Health inspection·July 18, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, policy reviews, and clinical closed record review, it was determined the facility failed to ensure ombudsman notification procedures were followed for one of one resident reviewed. (Resident 6), and to document return of personal items upon discharge or death for two of three residents reviewed (Resident 139 and 140).Findings Include: Review of Resident 6’s clinical record revealed diagnoses including pulmonary embolism. (A pulmonary embolism (PE) is a blood clot in one of the blood vessels in your lung.) Interview with Director of Nursing on [DATE] at 10:02 AM confirmed no notification was sent to ombudsman Review of facility policy titled Personal Property: Patient's revealed, personnel will identify and record the resident's belongings upon admission to the facility. Return of any personal property remaining in the facility must be made within 30 days after discharge or death. Review of nursing notes for Resident 139, dated [DATE], documents the resident was discharged to [NAME] Hospital related to lower back pain. No further information was documented regarding Resident 139. Review of Resident 139's closed clinical record revealed a list of the resident’s personal items upon admission. Further review of Resident 139's closed clinical records failed to reveal documentation the resident's personal items were returned after discharge. Review of nursing notes for Resident 140's, dated [DATE], at 4:09 a.m., documenting Resident 140 was found unresponsive, RN on duty called to examine, Resident was pronounced at 03:30 am expired. Review of Resident 140's closed clinical record revealed a list of the resident’s personal items upon admission. Further review of Resident 140's closed clinical records failed to reveal documentation the resident's personal items were returned to family after the resident's death. Interview on [DATE], at 10:00 a.m. with the Director of Nursing (DON), when the above was presented, the DON confirmed there was no documentation of the resident's personal belongings be returned Page 1 of 9 395834 395834 07/18/2025 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0628 upon discharge or death. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 201.25 Discharge policy 28 PA Code 211.5(d) Clinical records Residents Affected - Few 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395834 Page 2 of 9 395834 07/18/2025 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 a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to properly follow physician orders for two of 32 residents reviewed (Resident 6 and 29).Finding include: Residents Affected - Few Review of Resident 6’s clinical record revealed diagnoses including essential hypertension. (Primary (essential) hypertension is high blood pressure that is multi-factorial and doesn’t have one distinct cause.) Review of Resident 6’s physician's orders revealed Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN Hold for SBP < 130 Review of Resident 6’s medication administration record (MAR) for the month of May 2025, June 2025, and July 2025 revealed the facility administered the above medication eight times outside of parameters. The facility failed to ensure Resident 6’s medication order Metoprolol Tartrate Oral Tablet 25 MG was administered as ordered. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 17, 2025 at 11:32 am. Review of the facility’s “Pain Management” policy, revised March 24, 2025, revealed at a minimum of daily, residents will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain. As needed pain medications will have defined parameters for use. Review of the facility’s “Pain Management” policy, failed to reveal guidance on pain severity levels. Review of facility policy titled Medication Administration General Guidelines dated 01/24 section 7.1. Medication administration: “Medications are administered in accordance with written orders of the prescriber. Review of Resident 29’s clinical records revealed medical diagnosis that include Malignant Neoplasm of Tongue (tongue cancer), and Tracheostomy Status (surgical hole in the B that assists with breathing), and Dysphagia, Oropharyngeal (difficulty transferring food from mouth to throat). Review of Resident 29’s physician orders revealed an order dated December 17, 2018, for NPO diet (nothing by mouth), Morphine Sulfate Oral Tablet (opioid pain reliever) 30 mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain, Risperdal Tablet 3 mg (antipsychotic), give 1 tablet by mouth at bedtime give with 0.5mg tablet to equal 3.5 total, Amoxicillin-Po Clavulanate