King Of Prussia Skilled Nursing And Rehabilitation
KING OF PRUSSIA SKILLED NURSING AND REHABILITATION in KING OF PRUSSIA, PA — inspection on April 30, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 1's wound consult report dated April 22, 2026, revealed Resident 1's wound right heel pressure ulcer was Stage Unstageable measuring Lx W x D 3x4.5.x1.
Unchanged Wound status.
There is moderate exudate (drainage) amount; wound margin is well defined; peri-wound is dry/scaly and necrotic material 50%.
Granulation (moist soft red bumpty tissue) between 0% and 25%- confluent (where multiple linear scratches or scrapes merge together into a single, large, and often haphazardly shaped wound )-beefy red.
Treatment recommendations ?cleanse the area with Dakin's 0.125% (1/4 strength) solution.
Primary dressing Dakin's 0.125% solution dampened gauze (1/4 strength).
Secondary Dressing: Silicone foam adhesive dressing.
This treatment will be done daily and as needed until discontinued.
Review of Resident 1's wound consult report dated April 29, 2026, revealed Resident 1's wound right heel pressure ulcer categorized as Stage Unstageable measuring L x W x D 3.7x5.x1.
There is malodorous odor Unchanged Wound status.
Treatment recommendations ?cleanse the area with Dakin's 0.12.5% (1/4 strength) solution.
Primary dressing Dakin's 0.125% solution dampened gauze (1/4 strength).
Secondary Dressing: Silicone foam adhesive dressing.
This treatment will be done daily and as needed until discontinued'.
Review of Resident 1's March 2026 and April 2026, Treatment Administration Record (TAR) revealed the April 10, 2026, and April 29, 2026, treatment recommendation/order of the wound doctor were not followed and the resident continued to receive the original treatment of Betadine and a foam dressing initiated on March 21, 2026, during which the pressure wound deteriorated.
Interview with the Director of Nursing on April 30, 2026, at 2:45pm confirmed the wound care recommendations from the wound specialist were not followed and the resident's wound care was never changed as recommended on April 10th, 2026, and April 29th, 2026.
The facility failed to ensure Resident 1's wound care changes were followed resulting in a harm of unstageable right heel pressure ulcer with wound deterioration. 28 Pa.
Code 211.11(d) Resident care plan28 Pa.
Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa.
Code 211.10 (d) Resident care policies
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.