facility failed to ensure a resident with a history of trauma was provided appropriate treatment and services for one of two residents (4) reviewed for mental health treatments. The failure to monitor and evaluate the resident's status and underlying causes for changes in mood/behavior, offer resources and services to help cope with their depression, and create an individualized treatment plan; resulted in psychosocial harm, unmet emotional needs, and a diminished quality of life. Findings included . RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had intact cognition. …
Based on interview and record review, the facility failed to ensure recommendations from mental health consultations were followed up on for 1 of 5 sampled residents (Resident 11) reviewed for unnecessary antipsychotic (mind altering) medications. This failure placed the residents at risk for increased side effects, increased behaviors and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include fracture of right arm, dementia (decline in cognitive function), diabetes (high blood sugar) and heart failure. Resident 11 was not able to communicate needs. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2024 | 0.03% | 0.24× |
| 2025 | 0.10% | 0.87× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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