Inspection visit

Health inspectionSeptember 29, 2023

KING OF PRUSSIA SKILLED NURSING AND REHABILITATIONCMS #39583430 citations on this visit

30 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 30 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage, or failed to provide 48-hour advanced notice, for one of three residents reviewed (Resident 122). Residents Affected - Some Findings include: Resident 122's medical record revealed that he began Medicare A services on June 15, 2023, and her last covered day was July 7, 2023. The medical record indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The facility had no documented evidence that the resident was issued a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form or an Advance Beneficiary Notice (ABN) as required. Interview with the Nursing Home Administrator on September 28, 2023, at 4:08 p.m. revealed that Resident 122 was not issued a SNF Beneficiary Protection Notification Review form or an ABN and that she should have been. 28 Pa. Code 201.18(e)(1) Management. Page 1 of 36 395834 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with residents and staff, it was determined that the facility failed to provide a clean and homelike environment on one of four nursing units. Findings included: Observations of the Arcadia unit on September 27, 2023, at 10:14 a.m. in room [ROOM NUMBER] revealed that the over-the-bed table by the door was covered with a coating of what looked like dried milk and the laminate on the table had peeled off in some spots exposing the particle board underneath. The wall at the foot of the beds had a large area of wall paper (approximately twenty-four inches tall by twelve inches wide) that was torn away and hanging loose. The room had an odor of urine, and the floor was dirty with a build up of grime, food and paper debris. The entire end wall of the resident's closet, approximately twenty-four inches wide, extending upward approximately eighteen inches, had signs of water damage. The wall was warped and the base board had pulled away from the wall in several spots exposing the drywall. On the other side of the closet wall, was the bathroom. The bathroom floor showed signs of water damage and there was an overwhelming odor of urine. The linoleum flooring in front of the bathroom sink had an area approximately twelve inches in size that was warped and bubbled, making it a trip hazard. Observations of room [ROOM NUMBER] on September 27, 2023, at 10:23 a.m. revealed a large area of wall paper approximately eighteen inches tall by six inches wide that was torn away and hanging loose. Observations of the hall floor on the Arcadia unit on September 27, 2023, at 10:30 a.m. revealed a build up of grime and dirt against the base boards along the entire length of the unit. The floor appeared to have a build up of dirt, and there were black scuff marks on the wall in several areas under the handrail. The overall appearance of the Arcadia unit was dirty and unkempt. Interview with Housekeeping/Floor Technician 1 on September 28, 2023, at 9:30 a.m. revealed that he was responsible for cleaning the floors and that he would take care of them. He agreed that the bathroom in room [ROOM NUMBER] needed to be cleaned. He stated that he tries to do every room every day but is not able to get to all of them. Interview with the Nursing Home Administrator on September 27, 2023, at 11:50 a.m. revealed that the facility has no current plans for renovations in the facility. A tour of the Arcadia unit on September 28, 2023, at 1:05 p.m. with Senior Maintenance Director 2 confirmed that the unit had issues and stated, I one hundred percent agree with you that it should not look like this and needs to be addressed. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility. 395834 Page 2 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to implement its written abuse prevention policies, by failing to ensure that reference checks were obtained prior to hire for one of five employee files reviewed (Nurse Aide 12). Residents Affected - Few Findings include: The facility's policy regarding abuse prohibition, undated, indicated that the facility would screen potential employees for a history of abuse, neglect, or mistreating residents, including attempting to obtain information from previous employers and/or current employers and checking with appropriate licensing boards and registries. The personnel file for Nurse Aide 12 revealed a hire date of July 13, 2023. There was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that they were not able to provide any evidence that employment reference checks were obtained prior to hire for Nurse Aide 12. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 395834 Page 3 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for nine of 56 residents reviewed (Residents 8, 22, 23, 24, 27, 28, 49, 50, 51). Residents Affected - Few Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the calendar days. A quarterly MDS assessment for Resident 8 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 22 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 23 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 24 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 27 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 28 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 49 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. A quarterly MDS assessment for Resident 50 had an ARD of August 19, 2023, but it was not completed (Section Z0500B) until September 6, 2023. A quarterly MDS assessment for Resident 51 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days. An interview with Clinical Reimbursement Coordinator 13 (CRC- ensures that healthcare providers receive the correct reimbursement for the services offered) on September 28, 2023, at 11:36 a.m. confirmed that the above referenced quarterly MDS assessments were completed late. 28 Pa. Code 211.5(f) Clinical records. 395834 Page 4 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for one of 56 residents reviewed (Resident 106). Findings include: The facility's policy regarding baseline care plans, undated, revealed that the center must develop and implement a baseline person-centered care plan with 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 106, dated September 20, 2023, revealed that the resident was admitted from the hospital on September 14, 2023, was understood, could understand, and required extensive assistance from staff for his daily care tasks. Physician's orders for Resident 106, dated September 14, 2023, included an order to ensure that personal protective equipment (PPE) is available (gown and gloves), to wear PPE during high contact activities, and place sign on the door to ensure visitors see staff prior to entering the room. A nursing note for Resident 106, dated September 14, 2023, revealed that the resident arrived at the facility from the hospital at 6:15 p.m. The resident's admission diagnosis was Urinary Tract Infection (UTI) due to extended-spectrum beta-lactamase (ESBL - an enzyme that is produced by bacteria to become resistant to certain antibiotics) producing Escheria coli (a type of bacteria that normally lives in your intestines). Observations of Resident 106 on September 27, 2023, at 10:04 a.m. revealed that the door to the resident's room was closed. There was a sign on the resident's doorway indicating to stop see nurse for instructions, as well as a three-drawer plastic bin outside the resident's room containing PPE. As of September 27, 2023, there was no documented evidence that a baseline care plan with individualized interventions to meet Resident 106's immediate care needs for his isolation related to ESBL was developed within 48 hours of his admission on [DATE]. Interview with the Director of Nursing on September 28, 2023, at 2:35 p.m. confirmed that there was