Tablet (antibiotic) 875-125 mg, give 1 tablet by mouth every 12 hours for pneumonia for 5 days give twice daily for 5 days, Docusate Sodium Liquid (stool softener) 50 mg/5ml, give 10 ml by mouth two times a day for constipation and Enteral Feed (intake of nutrition via tube) five times a day Osmolite 1.5 formula, Bolus feeds of 275 ml 5x per day (1375 ml total volume). Review of Resident 29’s June and July 2025 Medication Administration Reports (MAR) revealed 395834 Page 3 of 9 395834 07/18/2025 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 - Few nursing staff document administering the Morphine, Risperdal, Amoxicillin and Docusate via mouth although the resident has orders of NPO, and all medications should be administered via the resident’s Percutaneous Endoscopic Gastrostomy (PEG)-Tube (feeding tube inserted wall of stomach). Further review of Resident 29’s June and July 2025 MARs revealed Morphine Sulfate Oral Tablet 30 mg, give 1 tablet every 4 hours as needed for moderate to severe pain was administered to the resident with a documented pain level of 0 to 2 from June 24, 2025, through July 9, 2025. Interview with Resident 29 on July 17, 2025, at 10:00 a.m., Resident 29 confirmed he/she receives nothing by mouth, everything is administered via peg-tube. Interview with Unit Manager Employee E5 on July 17, 2025, at 10:10 a.m., E5 stated Resident 29 only receives medications via peg-tube. E5 confirmed the resident’ s NPO status and confirms the resident receives nothing by mouth. E5 confirmed Resident 29 received Morphine for moderate to severe pain with documented pain levels of 0 to 2. E5 stated staff documents the residents clinical pain level (the resident’s physical appearance of pain), not the resident’s stated pain level, which is usually 7. Interview July 18, 2025, at 10:00 a.m. with Director of Nursing (DON), DON confirmed Resident 29 receives nothing by mouth. DON confirmed documentation errors for Resident 29’s physician orders noting take by mouth. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services 395834 Page 4 of 9 395834 07/18/2025 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 upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 15 residents reviewed (Resident 8, Resident 60). Residents Affected - Few Finding include: Review of facility policy and procedure titled Weights and heights, revised July 15, 2025, revealed Based on patients’ comprehensive assessment, the center will ensure that all patients maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, unless the patient clinical condition demonstrates that is not possible for the patients' preferences to indicate otherwise Review of Resident 8’s diagnosis list revealed diagnoses including Gastro-esophageal reflux disease without esophagitis. (Gastroesophageal reflux disease (GERD) happens when acidic stomach contents flow back into the esophagus.) Review of Resident 8’s physician orders dated July seventh, 2025, revealed an order for weights every Monday. Review of Resident 8's Weight Summary revealed July 1, 2025; Resident 8 weighed 127.5 pounds. Further review of Resident 8's Weight Summary revealed on July 14, 2025. Resident 8 weighed 119.6 pounds Resident 8’s weighed 119.6 pounds on July 14, 2025. This indicated a 6.2% weight loss between July 1, 2025, and July 14, 2025. Further review of Resident 8's clinical record failed to reveal evidence of a reweight after the July 14, 2025, was obtained. Further review of Resident 8's clinical record failed to reveal evidence that the facility dietitian was notified of Resident 8's weight loss. Review of Resident 60’s clinical record revealed diagnoses of localized edema (accumulation of fluid in a specific area of the body) and dementia. Review of Resident 60's clinical record revealed that weights were obtained as follows: December 2, 2024 – 140.6 pounds, January 1, 2025- 131.2 and February 2, 2025 – 112.5 pounds indicating a loss 18 pounds (14.25% Loss). Review of Resident 60’s clinical records and nutrition assessment failed to reveal evidence of significant weight loss being identified and interventions being put in place to address the weight loss. Interview with Dietician on July 17, 2025, at 10:50am confirmed the above information was true for Resident 60. Interview with the dietitian on July 17, 2025, at 11:07am confirmed that no reweight was obtained and further confirmed the dietitian was not notified of Resident 8's weight loss. 395834 Page 5 of 9 395834 07/18/2025 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0692 28 Pa. Code 211.10(c) Resident Care Policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(c)(d)(3) Nursing