Based on record review and interviews conducted during the survey, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (1) of three (3) residents (Resident #11) reviewed. Specifically, on [DATE] between 5:00 AM and 5:30 AM, Resident #11 had labored breathing and an oxygen saturation level (amount of oxygen in the blood) of 40 percent (normal is 95 -100 percent). The oxygen flow rate was increased to 10 liters per minute without a physician order and the resident's oxygen saturation level dropped to 26 percent on 10 liters of oxygen. The physician was not notified of the resident's significant change in respiratory status. …
F580 citations in New York
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New York cites F580 less often than its own record predicts
0.69 times the national share — cited less often here than elsewhere.
Of every deficiency written in New York in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New York surveyors wrote
F580 findings written in New York, 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 record review and interviews, the facility failed to consult with the physician when there was a significant change in a resident's physical status for one of three residents (Resident #1) reviewed. Specifically, Resident #1 had an acute physical decline on 05/24/2026, including inability to swallow, unresponsiveness, and increased signs and symptoms of discomfort, and the physician was not notified of the resident's change in status. Resident #1 was subsequently hospitalized upon the family's request and diagnosed with sepsis (extreme response to infection). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. …
Based on record review, and interviews, conducted during survey, the facility failed to ensure the resident or resident's representative was immediately notified of a significant change in the resident's physical status. This was evident for one of three residents (Resident #1) reviewed for notification. Specifically, on 03/06/2026 at 3:30 PM, License Practical Nurse #1 documented Resident #1 was observed with redness and skin tear to the sacral area and notified the Physician #1. There was no documented evidence that Resident # 1's adult child (the Complainant) was notified of skin changes on 03/06/2026. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 1.46% | 1.02× |
| 2024 | 1.09% | 0.71× |
| 2025 | 1.03% | 0.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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