no documented evidence that any individualized interventions were developed to meet Resident 106's immediate care needs for his isolation related to ESBL. 28 Pa. Code 211.11(e) Resident care plan. 395834 Page 5 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs for two of 56 residents reviewed (Residents 88, 95). Findings include: The facility's current policy for Person-Centered Care Plans indicated that a comprehensive, individualized care plan for each resident will be developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) and the care plan will be reviewed and revised after each assessment. An annual MDS assessment for Resident 88, dated, August 2, 2023, revealed that the resident was cognitively intact, was independent with personal care needs, and had diagnoses that included diabetes, renal (kidney) failure, and deep vein thrombosis (blood clot). Physician orders for Resident 88, dated July 28, 2023, included for the resident to receive sliding scale (insulin dose varies based on blood sugar levels) insulin lispro (rapid acting insulin used to treat high blood sugar) one time a day for diabetes. There was no documented evidence that a care plan was developed to address Resident 88's individual care and treatment needs related to his diagnosis of diabetes, which required blood sugar checks and as-needed insulin administration. An interview with the Director of Nursing on September 29, 2023, at 2:51 p.m. confirmed that a care plan to address the care needs related to Resident 88's diabetes was not developed and should have been. A significant change MDS assessment for Resident 95, dated August 15, 2023, revealed that he had clear speech, was understood and could understand, required extensive assistance for care needs, does not ambulate, has an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine), and has diagnoses that include cancer and diabetes. Physician's orders for Resident 95, dated August 15, 2023, included an order to maintain the foley catheter with a size 16FR/10cc, and to monitor patency and maintain cover over bag every shift. There was no documented evidence that a care plan was developed to address Resident 95's care needs and treatment related to his indwelling urinary catheter. An interview with the Director of Nursing on September 29, 2023, at 2:51 p.m. confirmed that a care plan to address the care needs related to Resident 95's indwelling urinary catheter was not developed and should have been. 28 Pa. Code 211.11(d) Resident care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395834 Page 6 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 56 residents reviewed (Resident 84). Findings include: The facility's current policy for person-centered care plans indicated that care plans would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 7, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance for personal hygiene needs, had diagnoses that included dementia and generalized muscle weakness, and was receiving hospice care. A review of care plans for Resident 84, dated October 21, 2022, included that the resident was receiving chemotherapy related to breast cancer and should be free of complications related to chemotherapy side effects. Interview with the Director of Nursing on September 28, 2023, at 1:42 p.m. confirmed that Resident 84 was receiving hospice care services and was no longer receiving chemotherapy; therefore, her care plan should have been revised but was not. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 7 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for 13 of 56 residents reviewed (Residents 18, 24, 27, 32, 33, 54, 64, 71, 84, 95, 101, 103, 112). Residents Affected - Some Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated August 8, 2023, indicated that the resident was understood and able to understand others, required supervision with personal hygiene needs, assist of one with transfers, bathing did not occur, and it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Bathing documentation for August 1 through September 26, 2023, indicated that Resident 18 was to receive a shower/bath during the day shift on Monday and Thursdays. There was no documented evidence that the resident received a shower during the month of August. Documentation also revealed that the resident only received one shower during the month of September, which occurred on the 18th. Interview with Resident 18 on September 27, 2023, at 10:10 a.m. revealed that she does not get showers or baths very often. A quarterly MDS assessment for Resident 24, dated July 13, 2023, revealed that the resident required extensive assistance for daily care needs and was dependent on staff for bathing. Review of daily nurse aide documentation, including baths and showers for Resident 24 for August and September 2023, revealed multiple days that were blank. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:25 p.m. confirmed that she had no documented evidence that the care was done. A quarterly MDS assessment for Resident 27, dated July 13, 2023, revealed that the resident was cognitively intact and required extensive assistance from staff for personal hygiene, that she had not bathed in the last seven days, and it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Bathing documentation for August 1 through September 26, 2023, indicated that Resident 27 was to receive a shower/bath during the day shift on Sunday and Thursdays. There was no documented evidence that the resident received a shower on August 10, August 24, September 3, September 7, September 10, September 14, September 17, or September 21. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:22 p.m. revealed that there was no documented evidence that Resident 27 had been showered or bathed, or offered and refused, a shower or tub bath on the above referenced dates and that she should have been. A quarterly MDS assessment for Resident 32, dated August 30, 2023, indicated that the resident was cognitively intact and was dependent on staff for transfers and bathing. An annual MDS assessment, dated December 7, 2022, indicated that it was very important for the resident to choose between a bed bath, sponge bath, tub bath, or shower. 395834 Page 8 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Bathing documentation for July 1 through September 25, 2023, indicated that Resident 32 was to receive a shower/bath during the day shift on Tuesday and Fridays. There was no documented evidence that the resident received a shower/bath on July 4, 7, 11, 21, 25, 28; August 1, 8, 18, 22, 25; and September 5 and 8, 2023. Interview with Resident 32 on September 27, 2023, at 10:30 a.m. revealed that he was not getting showered like he should be. Interview with Licensed Practical Nurse 3 on September 29, 2023, at 12:29 p.m. confirmed that there was no documented evidence that Resident 32 received a shower/bath on the mentioned dates. A quarterly MDS assessment for Resident 33, dated August 21, 2023, revealed that the resident required extensive assistance for daily care tasks and was dependent on staff for bathing. Review of daily nurse aide documentation, including baths and showers for Resident 33 for August and September 2023, revealed multiple days that were blank. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:25 p.m. confirmed that she had no documented evidence that the care was done. An annual MDS assessment for Resident 54, dated July 13, 2023, revealed that the resident required limited assistance for daily care tasks and bathing. Review of daily nurse aide documentation, including baths and showers for Resident 54 for August and September 2023, revealed multiple days that were blank. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:25 p.m. confirmed that she had no documented evidence that the care was done. A quarterly MDS assessment for Resident 64, dated August 21, 2023, revealed that the resident was cognitively intact, required extensive assistance with transfers, and was dependent on staff for bathing. An admission MDS, dated [DATE], indicated that it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Bathing documentation for August 1 through September 26, 2023, indicated that Resident 64 was to receive a shower/bath during the day shift on Saturdays and Wednesdays. There was no documented evidence that the resident received a shower/bath on August 2, 5, 9, 12, 16, 26 and September 2, 6, 9, 13, and 23, 2023. Interview with Resident 64 on September 27, 2023, at 10:30 a.m. revealed that she does not feel she gets good personal care from most staff at the facility. A quarterly MDS assessment for Resident 71, dated June 15, 2023, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care needs including bed mobility and transfers, and was dependent on staff for bathing. An annual MDS assessment, dated March 15, 2023, indicated that it was very important for the resident to choose between a bed bath, sponge bath, tub bath, or shower. Bathing documentation for July 1 through September 25, 2023, indicated that Resident 71 was to receive a shower/bath during the evening shift on Monday and Thursdays. There was no documented evidence that the resident received a shower/bath on August 3, 7, 10, 17, 21, 28, 31, and September 4, 14, 395834 Page 9 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0677 and 18, 2023. Level of Harm - Minimal harm or potential for actual harm Interview with Resident 71 on September 27, 2023, at 10:35 a.m. revealed that she was not getting showered like she should be. Residents Affected - Some Interview with Licensed Practical Nurse 3 on September 29, 2023, at 12:29 p.m. confirmed that there was no documented evidence that Resident 71 received a shower/bath on the mentioned dates. A quarterly annual MDS assessment for Resident 84 dated August 7, 2023, indicated that the resident was usually understood and could usually understand others, required limited assistance for transfers, and physical assistance of one for bathing. A significant change MDS, dated [DATE], indicated that it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Bathing documentation for August 1 through September 26, 2023, indicated that Resident 84 was to receive a shower/bath during the day shift on Mondays and Thursdays. There was no documented evidence that the resident received a shower/bath on August 3, 7, and September 7, 11, 14, 21, 25, 2023. A quarterly MDS assessment for Resident 95, dated September 19, 2023, revealed that the resident required extensive assistance with all care, including bathing. Review of daily nurse aide documentation, including baths and showers for Resident 95 for August and September 2023, revealed multiple days that were blank. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:25 p.m. confirmed that she had no documented evidence that the care was done. An admission MDS assessment for Resident 101, dated August 14, 2023, revealed that the resident was cognitively intact and required assistance from staff for her daily care needs including bathing. A review of Resident 101's bathing/showering record, dated August and September 2023, revealed that as of September 28, 2023, the resident had not received a shower or tub bath since her admission to the facility on August 7, 2023. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:22 p.m. revealed that there was no documented evidence that Resident 101 had been showered or bathed, or offered and refused, a shower or tub bath since her admission. A nursing note for Resident 103, dated September 20, 2023, revealed that the resident was admitted to the facility and that the resident was alert and oriented. Bathing documentation for September 20 through 28, 2023, indicated that Resident 103 was to receive a shower/bath during the evening shift on Mondays and Thursday. There was no documented evidence that the resident received a shower/bath on Monday September 25, 2023, and on Thursday September 21 and 28, 2023. A nursing note for Resident 112, dated September 20, 2023, revealed that the resident was admitted to the facility and that the resident was alert and oriented. Bathing documentation for September 20 through 28, 2023, indicated that Resident 112 was to receive a shower/bath during the evening shift on Mondays and Thursday. There was no documented evidence 395834 Page 10 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the resident received a shower/bath on Monday, September 25, 2023, and on Thursday, September 21, 2023. Interview with Licensed Practical Nurse/Unit Manager 3 on September 29, 2023, at 12:27 p.m. confirmed that there was no documented evidence that Residents 103 and 112 received a shower/bath on the mentioned dates. Interview with the Director of Nursing on September 29, 2023, at 12:27 p.m. confirmed there was no documented evidence that showers/baths were provided to the above-mentioned residents, and they should have been provided showers/baths as indicated on their shower schedules. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 11 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for four of 56 residents reviewed (Residents 23, 29, 88, 96). Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated August 16, 2023, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs. Physician's orders for Resident 23, dated February 16, 2023, included an order for the resident to receive 25 milligrams (mg) Hydralazine (blood pressure medication) if her systolic (top number) blood pressure is greater than 180 two hours after her Lisinopril (blood pressure medication) was administered. Resident 23's Medication Administration Record (MAR) for August 2023 revealed that the resident's blood pressure was 181/95 on August 12, 190/62 on August 16, and 189/73 on August 27. However, there was no indication that the staff rechecked the resident's blood pressure two hours after the administration of Lisinopril or administered the Hydralazine per the physician's orders. Interview with the Director of Nursing on September 29, 2023, at 12:39 p.m. confirmed that Resident 23 was not medicated per the physician's orders and she should have been. A quarterly MDS assessment for Resident 29, dated August 18, 2023, revealed that the resident was cognitively intact, had a tracheostomy (surgically created airway in the windpipe), received tracheostomy care, and had diagnoses that included cancer of the tongue. Physician's orders, dated June 20, 2022, included an order for 1 milligram per three days scopolamine patch to be applied every three days for secretions. Resident 29's Medication Administration Record (MAR) for June, July, August and September 2023 revealed that there was no documented evidence that the scopolamine patch was applied on June 28, July 10 and 19, August 24 and 30, and September 8, 11, 17, 20, and 26, 2023. Interview with the Director of Nursing on September 29, 2023, at 2:50 p.m. confirmed that there was no documented evidence that Resident 29's scopalomine patch was applied as ordered on the mentioned dates. An annual MDS assessment for Resident 88, dated August 2, 2023, revealed that the resident was cognitively intact, was independent with personal care needs, and had diagnoses that included diabetes, renal (kidney) failure, and deep vein thrombosis (blood clot). Current physician's orders for Resident 88 included for the resident to receive 500 mg of ascorbic acid (vitamin C) one time a day, 325 mg of ferrous sulfate (use to treat iron deficiency) one time a day, 150 mg of polysaccharide iron complex (iron supplement) one time a day, and 25 mg of Zoloft (antidepressant) one time a day. Review of the MAR for September 2023 revealed there was no documented evidence that these medications were administered or refused on September 4, 5, 8, 