King Of Prussia Skilled Nursing And Rehabilitation

F 0760 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 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 Resident R1 was discharged [DATE REDACTED], 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 Resident R2's room, asking the resident if they were Resident 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 Resident R2 but Resident Resident R1, after which Employee E1 obtained vital signs of Resident 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 Resident R1 was not administered medications prescribed for another resident, resulting in a significant medication error with actual harm to Resident 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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

King of Prussia Skilled Nursing and Rehabilitation

600 West Valley Forge Road King of Prussia, PA 19406

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on facility policy review, observations and staff interview it was determined the facility failed to properly store medications for one resident reviewed. (Resident 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 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 services28 Pa Code 211.12(d)(5) Nursing services

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