King of Prussia Skilled Nursing: Wrong Medication ICU - PA
The mix-up sent the resident to the hospital with an accidental drug overdose requiring emergency intubation and intensive care.
Employee E1 entered Resident R2's room and asked the person inside if they were Resident R2. The individual said yes. Employee E1 administered the 8 p.m. medications prescribed for Resident R2.
But the person in the room was actually Resident R1.
Another resident later alerted Employee E1 that the wrong person had received the medications. Only then did Employee E1 take vital signs and report the incident to a supervisor.
Hospital records show Resident R1 required intubation in the emergency department after the overdose. A flexible tube was inserted into their windpipe to maintain an open airway and allow a ventilator to breathe for the patient. Resident R1 was transferred to intensive care, then later moved to another skilled nursing facility.
Employee E1 provided a written statement about the incident on January 11, 2026, but was unavailable for interview during the state inspection. The employee had been terminated and placed on the facility's do-not-hire list.
Facility leadership confirmed during interviews that they classified the incident as a medication error and acknowledged the resident required hospitalization as a result.
The facility implemented facility-wide audits, medication administration training, and change-in-condition training after the incident. All licensed practical nurses and registered nurses completed the training, verified through sign-in sheets.
State inspectors found the facility failed to prevent Resident R1 from receiving medications prescribed for another resident, resulting in actual harm that required emergency hospitalization and intensive care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for King of Prussia Skilled Nursing and Rehabilitation from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for King of Prussia Skilled Nursing and Rehabilitation
- Browse all PA nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 12, 2026 · Our methodology
KING OF PRUSSIA SKILLED NURSING AND REHABILITATION in KING OF PRUSSIA, PA was cited for violations during a health inspection on January 29, 2026.
The mix-up sent the resident to the hospital with an accidental drug overdose requiring emergency intubation and intensive care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at KING OF PRUSSIA SKILLED NURSING AND REHABILITATION?
- The mix-up sent the resident to the hospital with an accidental drug overdose requiring emergency intubation and intensive care.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in KING OF PRUSSIA, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from KING OF PRUSSIA SKILLED NURSING AND REHABILITATION or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395834.
- Has this facility had violations before?
- To check KING OF PRUSSIA SKILLED NURSING AND REHABILITATION's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.