9, 10, 22, and 26, 2023. Current physician's orders for Resident 88 included an order for the resident to receive 50 mg of 395834 Page 12 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Trazadone (antidepressant) one time a day. Review of the MAR for September 2023 revealed there was no documented evidence that this medication was administered or refused on September 8, 9, and 21, 2023. Current physician's orders for Resident 88 included for the resident to receive 40 mg of pantoprazole (used to decrease stomach secretions) two times a day. Review of the MAR for September 2023 revealed that there was no documented evidence this medication was administered or refused at 6:00 a.m. on September 1, 2, and 11, 2023, and at 4:00 p.m. on September 8, 9, and 21, 2023. Current physician's orders for Resident 88 included an order for the resident to receive 5 mg of Midodrine (used to treat low blood pressure) three times a day, hold for systolic blood pressure (SBP- top number on blood pressure reading) greater than 120. Review of the MAR for September 2023 revealed there was no documented evidence that this medication was administered or refused at 8:00 a.m. or 2:00 p.m. on September 4, 5, 8, 9, 10, and 22, and at 8:00 p.m. on September 8, 9, and 21, 2023. Review of the MAR also revealed that 5 mg of Midodrine was administered on September 7 at 8:00 p.m. when the resident's SBP was 153, September 12 at 8:00 p.m. when the resident's SBP was 132, September 15 at 8:00 p.m. when the resident's SBP was 130, September 16 at 8:00 p.m. when the resident's SBP was 124, September 17 at 2:00 p.m. when the resident's SBP was 124, September 23 at 8:00 a.m. when the resident's SBP was 126, September 25 at 8:00 p.m. when the resident's SBP was 136, and on September 27 at 2:00 p.m. when the resident's SBP was 132. Interview with the Director of Nursing on September 28, 2023, at 2:37 p.m. confirmed that there was no documented evidence that Resident 88 was administered or refused his above-mentioned medications on the dates and times identified and that he was given Midodrine on eight occasions in September when it should have been held. An admission MDS assessment for Resident 96, dated July 30, 2023, revealed that the resident was understood and could understand, required supervision for activities of daily living, had a significant weight gain, and diagnoses that included congestive heart failure (CHF-a condition in which the left ventricle of the heart is weak, causing fluid to build up). Physician's orders for Resident 96, dated July 25, 2023, included an order for daily weights, one time a day (at 6:00 a.m.) for CHF. The physician was to be called if the weight gain was greater than 3 pounds in 24 hours or 5 pounds in 5 days. A review of the daily weights for Resident 96 from July 26, 2023, through September 29, 2023, revealed 19 days (July 27, 31; August 1, 8, 19, 31; September 3, 7, 13, 16, 19, 20, 21, 23, 25, 26, 27, 28, 29) without documented evidence that a weight was obtained as ordered. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:25 p.m. confirmed that there was no documented evidence that daily weights were obtained on the dates mentioned. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395834 Page 13 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 56 residents reviewed (Resident 81). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated August, 24 2023, revealed that the resident was cognitively intact, required extensive assistance to total dependence on staff for daily care needs, and had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). Physician's orders, dated August 7, 2023, included an order for the sacrum (area at the lower end of the spine) to be cleansed with normal saline solution (mixture of salt and water), packed with gauze soaked in Vashe (wound cleanser), and covered with a foam dressing daily and as needed. Physician's orders, dated September 18, 2023, included an order for gauze-soaked acetic acid (used to prevent wound infections) applied to the wound bed of the sacrum and left on for five minutes, Thera Honey (honey based wound gel) applied to the wound bed, then packed with Vashe-soaked gauze, and covered with a form dressing daily and as needed. A wound consult, dated August 21, 2023, revealed that Resident 81 had a pressure ulcer on her sacrum that measured 5.0 x 7.0 x 2.0 centimeters (cm). A wound consult, dated September 25, 2023, revealed that the resident's pressure ulcer on her sacrum measured 2.8 x 6.5 x 2.0 cm. Resident 81's Treatment Administration Records (TAR's) for August and September 2023 revealed that there was no documented evidence that the treatments to the sacrum were completed as ordered on August 14 to 17, 20, 21, 23, 25, 28, and 30, and September 6, 7, 12, and 13, 2023. Interview with the Director of Nursing on September 29, 2023, at 2:50 p.m. confirmed that there was no documented evidence that Resident 81's treatments to the sacrum were completed on the above dates as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395834 Page 14 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 56 residents reviewed (Residents 23, 41). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated August 16, 2023, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs, including mobility on and off the unit. Observation of Resident 23 on September 28, 2023, at 12:21 p.m. revealed that the resident was sitting in a wheelchair while being transported to her room by Licensed Practical Nurse 4. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Licensed Practical Nurse 4 on September 28, 2023, at 12:27 p.m. revealed that the facility does not keep foot rests on Resident 23's wheelchair and she did not have time to go get them before pushing the resident back to her room for lunch. An interview with the Director of Nursing on September 28, 2023, at 2:41 p.m. confirmed that footrests should have been used when transporting Resident 23 in her wheelchair. An annual MDS assessment for Resident 41, dated June 29, 2023, revealed that the resident was cognitively impaired, required assistance with all care, and had diagnoses that included dementia and arthritis. A current care plan for Resident 41 revealed that she was at risk for falls due to dementia and a history of falls. Observations on the Arcadia unit on September 28, 2023, at 10:27 a.m. revealed that Resident 41 was in her wheelchair being transported by Nurse Aide 5 from room [ROOM NUMBER] to the dining room without footrests on the chair. The resident had her feet elevated approximately two inches off the floor. Interview with Nurse Aide 5 on September 28, 2023, at 10:28 a.m. confirmed that there should have been footrests on Resident 41's chair and that she was going to see if she could find some. Interview with the Director of Nursing on September 28, 2023, at 11:00 a.m. confirmed that footrests should have been used when transporting Resident 41 in her wheelchair. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 15 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for one of 56 residents reviewed (Resident 27). Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated July 13, 2023, revealed that the resident was cognitively intact and required extensive assistance from staff for her daily care needs. The resident's weight records revealed that she experienced a 12.08 percent (31.6 pound) (significant) weight loss in one month when his weight dropped from 261.6 pounds on May 20, 2023, to 230.0 pounds on June 28, 2023. There was no documented evidence that the physician was notified about the resident's significant weight loss. A dietary note for Resident 27, dated June 28, 2023, revealed that the resident was ordered daily weights to trend weight loss. There was no documented evidence that Resident 27's daily weights were obtained since ordered on June 28, 2023. As of September 27, 2023, the resident had not been weighed since June 28, 2023. Interview with the Director of Nursing on September 29, 2023, at 12:27 p.m. confirmed that Resident 27 was not re-weighed per the dietician's order to do so, and that the physician was not notified regarding the significant weight loss. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395834 Page 16 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 56 residents reviewed (Resident 79). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated August 27, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had a feeding tube. Physician's orders for Resident 79, dated August 22, 2023, included an order for the resident's feeding tube to be checked for placement every day and that she receives 1150 milliliters (ml) of Jevity 1.5 (type of liquid feeding given through a tube) formula every day. A care plan for Resident 79, dated August 21, 2023, indicated that the resident had a need for a feeding tube related to a swallowing impairment and that it should be checked for placement and residuals (amount of fluid/contents in the stomach) per guidelines or physician orders and signs of intolerance should be reported. Review of clinical records for Resident 79, including Medication Administration Records, Treatment Administration Records, physician's orders, and progress notes, dated August 21, 2023, through September 26, 2023, revealed no documented evidence that residual was being checked per the resident's care plan. Interview with the Director of Nursing on September 29, 2023, at 4:52 p.m. revealed that there was no documented evidence that residual was being checked on Resident 79's feeding tube as care planned, and there should have been. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 17 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that respiratory care was provided as ordered for one of 56 residents reviewed (Resident 29). Residents Affected - Some Findings include: A quarterly MDS assessment for Resident 29, dated August, 18 2023, revealed that the resident was cognitively intact, had a tracheostomy (surgically-created airway in the windpipe), received tracheostomy care, and had diagnoses that included cancer of the tongue. Physician's orders, dated December 10, 2018, included an order for the staff to provide tracheostomy care every shift. A care plan, dated October 9, 2020, indicated that trach care was to be provided per the protocol. Resident 29's Treatment Administration Record (MAR) for July, August, and September 2023 revealed that tracheostomy care was not provided every shift as ordered on July 9, 13, 14, 17, 18, and 19; August 3, 6, 11, 14-17, 20, 21, 23, 25, 28, 30, 31; and September 1, 3, 6, 7, 9, 11-13, 15, 18, 20, 22, 24-26, 2023. Observations of Resident 29 on September 27, 2023, at 10:30 a.m. revealed that he had a tracheostomy and had yellow drainage coming out of it. Interview with the Director of Nursing on September 29, 2023, at 11:13 a.m. confirmed that there was no documented evidence that Resident 29's tracheostomy care was completed every shift as ordered on the mentioned dates. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 18 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a physician performed the initial comprehensive visit with the resident and was seen by the physician at least once every 30 days for the first 90 days after admission for one of 56 residents reviewed (Resident 102). Residents Affected - Few Findings included: A nursing note for Resident 102, dated March 18, 2023, revealed that the resident was admitted to the facility. Resident 102's clinical record revealed that he was sent out to the hospital and admitted to the hospital on [DATE], and that he was readmitted to the facility on [DATE]. Resident 102's clinical record revealed that his initial physician visit was completed by the Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area) and not by the attending physician. Resident 102's clinical record revealed that he was seen by the CRNP again on March 31, 2023, and April 5 and 7, 2023. Resident 102's clinical record revealed that he was sent out to the hospital and admitted to the hospital on [DATE], and was readmitted to the facility on [DATE]. Resident 102's clinical record revealed that he was seen by the CRNP again on April 18 and 21, 2023. Resident 102's clinical record revealed that he was sent out to the hospital and admitted to the hospital on [DATE], and was readmitted to the facility on [DATE]. Resident 102's clinical record revealed that he was seen by the CRNP again on May 2, 5, and 10, 2023. Resident 102's clinical record revealed that he was discharged from the facility on May 10, 2023. Resident 102's clinical record revealed no documented evidence that he was seen by the physician. Interview with Licensed Practical Nurse 3 on September 29, 2023, at 2:00 p.m. confirmed that there was no documented evidence that the physician completed the initial visit or had seen Resident 102. 28 Pa Code 211.2(a) Physician services. 395834 Page 19 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for three of three nurse aides reviewed (Nurse Aides 6, 7, 8). Residents Affected - Few Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations for Nurse Aides 6, 7 and 8 were due between March 27 and May 11, 2023. As of September 29, 2023, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7 and 8. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that he could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7 and 8. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development. 395834 Page 20 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 56 residents reviewed (Resident 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 7, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance for personal hygiene needs, had diagnosis that included dementia and generalized muscle weakness, and was receiving hospice care. Physician's orders for Resident 84, dated August 4, 2023, included an order for the resident to receive 25 milligrams (mg) of Tramadol (a controlled pain medication) every six hours as needed for pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 84 for August and September 2023 indicated that a dose of Tramadol was signed out on August 4 at 10:30 a.m., September 7 at 5:00 p.m., September 10 at 10:00 a.m., September 19 at 11:30 a.m., September 20 at 5:00 p.m., and September 22 at 12:30 p.m. Review of Resident 84's Medication Administration Record (MAR) and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on these dates and times. Interview with the Director of Nursing on September 29, 2023, at 11:15 a.m. confirmed that there was no documented evidence in Resident's 84's clinical records to indicate that the signed-out doses of Tramadol mentioned above were administered to the resident. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395834 Page 21 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs that were used for a longer duration than what was ordered by the physician for one of 56 residents reviewed (Resident 81). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated August, 24 2023, revealed that the resident was cognitively intact, had a pressure ulcer, and received an antibiotic medication. A nursing note for Resident 81, dated August 17, 2023, at 3:11 p.m. revealed that the resident had a Stage 4 pressure ulcer to her sacrum (area located at the end of the spine) that had a copious (large) amount of sero-purulent (watery drainage containing pus) drainage and a strong, foul odor. The Certified Registered Nurse Practitioner (CRNP-registered nurse with specialized training) was notified and an order was received for Keflex (antibiotic). Physician's orders, dated August 17, 2023, included an order for the resident to receive 500 milligrams (mg) of Keflex twice a day for seven days for a foul smelling wound. Resident 81's Medication Administration Record (MAR) for August 2023 revealed that staff administered Keflex to the resident one time on August 17, then two times a day from August 18 through 24, and then one time on August 25, for a total of 16 doses, instead of 14 doses as ordered by the physician. Interview with the Director of Nursing on September 29, 2023, at 2:50 p.m. confirmed that staff administered 16 doses of Keflex to Resident 81, instead of 14 doses as ordered by the physician. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 22 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of as needed antianxiety medications for one of 56 residents reviewed (Resident 101). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 101, dated August 14, 2023, indicated that the resident was cognitively intact, had no behavior symptoms, and required assistance from staff for her daily care needs. The resident's care plan, dated August 20, 2023, revealed that staff were to keep her busy with desirable activities. There were no interventions listed to attempt prior to administering antianxiety or antidepressant/sedative medication. Physician's orders for Resident 101, dated August 9, 2023, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety medication) every six hours as needed for anxiety. Resident 101's Medication Administration Records (MAR's) for August and September 2023 revealed that staff administered as needed Ativan to the resident on August 12 at 8:29 a.m.; August 13 at 8:24 a.m. and 4:28 p.m.; August 14 at 2:00 p.m.; August 16 at 8:00 a.m.; August 17 at 12:09 a.m.; August 19 at 12:36 a.m. and 2:26 p.m.; August 23 at 1:30 p.m.; August 24 at 11:00 a.m.; August 26 at 11:33 a.m.; August 27 at 1:40 p.m.; August 29 at 10:15 p.m.; August 30 at 1:50 p.m.; August 31 at 6:14 p.m.; September 1 at 8:00 a.m.; September 2 at 9:30 p.m.; September 3 at 6:20 p.m.; September 5 at 6:21 p.m.; September 6 at 7:20 p.m.; September 9 at 12:00 a.m., 8:00 a.m., and 3:42 p.m.; September 10 at 10:38 a.m. and 6:05 p.m.; September 14 at 3:47 p.m.; September 15 at 6:57 p.m.; September 16 at 8:30 a.m.; September 17 at 7:00 p.m.; September 19 at 3:20 p.m.; and September 20 at 3:36 p.m. and 9:45 p.m. There was no corresponding documentation in Resident 101's clinical record regarding any non-medication interventions that were attempted prior to the administration of as needed Ativan on the above dates/times. Interview with the Assistant Director of Nursing on September 29, 2023, at 3:32 p.m. confirmed that there was no documented evidence that staff attempted one or more non-medication interventions prior to administering as needed Ativan on the above dates/times. 28 Pa. Code 211.12(d)(5) Nursing services. 395834 Page 23 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for two of 56 residents reviewed (Residents 29, 88). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated August, 18 2023, revealed that the resident was cognitively intact, received an anti-psychotic medication, and had diagnoses that included schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Physician's orders for Resident 29, dated May 24, 2023, included an order for the resident to receive 1 milliliter (mL) of 100 milligrams/mL of haldol decanoate (used to treat schizophrenia) one time a day every 21 days. The resident's care plan, dated May 17, 2021, indicated that the resident had diagnoses that included schizophrenia and his medications were to be administered as ordered by the physician. Resident 29's Medication Administration Records (MAR's) for June, July and August 2023 revealed that there was no documented evidence that haldol decanoate was administered as ordered on June 14, July 26, and August 16, 2023. Interview with the Director of Nursing on September 29, 2023, at 11:13 a.m. confirmed that there was no documented evidence that Resident 29's haldol decanoate was administered on the mentioned days and there should have been. An annual MDS assessment for Resident 88, dated, August 2, 2023, revealed that the resident was cognitively intact, was independent with personal care needs, and had diagnoses that included diabetes, renal (kidney) failure, and deep vein thrombosis (blood clot). Physician's orders for Resident 88, dated November 4, 2022, included that the resident receive 5 (milligrams) mg of Apixaban (a blood thinner) two times a day. Review of the MAR for Resident 88, dated August 2023 and September 2023, revealed that 5 mg of Apixaban was not administered as ordered by the physician at 8:00 a.m. on August 12, 13, 18, 25, 26 and September 4, 5, 8, 9, 10, 22, and 26, 2023. It was not administered as ordered at 8:00 p.m. on September 8, 9, and 21, 2023. Interview with the Director of Nursing on September 28, 2023, at 2:37 p.m. confirmed that Resident 88 did not receive Apixaban as ordered by the physician on the above dates and times, as he should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395834 Page 24 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Residents Affected - Some Findings include: The facility's food handling policy, dated May 1, 2023, revealed that cold foods are to be maintained at 40 degrees Fahrenheit (F) or below. If the food temperature rises above 40 degrees F, return to refrigerator and re-chill to 40 degrees F. Hot beverages, such as coffee, tea and hot chocolate are brewed and held at temperatures of 160-185 degrees F. Interview with Resident 11 on September 27, 2023, at 11:22 a.m. revealed that the food was terrible and the coffee was never hot. Interview with Resident 27 on September 27, 2023, at 12:32 p.m. revealed that the food was not good and the meat was hard to chew. Interview with Resident 42 on September 27, 2023, at 10:15 a.m. revealed that the food was terrible. Interview with Resident 50 on September 27, 2023, at 12:30 p.m. revealed that the food is always cold, and that she asked to get her tray delivered from the cart sooner so that her food would be warmer. Interview with Resident 71 on September 27, 2023, at 10:30 a.m. revealed that the food sucked, it was the same food all of the time, and it was not hot. Interview with Resident 78 on September 27, 2023, at 11:10 a.m. revealed that the food is terrible and that you never know what you are going to get. Observation of the tray line for the lunch meal on the Valley [NAME] nursing unit on September 28, 2023, at 11:35 a.m. revealed that the cart left the kitchen at 11:50 a.m., arrived on the nursing unit at 11:50 a.m., and the last resident was served at 12:02 p.m. The test tray was tasted at 12:03 p.m. and the jello was 53.4 degrees F and watery, and the coffee was 119.9 degrees F and barely warm. Interview with Food Service Director 10 on September 28, 2023, at 12:08 p.m. confirmed that the jello and coffee were not served at the proper temperatures. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.6(c) Dietary services. 