Inspection visit

Health inspectionAugust 15, 2024

KING OF PRUSSIA SKILLED NURSING AND REHABILITATIONCMS #39583422 citations on this visit

22 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 22 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse for one of the 29 residents reviewed (Resident 54). Residents Affected - Few Findings include: Review of the facility's policy titled Abuse Prohibition with review date of February 23, 2021, revealed the center will implement an abuse prohibition program through the identification of possible incidents or allegations that need investigations. The same policy revealed that upon receiving a report of suspected or alleged abuse, mistreatment, or neglect, the designee will initiate an investigation that focuses on whether abuse or neglect occurred and to what extent. The investigation will be thoroughly documented, ensure that documentation of witnessed interviews will be included. Review of Resident 54's diagnosis list includes Cerebrovascular Disease (stroke), and Anxiety disorder. Review of Resident 54's plan of care revealed resident was resistive and non-compliant with care. Review of Resident 54's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated March 27, 2024, revealed that the resident had a moderate cognitive impairment. Review of Resident 54's nursing progress notes dated March 12, 2024, at 11:59 a.m., revealed Resident 54 reported an aide got angry and hit her/him in the face this morning or last night, The resident was unclear of the time of the incident. The resident was unable to remember the staff name. The resident was assessed with no visible injuries, son was notified. Review of the facility's documentation, Incident Report revealed that on March 12, 2024, at 11:51 a.m., the resident reported that a Nursing Assistant (NA) got angry and hit her/him in the face this morning or last night. The resident reported that the NA was angry and frustrated and hit her in the face. The son was notified and reported that he does not think that the incident happened because the resident always complains about the NAs, the son expressed that if it did happen it probably was an accident. The resident was assessed and revealed no visible injury. Review of the facility's documentation, unlicensed staff Employee E14 statement revealed that while providing care, the resident reported being hit in the head by a staff, the resident stated it was a young lady. Review of the licensed staff Employee E15's statement revealed the resident reported that an NA got angry and hit her/him in the face this morning or last night, the resident was unclear (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 26 Event ID: 395834 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 of the time of the incident and was unable to remember the name of the staff. Level of Harm - Minimal harm or potential for actual harm Review of the facility's documentation, and investigation reports, revealed that aside from the two employees who received the report of the alleged physical abuse, no other employees including staff that worked the day/night before and in the morning were interviewed. Residents Affected - Few Interview conducted with the Nursing Home Administrator on August 15, 2024, at 11:00 a.m., confirmed that only two staff members were interviewed regarding the alleged physical abuse. The facility failed to ensure Resident 54's alleged physical abuse was thoroughly investigated. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code §201.14(a) Responsibility of licensee 28 Pa. Code §201.18(b)(1)(3) Management 28 Pa. Code §211.10(c)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 2 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for four of eight residents reviewed (Residents 17, 96, 332, and 333). Findings include: Rview of Resident 17's clinical record revealed the resident was transferred to the hospital on May 4, 2024, due to two episodes of vomiting and weakness. There was no documented evidence to indicate the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Review of Resident 96's clinical record revealed the resident was transferred to the hospital on August 10, 2024, due to a fall with laceration to the forehead. There was no documented evidence to indicate the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Review of Resident 332's clinical record revealed the resident was transferred to the hospital on April 5, 2024, for a clogged feeding tube and shoulder pain, May 6, 2024, for lethargy and vomit in trach collar, and gastronomy tube, and July 9, 2024, for dislodged feeding tube. There was no documented evidence to indicate the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Review of Resident 333's clinical record revealed the resident was transferred to the hospital on July 15, 2024, due to bleeding from nose and mouth, July 23, 2024, for change in mental status, and August 7, 2024, due to dislodged feeding tube. There was no documented evidence to indicate that the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Interview on August 15, 2024 at 10:30 a.m with Director of Social Services confirmed the above noted findings regarding transfer notices to the State Long Term Care Ombudsman office. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 3 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 32 residents reviewed (Residents 25). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), revealed that Section O0110 was to be completed with the resident's special treatments, procedures, and programs, and Section O0110 was to be coded for the use of Tracheostomy(a medical procedure that involves creating an opening in the neck in order to place a tube into a person's trachea, or windpipe) Care. Column (2) was to be checked if Tracheostomy Care was used while a resident of the facility within the last 14 days. Review of Resident 25's care plan, revised on July 11, 2024, indicated that the resident at risk for respiratory impairment related to tracheostomy. Physician's orders for Resident 25, dated November 11, 2023, included an order for the resident to receive Trach care daily. Review of Resident 25's annual MDS assessment, dated May 18, 2024, revealed that column (2) of Section 00110E (Tracheostomy Care) was not marked with a checkmark indicating that the resident received Tracheostomy Care. Interview on August 14, 2023, at 11:23 a.m. with Licensed Practical Nurse (LPN) MDS Coordinator Employee E8, who was responsible for the completion of the MDS assessment, confirmed that Section O0110C of Resident 45's MDS assessment was inaccurate and should have indicated that the residents received Tracheostomy Care. 28 Pa. Code 211.5(f) Clinical Records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 4 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of eight residents reviewed (Resident 333). Findings include: Review of Resident 333's clinical records revealed the resident was admitted into the facility on July 9, 2024, with medical diagnoses that include Seizures, Nontraumatic Intracerebral Hemorrhage (bleeding into the brain), Acute Respiratory Failure, Gastrostomy (creation of an artificial external opening into the stomach for nutritional support), Hepatic Encephalopathy (loss of brain function), Cirrhosis of Liver with Ascites (fluid in abdomen), and Rhabdomyolysis (breakdown of skeletal muscle). Review of Resident 333's physician orders dates July 9, 2024, to cleanse sacral wound with spray, apply calcium alginate and cover with foam dressing, Review of Resident 333's care plan dated July 10, 2024, revealed plans for wound management and documents pressure ulcer. Review of Resident 333's admission Minimum Data Set (MDS) dated [DATE], revealed the resident was admitted with a stage 2 pressure ulcer. Review of Resident 333's clinical records revealed progress notes documenting the resident was hospitalized on [DATE], through July 25, 2024, for change of mental status. Review of Resident 333's readmission physician orders dated July 26, 2024, failed to document orders for pressure ulcer care. Review of Resident 333's care plan dated July 26, 2024, failed to document the resident had a pressure ulcer. Review of Resident 333's Treatment Administration Report (TAR) for July 2024 and August 2024, revealed the resident was receiving treatment for a sacral pressure ulcer. Review of Resident 333's progress notes from July 26, 2024, thru August 14, 2024, revealed the resident was provided with treatment for a sacral pressure ulcer daily except when the resident refused care. During interview on August 15, 2024, at 9:20 a.m., Employee E11, wound nurse, stated Resident 333 did not currently have a pressure ulcer. Interview conducted on August 15, 2024, at 10:15 a.m.,with the Director of Nursing (DON) confirmed the Resident 333 does have a sacral pressure wound but the focus, goals, and interventions were not included in the resident's July 26, 2024, readmission care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 5 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 28 Pa Code 211.10(d) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12(d)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 6 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 clinical record review and staff interview it as determined the facility failed to administer medications as ordered to one of 24 residents reviewed. (Resident 20) Residents Affected - Few Findings Include: Review of Resident 20's physician orders revealed an order for Midodrine (increases blood pressure) 5 milligrams (mg) three times a day (TID) for hypotension (low blood pressure) hold for systolic blood pressure greater than 140. Review of Resident 20's Medications Administration Record (MAR) from August 1-13 2024 revealed the resident received the midodrine four times when the systolic blood pressure was above 140. Review of Resident 20's MAR for the entire month of July 2024 revealed the resident received the midodrine 13 times when the systolic blood pressure was above 140. Interview with the Director of Nursing on August 15, 2024 at 11:30 a.m. confirmed the medication was not administered as ordered by the physician. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 7 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for two of the 29 residents reviewed (Resident 54 and 127). Residents Affected - Few Findings include: Review of the facility's policy titled Skin Integrity and Wound Management with a revised date of May 1, 2024, revealed that the licensed nurse will perform daily monitoring of wound dressing for the presence of complications and declines, implement skin/wound care guidelines, and implement special wound care treatments as indicated and ordered. Review of Resident 54's wound consult report dated July 29, 2024, revealed that the resident had a Stage 4 Pressure Ulcer (full-thickness skin and tissue loss) to the sacrum (tail bone) measuring 1.8 x 0.6 x 0.1 cm. The wound order recommendation was to cleanse the sacral wound with a normal saline solution and apply Calcium Alginate (wound dressing that absorbs excess moisture and promotes healing), and Puracol (wound product that contains collagen designed to promote wound healing). Change dressing daily due to incontinence and daily soiling of dressing. Cover with Silicone bordered foam dressing daily. Review of Resident 54's physician orders dated July 29, 2024, revealed an order to cleanse the sacrum with normal saline solution, apply Puracol, and calcium alginate, and cover with foam dressing daily and PRN (as needed) every day shift every other day for Stage 4 pressure ulcer. Review of Resident 54's August 2024, Treatment Administration Record (TAR) revealed Resident 54's sacral wound was not treated on the following dates: August 2, 4, 6, 8, 10, 12, and 14, 2024. Interview with the Director of Nursing (DON) on August 14, 2024, at 1:00 p.m., revealed the wound nurse transcribed the order incorrectly. Resident 54's sacral wound treatment was transcribed every other day instead of daily and as needed every other day. Review of Resident 127's wound consult dated June 24, 2024, revealed that the resident had an Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) to the sacrum measuring 5.0 x 8.0 x 0.1 cm. The wound order recommendation was to cleanse the sacrum with wound cleanser, apply calcium alginate, and cover with Silicone foam dressing daily. Review of Resident 127's physician order dated June 24, 2024, revealed an order to cleanse the sacrum with wound spray, apply calcium alginate, and cover it with foam dressing daily and PRN everyday shift. Review of Resident 127's June and July 2024 TAR, revealed Resident 127's sacral wound was not treated from June 26, 2024, until July 8, 2024. The facility was unable to provide documented evidence that Resident 127's sacral wound was treated on the dates mentioned above. The facility failed to ensure Resident 54 and 127's wounds were treated as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 8 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 28 Pa. Code 211.12(d)(1)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(c)(d) Resident care policies Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 9 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. Based on Facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide interventions to prevent a potential elopement for one of two residents reviewed. (Resident 101) Findings Include: Review of Facility policy and procedure titled Wandering, last revised May 1, 2022, revealed wandering behavior symptoms will be documented on the Behavior Monitoring and Intervention Flow Record or Behavior Tracking Form. Forms will be reviewed to determine triggers associated with the behavior and effectiveness of non-pharmacological interventions. Behavior symptoms will be addressed in the care/service plan. Review of Resident 101's progress notes revealed a social service entry dated July 26, 2024 at 2:17 p.m. stating, resident also reported that she tried to escape this joint and admitted to going into the staircase and attempt to walk upstairs. Further review of Resident 101's clinical record revealed there were no assessments completed to determine the residents risk for elopement and no care plan developed with interventions placed to prevent elopement. Interview with the Director of Nursing on August 15, 2024 at 11:30 a.m. confirmed there was no further assessment or interventions developed for the prevention of elopement of Resident 101 after the statements made to the social worker on July 26, 2024. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 10 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and procedure review, observations, and staff interview it was determined the facility failed to provide care and services for foley catheters for one of five residents reviewed. (Resident 20) Findings Include: Review of facility policy and procedure titled Catheter: Urinary-Justification for Use, last revised August 7, 2023, revealed Patients who have urinary catheters upon admission or subsequently receive one will be assessed for removal of the catheter as soon as possible unless the patients clinical condition demonstrates that catheterization is necessary. If the patients condition meets any of the indwelling catheter criteria, obtain a physician order, include in care plan. Observation of Resident 20 on August 12, 2024 at 9:30 a.m. revealed the resdient had a Foley Catheter (tube placed into the bladder to drain urine). Review of Resident 20's progress notes revealed a Nursing Clinical admission Notes dated June 19, 2024 at 2:46 p.m. stating the resident returned from the hospital and had a foley catheter. Review of Resident 20's progress notes revealed a physician entry dated Jun 25, 2024 stating the resident had just returned from the hospital and had a foley catheter and would need to follow up with urology. Review of Resident 20's entire clinical record revealed there was no physician order for a foley catheter, no assessment to determine the need of the foley catheter and no documented evidence the resident had received any care to the foley catheter since readmitted on [DATE]. There was also no order for the resident to be seen by urology or a consult report of the resident having been seen by urology since the physician note of June 25, 2024. Interview with the Director of Nursing on August 15, 20204 at 11:30 a.m. confirmed there was no order, assessment, urology consult, or documented evidence of care provided for Resident 20's foley catheter. 28 Pa. Code 211.5 (f) Clinical record 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 11 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to appropriately monitor, provide appropriate interventions, and timely notify the physician of a significant weight change for two of 29 residents reviewed (Residents 85 and 127). Residents Affected - Few Findings include: Review of the facility's policy titled Weights and Heights last reviewed on June 15, 2022, revealed that patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. The purpose was to obtain baseline weight and identify significant weight changes. Review of Resident 85's dietary notes dated June 24, 2024, revealed the resident with a diagnosis of Progressive Supranuclear Ophthalmoplegia (movement disorder that occurs from damage to certain nerve cells in the brain). The same note revealed resident was on NPO (nothing per mouth), had a gastrostomy tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth), and receiving a feeding of Jevity 1.5 @ 86 ml/hr x 20 hr for TV of 1720 ml. Review of Resident 85's weights and vitals revealed a monthly weight of 108.6 pounds on July 5, 2024, and 143.2 pounds on August 5, 2024, a 34.6 pounds (31.86 %) significant weight gain in one month. Review of the dietitian's progress notes dated August 7, 2024, revealed Resident 85 had 32% weight gain in a month which is clinically significant. A reweigh is needed to confirm significant weight gain, re weight requested. Review of the clinical records failed to reveal that the resident was re-weighed to ensure the accuracy of the weight change and the physician was notified of the significant weight change identified on August 5, 2024. Review of Resident 127's hospital record revealed a weight of 140 pounds. Review of Resident 127's clinical record revealed Resident 127 was admitted to the facility on [DATE], with a diagnosis of multiple fractures from a motor vehicular accident. Clinical records also revealed resident was admitted with a sacral (tailbone) pressure ulcer and a gastrostomy tube. (GT- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Review of Resident 127's admission assessment failed to reveal admission weight was taken. Review of Resident 127's nutrition note completed by licensed employee E12 on June 14, 2024, at 10:01 a.m., revealed resident weighed 140 pounds. The same note revealed resident's IBW (Ideal body weight) was 166 pounds. Employee E12 documented that the resident was at risk for malnutrition related to having a wound, being on a tube feed regimen, mechanically altered diet texture, and previous medical history, interventions include monitor weights; Jevity 1.5 at 65 cc ml/hr x 20 hrs. for total volume of 1,300 ml; Vit C, Zinc Sulfate, and multivitamin for wound healing. Review of Resident 127's weight and vitals revealed a weight of 166 pounds recorded by Employee 12 on June 14, 2024, at 10:23 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 12 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of Resident 127's clinical records failed to reveal that Resident 127's weight was monitored from June 15, 2024, until June 25, 2024. Review of Resident 127's weights and vitals dated July 18, 2024, revealed a weight of 116.6 pounds, a 49.4 pounds (29.79%) significant weight loss in one month. Residents Affected - Few Review of Resident 127's nutrition note completed by Employee E12 on July 18, 2024, revealed Resident 127 had a 50-pound weight loss in one month which is clinically significant, reweight was requested. Review of Resident 127's nutrition note completed by Employee E12 on July 22, 2024, revealed the following weight recorded of 166 pounds on June 14, 2024, appears to be an outlier from resident baseline, confirmed by a couple of reweights: (116.6 pounds on July 18, 2024, and 116.5 pounds on