Services Residents Affected - Few 395834 Page 6 of 9 395834 07/18/2025 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 review, and policy and procedures review, it was determined the facility failed to follow a physician's order for oxygen therapy for one of three residents reviewed (Resident 10). Findings include:Review of facility policy, titled Procedure: OXYGEN: NASAL CANNULA revision date 08/07/2023 revealed place oxygen source in room according to equipment specific procedure.Review of Resident 10's clinical record revealed there was a current physician's order for the resident to be receiving oxygen therapy via a nasal cannula. The cannula was to be used continuously.Review of Resident 10's clinical record revealed the following nursing statement. The resident also is on continuous oxygen, however O2 was not in use during ambulation. Staff and therapist were re-educated on ensuring oxygen is maintained during all mobility activities, including with portable tanks when appropriate.Interview conducted with the Director of Physical therapy, Employee E3, at 07/18/2025 12:51 PM, when they were informed of the above information and deficient practice was identified.The facility failed to follow a physician's order for oxygen therapy for Resident 10. PA Code 211.10(c) Resident Care Policies Residents Affected - Few 395834 Page 7 of 9 395834 07/18/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations and interviews, it was determined that the facility failed to document medication disposition for one of three discharged residents. (Resident 139). Findings include: Review of facility policy titled Disposal of Medication Waste, documents all medications will be disposed of in accordance with applicable federal, state, and local regulations for the disposal of chemical and potentially dangerous or hazardous pharmaceuticals. Medication for disposal includes medications which are not taken with the resident upon discharge. Medications that cannot be returned to the pharmacy, discharged with the resident, or donated will be placed in medication disposal bins labeled controlled substance waste. A licensed pharmaceutical waste disposal company will remove medication waste.Review of resident 139's clinical records revealed physician orders that included Morphine Sulfate Oral Tablet 15 MG (for pain).Review of Resident 139's clinical records revealed a progress note dated April 17, 2025, at 5:54 a.m., documenting the resident was admitted to [NAME] Hospital for observation related to chronic (recurring) mid-line low back pain. No further information was documented concerning Resident 139's discharge. Review of Resident 139's closed records revealed a medication administration form dated April 13, 2025, documenting the resident received 30 Morphine Sulfate Oral Tablets. Per the medication administration form none of the medication was administered to Resident 139. Further review of Resident 139's closed records failed to reveal documentation of the proper disposition of Resident 139's 30 Morphine Sulfate Oral Tablets. Interview on July 18, 2025, at 10:00 a.m., with Director of Nursing (DON) when the above information was presented, The DON confirmed there was no medication disposition sheet for Resident 139. 42 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records.28 Pa. Code 211.9(j) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services. 395834 Page 8 of 9 395834 07/18/2025 King of Prussia Skilled Nursing and Rehabilitation 600 West Valley Forge Road King of Prussia, PA 19406

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (dishwasher and sink faucet) in safe, operating condition. Findings include:Observation of the facility's main kitchen on 7/14/2025, between 6:13p.m. and 6:25 p.m., revealed a puddle of water on the floor by the dishwasher. During an interview at the time of the observation, Employee 6 indicated that the puddle of water was due to a drain issue and that maintenance was made aware three month ago. Observations of the use of the sink faucet by the dishwasher on 7/15/2025 at 9:25am revealed a puddle of water on the floor and leak in the faucet. Interview with the Maintenance Director on 7/15/2025 at 9:36am confirmed that there was a leaking faucet and were made aware of it a month ago (June 2025) and stated that there was an issue with the water line.Review of work orders provided revealed a work order for faucet repair was put in on 7/15/2025.Interview with the Nursing Home Administrator on 7/16/2025 at 2:11pm confirmed the above findings. 28 Pa Code: 207.2(a) Administrator's responsibility. Residents Affected - Few 395834 Page 9 of 9