King of Prussia Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at King of Prussia Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 30, 2026

  Based on a review of facility's policy, facility documentation, clinical records, and staff interview, it was determined the facility failed to follow wound physician's treatment orders/recommendations and provide consistent and appropriate treatment for an Unstageable Pressure Ulcer on the right heel (obscured full-thickness skin and tissue loss), resulting in wound deterioration and actual harm for one of four residents reviewed. (Resident 1)Findings include:Review of the facility's policy titled Skin Integrity and Wound Management, reviewed September 15, 2025, revealed Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. […]

• Actual harm, isolatedF760Jan 29, 2026

  Based on observation, record review, and staff interviews, the facility failed to ensure residents were free from significant medication errors, resulting in actual harm when Resident R1 required transfer to the hospital with the need for intubation and admission to the Intensive Care Unit, this was found to be a past noncompliance incident for one of 15 residents reviewed. (Resident R1) Findings include:Review of the facility policy titled Medication Administration, dated January 2025, revealed that prior to medication administration, staff are required to review and confirm medication orders for each resident on the Medication Administration Record (MAR) and compare the medication label with the MAR.Review of Rights of Medication Administration, revealed the following:Right patient: you… […]

• Actual harm, isolatedF600Oct 12, 2021

  Based on review of clinical records, review of facility documentation, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to ensure that Resident R1 was free of neglect for one of nine clinical records reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who was not properly turned in bed while receiving incontinence care, resulting in a fall and sustaining a fracture to cervical vertebra. Findings include: Review of the facility policy titled Incontinence Care dated August 2014, revealed the caregiver is to assist to side lying position by turning towards care giver, unless more than one caregiver is present. […]

• Actual harm, isolatedF657Oct 12, 2021

  Based on review of clinical records, review of facility documentation, review of facility policy and interviews with residents and staff, it was determined that the facility failed to ensure that comprehensive care plans for fall prevention were developed for one of nine clinical records reviewed (Resident R1). This failure resulted in actual harm to Residents R1 who sustained a fall resulting in fracture to the cervical vertebra. Findings include: Review of the facility policy titled Falls Practice Guide dated December 12, 2011, revealed that If, upon completion of the Patient Admission/Readmission Screen, the patient is found to be at risk or has a history of falls, the physician is contacted for orders as appropriate; an initial plan of care is developed and individualized… […]

• Actual harm, isolatedF689Sep 9, 2021

  Based on review of facility policy, clinical record review and interviews with staff and residents, it was determined that the facility failed to ensure that one of 30 residents reviewed (Resident R86) received the appropriate level of assistance during a transfer from the chair to the bed. This failure resulted in actual harm to Resident R86 who sustained a right humerus fracture requiring transfer to the hospital. The facility failed to ensure appropriate staff supervision and maintain an environment free of potential hazards related to an alleged ingestion of hand sanitizer for one of 30 residents reviewed. […]