Pennsylvania Department of Health
KING OF PRUSSIA SKILLED NUSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KING OF PRUSSIA SKILLED NUSING AND REHABILITATION CENTER
Inspection Results For:

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KING OF PRUSSIA SKILLED NUSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Findings of an Abbreviated Complaint Survey completed on January 30, 2026, at King of Prussia Skilled Nursing and Rehabilitation, identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations: Based on observation, record review, and staff interviews, the facility failed to ensure residents were free from significant medication errors, resulting in actual harm when Resident R1 required transfer to the hospital with the need for intubation and admission to the Intensive Care Unit, this was found to be a past noncompliance incident for one of 15 residents reviewed. (Resident R1) Findings include: Review of the facility policy titled "Medication Administration," dated January 2025, revealed that prior to medication administration, staff are required to review and confirm medication orders for each resident on the Medication Administration Record (MAR) and compare the medication label with the MAR. Review of Rights of Medication Administration, revealed the following: Right patient: you must have 2 resident identifiers prior to administering medications (examples: photo, name band, name/DOB verification)Right drug: this requires a triple check to ensure accuracyRight dose: this requires a triple check to ensure accuracyRight route: in which the medication is given (IV, PO, SQ, Topical, etc)Right time and frequencyRight to refuse: all residents have the right to refuse medications and treatments. If they do refuse, it must be documented as such.Resident R1 was admitted to the facility on December 31, 2025, with diagnoses that include unspecified sequelae of cerebral infarction (stroke). Major Depressive Disorder (persistent feelings of sadness and loss of interest in activities), generalized anxiety disorder (persistent and excessive worry about various aspects of life), and adult Failure to Thrive. Review of information submitted to the state agency on January 12, 2026,revealed that on January 11, 2026, at approximately 8:00 p.m., Resident R1 was administered nine medications prescribed to another resident (Resident R2). The medications administered in error included: Hydralazine 50 mg (for high blood pressure)Buprenorphine 8 mg sublingual (for chronic pain)Quetiapine 25 mg (antipsychotic)Prazosin 1 mg (for high blood pressure)Clonidine 0.3 mg (for high blood pressure)Lorazepam 0.5 mg (antianxiety)Melatonin 5 mg (sleep aid)Mirtazapine 45 mg (antidepressant)Atorvastatin 40 mg (for high blood pressure)Further review of the Electronic Event submitted to the state agency on January 12, 2026 revealed The nurse notified the supervisor that she made a medication error. The supervisor immediately assessed the resident, and V/S (vital signs) were taken. The resident was awake but drowsy, has good po (oral) intake, b/p (blood pressure) 110/61 (normal 120/80), O2 sat (measurement of how much oxygen is in the blood) was 72% (normal above 90%). O2 2L (supplemental oxygen) was placed on the resident and pulse ox went up to 94%. The MD (medical doctor) was notified and gave the order to monitor, give oxygen, start neuro checks (a series of rapid or comprehensive evaluations assessing brain, spinal cord, and nerve function, typically including mental status (alertness/cognition), cranial nerve assessment (vision/pupils), motor strength, coordination, and reflexes) and call with any changes. The resident's RP (responsible party) was notified. Around 10:20 pm the supervisor called the MD back to report the resident is now lethargic and is only arousable to sternal rub and is now snoring. their B/P was 51/73. The MD gave an order to send to the ER (Emergency Room) for evaluation. Review of hospital records revealed Resident R1 was admitted with a diagnosis of accidental drug overdose, required intubation (flexible tube is inserted into the windpipe to maintain an open airway, deliver oxygen, or allow a ventilator to breathe for a patient) in the emergency department, and was subsequently transferred to the intensive care unit (ICU). Hospital records further revealed Resident R1 was discharged January 27, 2026, and transferred to another skilled nursing facility. Interview was unable to be conducted due to Licensed staff member Employee E1 was unavailable for interview due to separation from employment and placement on the facility's do-not-hire list. Review of written statement provided by Licensed staff member Employee E1, dated January 11, 2026, revealed Employee E1 reported entering the Resident R2's room, asking the resident if they were Resident R2, receiving an affirmative response, and administering the 8:00 p.m. medications. The statement further revealed that Employee E1 was later alerted by another resident that the individual was not Resident R2 but Resident R1, after which Employee E1 obtained vital signs of Resident R1 and reported the incident to the supervisor. Interviews conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on January 29, 2026, at approximately 10:50 a.m. revealed the facility implemented facility-wide audits, change-in-condition training, and medication administration training, and the Rights of Medication Administration. Review of training documentation revealed 100% of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) completed the identified training. Interviews conducted with licensed staff Employees E2, E3, E4, E5, E6, and E7 confirmed receipt of the training, which was verified through sign-in sheets. During a follow-up interview conducted with the DON and NHA at approximately 11:13 a.m., facility leadership confirmed the incident was identified as a medication error and acknowledged the resident required hospitalization as a result. The facility failed to ensure Resident R1 was not administered medications prescribed for another resident, resulting in a significant medication error with actual harm to Resident R1 who was transferred to the hospital and required intubation and care in the Intensive Care Unit. This was a past non-compliance situation with the facility completing the above interventions on January 12, 2026. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 02/23/2026

Past noncompliance: no plan of correction required.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations: Based on facility policy review, observations and staff interview it was determined the facility failed to properly store medications for one resident reviewed. (Resident R6) Findings include: Review of facility policy "storage of Medication" dated January 2025. Revealed "The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including those established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. During an onsite investigation conducted on January 29, 2026, at approximately 10:15 a.m., an unidentified pill on the floor outside the entrance of Resident R6's room. The pill was not labeled, packaged, or stored in a secure medication container. Interview with licensed employee E13 conducted on January 29, 2026, at 12:20 p.m. revealed staff were unable to identify the pill and could not determine which resident, if any, the medication was prescribed to. Interview with the Director of Nursing, conducted on January 29, 2026, at approximately 12:33 p.m. confirmed that medications are required to be secured at all times and acknowledged that an unidentified pill found outside a resident room posed a risk for unintended ingestion. The facility failed to ensure medications were properly controlled. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 02/24/2026

R6 medications were checked and loose pill that was found was not prescribed to resident. The resident received his medication.
The facility will conduct an audit if residents prescribed metoprolol 50 mg to ensure those residents received their medication.
The Staff developer or designee will educate licensed nurses on facility policy and procedure for label/storage drugs and biologicals.
The unit manager or designee will audit medication carts to ensure medication is labeled, packaged and stored in a secure medication container. Any loose pills identified as not meeting facility requirements will be discarded per protocol. Audits will be done weekly x4 then monthly x2. The results of these audits will be brought to QAPi.

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