July 19, 2024). The weight has been struck out due to correction, BMA of 16.7 underweight per standard. The dietitian added apple juice at 2:00 p.m. Interview conducted with the Director of Nursing and Corporate Dietitian on August 15, 2024. The facility was unable to explain why Employee E12 documented that the initial weight of 166 pounds taken on June 14, 2024, was not the correct weight after weighing the resident a month later with a re-weigh indicating a significant weight loss. The clinical records review failed to reveal the physician was notified, and the resident nutritional status was thoroughly assessed after a significant weight loss was identified on July 18, 2024. The facility failed to ensure Resident 54 and 127's weight was appropriately monitored, significant weight change was appropriately addressed and the physician was timely notified. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12(c)(d)(1)(3)(5)Nursing Services. 28 Pa. Code §201.14(a) Responsibility of licensee 28 Pa. Code §201.18(b)(1)(3) Management 28 Pa. Code §211.10(c)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 13 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of eight residents reviewed. (Resident 332) Findings include: Review of Resident 332's clinical record revealed the resident admitted from the hospital on March 13, 2024, with medical diagnoses that include history of Traumatic Brain Injury, Gastrostomy (artificial external opening into the stomach for nutritional support), Epilepsy (recurring seizures), and Encephalopathy (disease of the brain). Review of Resident 332's physician orders revealed an order dated July 19, 2024, for Osmolite 1.5 @100 ml/hr. X 16 hrs. for TV (total volume) of 1600, FWF (amount of liquid that is water) 70 ml x 16 hrs for 1120 TV TF +FWF=2340 water total. Review of Resident 332's Medication Administration Record (MAR) for the months of July and August 2024 revealed there were no days where it was documented the resident received a total of 1600 ml per day as ordered by the physician. Interview with the Nursing Home Administrator and Director of Nursing on August 14, 2024, at 9:45 a.m. confirmed there was no documented evidence Resident R332 had received the amount of tube feeding as ordered by the physician. 28 Pa Code: 211.5(f) Clinical records 28 Pa code: 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 14 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review, facility policy and procedure review and staff interview it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications for two of six residents reviewed. (Residents 65 and 101) Findings Include: Review of facility policy and procedure titled Behaviors: Management of Symptoms last reviewed July 1, 2024 revealed, when medication sis ordered for behavior symptoms completed the Psychotropic/Therapeutic Medication use evaluation when a patient is newly prescribed psychotherapeutic medication and then quarterly. Complete the Abnormal Involuntary Movement Scale (AIMS) per nursing schedule for patient receiving antipsychotic medications. Review of Resident 65's progress notes revealed a psychiatrist entry dated July 5, 2024 with a plan for the residents current Depakote (mood stabilizer) 250 milligrams twice a day to be discontinued and a new order to increase the Depakote 250 milligrams to three times a day. Review of Resident 65's current physician orders revealed the resident was still receiving Depakote 250 milligrams twice a day and not three times a day as recommended on July 5, 2024. Interview with the Director of Nursing on August 15, 2024 at 11:30 a.m. confirmed Resident 65's medication should have been changed from twice a day to three times a day as recommended by the psychiatrist on July 5, 2024. Review of Resident 101's physician orders revealed an order date July 30, 2024 for Risperidone (antipsychotic) 0.5 milligrams twice a day for psychosis, hallucinations, and delusions. Further review of Resident 101's physician orders revealed the resident had an order dated April 18, 2023 for Abilify (antipsychotic) 10 milligrams once a day for Bi-polar disease which was discontinued on July 20, 2024. Review of resident 101's clinical record revealed there was no documented evidence the facility was monitoring the behaviors, or the side effects of the resident related to the Psychotropic medication and there was no AIMS test completed after medications were ordered. Interview with the Director of Nursing on August 15, 2024 at 11:30 am. confirmed there was no monitoring of Resident 101's behaviors and no AIMS testing per policy for being on antipsychotic medications. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 15 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility policy and procedure review and staff interview it was determined the facility failed to date and label insulin pens on two medications carts and reconcile medications on discharge for one of three residents. (Resident: 131) Findings Include: Review of facility policy and procedure Insulin Pens, last reviewed July 1, 2024, revealed Insulin Pens will be clearly labeled with the patient name, physician name, date used; a new pen must be ordered from the pharmacy. Observations of the medication cart 1 on the skilled nursing unit on August 15, 2024 at 9:15 a.m. revealed four insulin pens that were opened and being used but had no date of when they were opened or when they were to be discarded. Interview with Licensed Nursing Employee E10 at the time of the observation confirmed that these pens were opened and in use and should have been dated with the date they were first used. Observations of the medication cart 2 on the skilled nursing unit on August 15, 2024 at 9:15 a.m. revealed one insulin pen that was opened and being used but had no date of when they were opened or when they were to be discarded. Interview with Licensed Nursing Employee E5 at the time of the observation confirmed that these pens were opened and in use and should have been dated with the date they were first used. Review of closed record Resident 131 indicated the resident was admitted to the facility on [DATE], and subsequently passed away at the facility on June 2, 2024. Examination of Resident 131's medical record showed active orders for Morphine Sulfate Solution 20 milligrams (mg), indicated for the management of moderate to severe pain, and Lorazepam Intensol Oral Concentrate 2 mg, prescribed for the treatment of anxiety. Further review of the medical record revealed that the medication disposition form, which is intended to document the destruction of unused medications, did not specify the quantities of Morphine Sulfate Solution or Lorazepam that were destroyed. Additionally, it was noted that the facility staff responsible for the disposal of these medications failed to sign the medication disposition form. An interview with the Director of Nursing (DON) on August 14, 2024, at 1:37 p.m. confirmed the medication disposition form was not completed correctly. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 16 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview it was determined the facility failed to obtain laboratory studies as ordered for one of 24 residents reviewed. (Resident 20) Residents Affected - Few Findings Include: Review of Resident 20's physician orders revealed an order dated August 1, 2024 for a CBC (comprehensive blood count- count of all the cells in the blood) and a CMP (comprehensive metabolic panel- a routine blood test that measures 14 different substances in a sample of your blood). Review of resident 20's Results for laboratory studies revealed these lab studies were not completed as ordered. Review of Resident 20's physician orders revealed an order dated July 5, 2024 for a CBC and a CMP and a tacrolimus level (measures the amount of drug in the blood to determine whether concentrations have reached therapeutic levels). Review of resident 20's Results for laboratory studies revealed these lab studies were not completed as ordered. Review of Resident 20's physician orders revealed an order dated June 24, 2024 for a CBC and a CMP and a tacrolimus level. Review of resident 20's Results for laboratory studies revealed these lab studies were not completed as ordered. Interview with the Director of Nursing on August 15, 20204 at 11:30 a.m. confirmed these laboratory studies for Resident 20 were not completed as ordered. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 17 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on clinical record review and staff interview it was determined the facility performed laboratory studies without a physician order for one of 24 residents reviewed. (Resident 24) Residents Affected - Few Findings Include: Review of Resident 20's laboratory results revealed the results for a Magnesium level (blood test to determine the amount of magnesium in the blood), BMP (Basic Metabolic Panel- a test that measures eight different substances in your blood) and a CBC (comprehensive blood count- count of all the cells in the blood) completed on August 12, 2024. Review of resident 20's physician orders revealed there was no order for these laboratory studies. Review of Resident 20's laboratory results revealed the results for a CBC completed on June 24, 2024. Review of resident 20's physician orders revealed there was no order for this laboratory study. Review of Resident 20's laboratory results revealed the results for CMP (a routine blood test that measures 14 different substances in a sample of your blood) and a CBC completed on June 21, 2024. Review of resident 20's physician orders revealed there was no order for these laboratory studies. Review of Resident 20's laboratory results revealed the results for a UA C+S (urinalysis with a culture and sensitivity - test of the urine to determine if there is an infection and if so what kind and what antibiotics it is susceptible to) completed on June 11, 2024. Review of resident 20's physician orders revealed there was no order for these laboratory studies. Interview with the Director of Nursing on August 15, 2024 at 11:30 a.m. confirmed the above laboratory studies were completed with out the order of a physician. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 18 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observations, and staff interviews, it was determined that the facility failed ensure infection control management was implemented during a tracheostomy care and failed to follow policy related transmissions-based precautions and use of personal protective equipment for two of 32 sampled residents. (Resident 4 and Resident 85). Residents Affected - Few Findings include: Review of Resident 4's clinical record revealed an active order for indwelling catheter (a tube inserted into a bladder to drain urine) with a start date of January 15, 2024. Observations conducted of the Resident 4 on August 12, 2024, confirmed Resident 4 had an indwelling catheter. Additional observations of Resident 4 revealed an absences of Enhanced Barrier Precaution signs located in Resident 4's room or outside his room. Additional review of Resident 4's clinical record failed to reveal an order for Enhanced Barrier Precautions. Interview conducted with the Director of Nursing (DON) on August 13, 2024, at 1:55 a.m. confirmed the facility failed to place Resident 4 on Enhanced Barrier Precautions related to his indwelling catheter. Review of Resident 85's physician order revealed an order for a tracheostomy ( A procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside of the neck) care every day and night shift and as needed. Observation of tracheotomy care conducted with licensed Employee E9 on August 14, 2024, at 9:30 a.m. The observation revealed as follows: Without performing hand hygiene, Employee E9 put on a gown, a surgical mask, an eye shield, and unsterile gloves. Employee E9 opened a package of sterile gloves and put it on his/her right hand on top of the unsterile glove then started suctioning the resident. After suctioning, the employee took off the sterile glove on his/her right hand removed the old gauze on the tracheostomy area, wiped the secretions, and removed the old tracheostomy tube (Shiley). Without changing the gloves and washing hands, Employee E9 opened the package of the sterile tracheostomy tube picked it up, and placed it on the resident ' s tracheostomy opening then placed a clean gauze underneath. The above was discussed with the Director of Nursing on August 14, 2024, at 1:00 p.m. The facility failed to ensure infection control prevention and management were implemented during Resident 85's tracheostomy care. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 19 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, facility documentation, facility personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for new hires and existing staff. Residents Affected - Many Findings include: Interview conducted with the Staff Educator Employee (E7) on August 15, 2024, at 12:45 p.m. reported she was unable to provide a facility policy regarding an effective training program for all new and existing staff. Interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on August 15, 2024, at 1:05 p.m. confirmed the facility failed to develop a training program for all new and existing staff. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 20 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility documents, and staff interview, it was determined that the facility failed to provide training on effective communication for four out of five staff members (Employee E3, Employee E4, Employee E5, Employee E6,). Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on effective communication. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. During an interview on August 15, 2024, at approximately 12:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide training on effective communication for four out of five staff members. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 21 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of new hire personnel records and interviews, it was determined that the facility failed to provide training on Resident Rights for four out of five staff members (Employee E3, Employee E4, Employee E5, Employee E6, Employee E7). Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on Resident Rights. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 2024, at 12:45 p.m. reported she was unable to provide evidence the employees above received training regarding Resident Rights. Interview conducted with the Nursing Home Administrator (NHA) at 1:05 p.m. confirmed the above. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 22 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on staff interviews and a review of facility training and orientation records, it was determined that the facility failed to provide training on the facility's abuse prohibition policy and facility specific procedures for one out of five new hires (Employee E6). Findings include: Review of Dietary Aid Employee E6's personnel record revealed he/she had a hire date of July 29, 2024. Further review of the personnel record failed to provide evidence that Dietary Aid E6 received training on abuse, neglect, and exploitation between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 2024, at 12:45 p.m. reported she was unable to provide evidence the employees above received training regarding abuse, neglect, and exploitation. Interview on August 15, 2024 at 1:05 p.m. conducted with the Nursing Home Administrator (NHA) confirmed the above. 