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
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: August 5, 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.