Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to notify and consult with a resident's physician regarding a significant change in condition for one of five sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of the facility policy entitled, Physician/Advanced Practice Provider (APP) Notification, dated [DATE], revealed that upon identification of a resident who has a change in condition, abnormal laboratory values, or abnormal diagnostics (tools used to identify, confirm, monitor, or rule out diseases and health conditions), a licensed nurse would perform… …
F580 citations in Pennsylvania
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
Pennsylvania 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 Pennsylvania 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 Pennsylvania surveyors wrote
F580 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of six residents reviewed (Resident 2) who required hospitalization for hypoxia, congestive heart failure and pleural effusion.Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 22, 2026, indicated that the resident had severe cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included heart failure (heart muscle cannot pump blood and oxygen effectively enough to meet the body's needs). A nurse's note for Resident 2 dated April 16, 2026, at 6:35 p.m. …
Based on select facility policy, a review of clinical records, and staff interviews, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one out of 31 residents reviewed (Resident 171).Findings include: A review of a facility policy for Acute Change in Condition last reviewed January 29, 2026, revealed the purpose of the policy is to ensure that the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status or when there is a need to alter treatment significantly. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 1.68% | 1.17× |
| 2024 | 1.52% | 1.00× |
| 2025 | 1.03% | 0.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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