28 Pa Code 201.20(b) Staff Development 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(a)(c) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 23 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on review personnel records, and staff interview, it was determined that the facility failed to provide training on Infection Control for four out of five new hires (Employee E3, Employee E4, Employee E5, and Employee E6). Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on Infection Control. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 2024, at 12:45 p.m. reported Employee E7 was unable to provide evidence the employees above received training regarding Infection Control. Interview conducted on August 15, 2024, at approximately 12:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide training on Infection Control for four out of five staff members. 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 24 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 file for nursing assistants employed by the facility, it was determined the facility failed to ensure consistent in-service training and competencies were completed as required for one of five personnel files reviewed. (Employee E13) Findings include: Review of documentation of annual performance evaluations and logs of regular in-service training and competencies for Employee E13 failed to reveal ongoing training or annual evaluation. Interview with the Nursing Home Administrator, and Director of Nursing at 1:30 p.m., on August 15, 2024, confirmed that Employee E13 was the only nursing assistant employed with the facility for over twelve consecutive months. Further interview with the Nursing Home Administrator revealed that there was no documentation of nurse aide in-services at least twelve hours in a year, including dementia training, abuse prevention training, areas of weakness as determined in the nursing aide's performance review, facility assessment, special needs of residents and care of cognitively impaired residents for Employee E13. 28 Pa. Code 211.12(c)(d)(4)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 25 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for four out of five staff members (Employee E3, Employee E4, Employee E5, and Employee E6) Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on Behavioral Health. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 2024, at 12:45 p.m. reported she was unable to provide evidence the employees above received training regarding Behavioral Health. During an interview on August 15, 2024, at approximately 12:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide training on Behavioral Health for four out of five staff members. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395834 If continuation sheet Page 26 of 26

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

22 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.

0949GeneralS&S Fpotential for harm
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
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
0684GeneralS&S Dpotential 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.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0693GeneralS&S Dpotential 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.
0758GeneralS&S Dpotential 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.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0770GeneralS&S Dpotential for harm
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
0773GeneralS&S Dpotential for harm
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0940GeneralS&S Fpotential for harm
F940 - Training Requirements
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
0941GeneralS&S Fpotential for harm
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
0942GeneralS&S Fpotential for harm
F942 - Training Requirements
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
0943GeneralS&S Fpotential 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.
0945GeneralS&S Fpotential for harm
F945 - Infection control
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
0947GeneralS&S Fpotential 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.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2024 survey of KING OF PRUSSIA SKILLED NURSING AND REHABILITATION?

This was a inspection survey of KING OF PRUSSIA SKILLED NURSING AND REHABILITATION on August 15, 2024. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at KING OF PRUSSIA SKILLED NURSING AND REHABILITATION on August 15, 2024?

Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide behavior health training consistent with the requirements and as determined by a facility assessment."

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.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 15, 2024