395834 Page 25 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of policies, observations, and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards of food service safety by failing to properly label and date stored foods and maintain a sanitary environment in the kitchen. Findings include: The facility's policy regarding food storage, dated May 1, 2023, revealed that foods in dry storage are to be in closed, labeled and dated containers; no open boxes or bags. For products that have been opened but not fully used, a use by date is included on the label. An initial tour of the kitchen on September 27, 2023, at 8:22 a.m. with Food Service Director 11 revealed that the floor was dirty with a build up of grime, the coffee machine drip tray had build up of dried coffee as well as dried splashes on the machine, a large bin of flour and sugar with a build up of grease and grime as well as drip stains on the lids and outsides of the containers, and a rack containing two large trays of bananas that were dark brown/black. Observations in the dry storage room on September 27, 2023, at 8:28 a.m. revealed one five-pound bag of elbow macaroni, one large box of ziti noodles and one large box of rice that were opened and undated, and the floor had scattered paper and food debris, including a ketchup packet, salt packets and styrofoam cups. Observations in the walk-in refrigerator on September 27, 2023, at 8:35 a.m. revealed that the floor was dirty with a build up of grime and scattered food and paper debris. Observations in the walk-in freezer on September 27, 2023, at 8:37 a.m. revealed one 40-count box of chopped beef steaks and one 240-count box of chocolate chip cookie dough that were opened, exposed to the air and undated, and the freezer floor was dirty and sticky with an unknown substance. Interview with Food Service Director 11 on September 27, 2023, at 8:53 a.m. confirmed that all the opened and undated foods should have been closed, labeled and dated; the coffee machine was dirty and needed to be cleaned; the storage bins and lids were dirty and needed to be cleaned; the kitchen, refrigerator and freezer floors were dirty and needed to be cleaned; and the two large trays of bananas were not being used for anything and should have been thrown out. 28 Pa. Code 211.6(f) Dietary services. 28 Pa. Code 207.4 Ice containers and storage. 395834 Page 26 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that the Facility Assessment was completed, and reviewed and revised, as needed, at least annually. Findings include: Review of facility documents revealed that there was no documented evidence that a Facility Assessment was completed or reviewed and revised, as needed, at least annually. An interview with the Nursing Home Administrator on September 29, 2023, at 3:25 p.m. confirmed that there was no evidence of a completed Facility Assessment. 28 Pa. Code 201.18(e) Management. 395834 Page 27 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 56 residents reviewed (Resident 64). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated August 21, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnosis that included muscle weakness and abnormal posture. Physician's orders for Resident 64, dated August 15, 2023, included an order for the resident's left elbow to be cleansed with normal saline, a small amount of thera-honey (medical grade honey used in the treatment of wounds) applied to it, and then a foam dressing applied daily. Review of the Treatment Administration Record (TAR) for Resident 64, dated September 2023, revealed documentation that the resident was receiving the ordered treatment to her left elbow daily on September 2-3, 5-9, and 11-27, 2023. Review of a wound consultation for Resident 64, dated August 21, 2023, indicated that the wound on the resident's left elbow was healed. Observation and interview with Resident 64 on September 27, 2023, at 11:00 a.m. revealed the resident resting in bed with no foam border dressing on her left elbow. She revealed that she felt her wound treatments done by nursing staff were hap hazard. Interview with Registered Nurse 9, the wound care nurse, revealed that the wound to Resident 64's left elbow had been healed and that there was no treatment being administered to it. Registered Nurse 9 revealed that documentation that a treatment was being provided to the resident's left elbow was inaccurate and the treatment order should have been discontinued. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services 395834 Page 28 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for three of 56 residents reviewed who were receiving hospice services (Residents 40, 84, 95). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated August 3, 2023, indicated that the resident was cognitively impaired, was dependent on staff for personal hygiene needs, had a diagnosis of dementia, and was receiving hospice care (end-of-life services). Physician's orders for Resident 40, dated September 2, 2022, included an order for the resident to be evaluated and treated by hospice. Care plan for Resident 40, dated September 6, 2022, indicated that the resident was receiving hospice services with Heartland Hospice. A quarterly annual MDS assessment for Resident 84, dated August 7, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance for personal hygiene needs, had diagnosis that included dementia and generalized muscle weakness, and was receiving hospice care. Physician's orders for Resident 84, dated November 7, 2022, included that the resident be evaluated for eligibility of need for hospice care. Care plan for Resident 84, dated November 14, 2022, indicated that the resident was receiving hospice care from Heartland Hospice due to a terminal illness. As of September 29, 2023, there was no documented evidence readily available in Resident 40 or 84's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice benefit of elections form, certification of terminal illness form, or the resident's hospice plan of care. Interview with the Director of Nursing on September 29, 2023, at 3:50 p.m. confirmed that Resident 40 and 84's election benefit form, certification of terminal illness, and current plan of care were not in the residents' clinical record and/or in the hospice provider's clinical record. A significant change MDS assessment for Resident 95, dated August 15, 2023, revealed that the resident has clear speech; is understood and usually understands; requires extensive assist of two for transfers and toilet use; extensive assist of one for bed mobility, dressing and hygiene; does not ambulate; has diagnoses that includes prostate cancer and diabetes; and is receiving hospice. A care plan for the resident, dated August 11, 2023, revealed that he was on hospice due to terminal illness. Physician's orders for Resident 95, dated August 11, 2023, included an order for Promedica Hospice services. 395834 Page 29 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0849 Level of Harm - Minimal harm or potential for actual harm There was no documented evidence in Resident 95's hard chart or e-chart of the hospice provider's clinical record that included progress notes or the provider's plan of care. Interview with Registered Nurse 14 on September 29, 2023, at 10:33 a.m. confirmed that the hospice information was not available on the nursing unit or in the Resident 95's clinical record. Residents Affected - Few 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395834 Page 30 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending November 9, 2022, and a complaint investigation survey ending April 5, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 29, 2023, identified repeated deficiencies related to Medicaid/Medicare liability notices, care plan timing and revision, the failure to provide quality of care, treatment and services to prevent pressure ulcers, free from accident hazards, nutrition and hydration, and records that are complete and accurately documented. The facility's plan of correction for a deficiency regarding Medicare/Medicaid liability notices, cited during the survey ending November 9, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F582, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding Medicare/Medicaid liability notices. The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending November 9, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan timing and revision. The facility's plan of correction for a deficiency regarding quality of care, cited during the surveys ending November 9, 2022, and April 5, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plan of correction for a deficiency regarding the treatment and services to prevent pressure ulcer development, cited during the survey ending November 9, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the treatment and services to prevent pressure ulcer development. The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending November 9, 2022, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the 395834 Page 31 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility's QAPI committee failed to maintain compliance with the regulation regarding a safe enviornment that is free of accident hazards. The facility's plan of correction for a deficiency regarding nutrition and hydration maintenance, cited during the survey ending on November 9, 2022, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F692, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding nutrition and hydration maintenance. The facility's plan of correction for a deficiency regarding a failure ensure that the medical records were complete and accurate, cited during the surveys ending on November 9, 2022, and April 5, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding complete and accurate medical records. Refer to F582, F657, F684, F686, F689, F692, F842. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 395834 Page 32 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that the Quality Assurance Committee met quarterly for two of three quarters reviewed (first and second quarter 2023). Residents Affected - Few Findings include: Review of Quality Assurance Committee sign-in sheets revealed no evidence that the facility held quarterly meetings in 2023 prior to September 27, 2023. Interview with the Director of Nursing on September 28, 2023, at 4:00 p.m. confirmed that there was no documented evidence of quarterly quality assurance meetings being held in the first and second quarter of 2023. 28 Pa. Code 201.14(a) Responsibility of licensee 395834 Page 33 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the water management policy was implemented for the detection and/or prevention of Legionella within the facility's water systems. Residents Affected - Few Findings include: The facility's policy regarding Legionnaires' Disease (a severe form of pneumonia), undated, revealed that appropriate infection control, environmental decontamination, and prevention measures will be followed for the prevention and management of legionella (Legionnaires' Disease). However, there was no documented evidence that the facility conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system; implemented a water management program that considered the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE - an American professional association seeking to advance heating, ventilation, air conditioning and refrigeration systems design and construction) industry standard and the Centers for Disease Control (CDC) toolkit; included control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; or specified testing protocols and acceptable ranges for control measures and documented the results of testing and corrective actions taken when control limits were not maintained. Interview with the Director of Maintenance on September 29, 2023, at 12:15 p.m. confirmed that there was no documented evidence that a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow was completed, of what control measures would be used, what specific testing protocols would be used, what the acceptable ranges would be for the control measures, documentation of the results of any testing, and the corrective actions that were taken when the control limits were not maintained. Interview with the Assistant Nursing Home Administrator on September 29, 2023, at 12:30 p.m. indicated that since the facility's recent ownership change, they have not been able to find any information regarding the facility's water management program. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 395834 Page 34 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policies and staff training records, as well as staff interviews, it was determined that the facility failed to provide annual abuse training for two of five employees (Licensed Practical Nurse 15, Registered Nurse 16). Findings include: The facility's abuse policy, undated, indicated that each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation. All facility staff were to be educated through orientation and a minimum of annually. A list of staff provided by the facility revealed that Licensed Practical Nurse 15 was hired on February 13, 2019. However, there was no documented evidence that Licensed Practical Nurse 15 received annual abuse training from February 13, 2022, through February 13, 2023. Registered Nurse 16 was hired on June 29, 2019. However, there was no documented evidence that Registered Nurse 16 received annual abuse training from June 29, 2022, through June 29, 2023. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that Licensed Practical Nurse 15 and Registered Nurse 16 did not have evidence of annual abuse training based on their hire dates, and they were not able to retrieve any training records from the previous company. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development. 395834 Page 35 of 36 395834 09/29/2023 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of personnel files and staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education annually for three of three nurse aides reviewed (Nurse Aides 6, 7, 8). Findings include: Nurse aide education records revealed that based on their hire dates, Nurse Aides 6, 7, and 8 did not have at least 12 hours of education annually as follows: Nurse Aide 6's hire date was April 19, 2022, and inservice records revealed that she had 0.0 hours of education between April of 2022 and April of 2023. Nurse Aide 7's hire date was May 11, 2022, and inservice records revealed that she had 0.0 hours of education between May of 2022 and May of 2023. Nurse Aide 8's hire date was March 27, 2006, and inservice records revealed that she had 0.00 hours of education between March of 2022 and March of 2023. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that the above-listed nurse aides did not have evidence of the required 12 hours of annual education based on their hire dates, and they were not able to retrieve any training records from the previous company. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 395834 Page 36 of 36

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Citations

30 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0868GeneralS&S Dpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0943GeneralS&S Epotential for harm
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
0947GeneralS&S Dpotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
0582GeneralS&S Bno actual harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0607GeneralS&S Dpotential for harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0638GeneralS&S Dpotential for harm
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0693GeneralS&S Epotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0712GeneralS&S Dpotential for harm
F712 - Frequency of physician visits
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
0730GeneralS&S Dpotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Epotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0838GeneralS&S Dpotential for harm
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0867GeneralS&S Dpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

FAQ · About this visit

Common questions about this visit

What happened during the September 29, 2023 survey of KING OF PRUSSIA SKILLED NURSING AND REHABILITATION?

This was a inspection survey of KING OF PRUSSIA SKILLED NURSING AND REHABILITATION on September 29, 2023. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at KING OF PRUSSIA SKILLED NURSING AND REHABILITATION on September 29, 2023?

Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 29, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 29, 2023