King of Prussia SNF: Wrong-Patient Medication Error - PA
The incident at King of Prussia Skilled Nursing and Rehabilitation, documented in a January 29, 2026 complaint inspection, was classified as actual harm. The resident, identified in inspection records as Resident R1, was transferred to a hospital and required intubation and ICU care as a result of the error.
According to a written statement the nurse, Employee E1, provided to the facility on January 11, 2026, she entered the room, asked the patient if she was Resident R2, received an affirmative response, and administered the medications. Another resident later alerted Employee E1 that the patient was not Resident R2. Employee E1 then obtained the patient's vital signs and reported the incident to her supervisor.
The nurse was not available for inspectors to interview. She had been separated from employment and placed on the facility's do-not-hire list before the January 29 inspection.
The Director of Nursing and Nursing Home Administrator confirmed to inspectors that the facility classified the incident as a medication error and acknowledged it resulted in the resident's hospitalization. The facility said it had completed corrective actions by January 12, 2026, including facility-wide audits and medication administration training for all licensed nurses. Sign-in sheets and interviews with six nursing staff members confirmed the training was completed.
The inspection report does not describe Resident R1's condition before the error, what medications she received, or her status after the ICU stay. What it records is that a nurse verified a patient's identity by asking her name, got the wrong answer, and proceeded anyway, and that the consequences required a machine to breathe for her.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 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 incident at King of Prussia Skilled Nursing and Rehabilitation, documented in a January 29, 2026 complaint inspection, was classified as actual harm.
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.