SILVER SPRING, MD - Federal inspectors found serious deficiencies in infection control practices and quality oversight at Fox Chase Rehabilitation and Nursing Center during a March 2025 survey, citing the facility for failing to properly implement safety protocols designed to prevent the spread of infections among vulnerable residents.
Infection Prevention Program Lapses
The most significant violations centered on the facility's infection prevention and control program, which inspectors found lacking in multiple critical areas. The nursing home failed to conduct proper ongoing surveillance for infections throughout 2024, with no documented system for gathering surveillance data, calculating infection rates, or interpreting infection trends.
When surveyors requested monthly infection surveillance reports for 2025, nursing staff initially could not provide the documentation. Eventually, staff produced only an incomplete two-page list of residents with antibiotic orders and a handwritten log showing seven infections for 2025. No monthly infection surveillance logs existed for the entire year of 2024, representing a fundamental breakdown in infection monitoring that is essential for protecting residents in congregate care settings.
The Director of Nursing acknowledged during interviews that the facility was "working on" infection surveillance reports but was unable to print them at the time of inspection. This lack of systematic infection tracking prevents the facility from identifying patterns, implementing targeted interventions, and protecting residents from preventable infections.
Enhanced Barrier Precautions Not Properly Implemented
Inspectors documented serious failures in implementing Enhanced Barrier Precautions (EBP), a critical infection control intervention designed to prevent transmission of multidrug-resistant organisms. The facility failed to properly protect three residents with indwelling urinary catheters and pressure ulcers, conditions that significantly increase infection risk.
In one case, surveyors observed a catheter drainage bag placed on the floor in a resident's room - a clear violation of basic infection control principles that could introduce bacteria into the urinary system. The same resident had an EBP sign posted outside their room but no cart containing personal protective equipment (PPE) readily available for staff use.
Two other residents with indwelling catheters had no EBP signage or PPE carts outside their rooms, despite facility policies requiring these protections. When confronted with these deficiencies, staff scrambled to post signs and place equipment during the inspection. One resident confirmed to inspectors that "staff were not wearing gown when giving direct contact care" and that nursing staff "would only wear gloves and sometimes would wear masks."
Staff confusion about proper EBP protocols was evident throughout the inspection. One nursing assistant incorrectly stated that EBP signs meant residents were "on oxygen" rather than requiring enhanced protection due to medical devices or wounds. This fundamental misunderstanding of infection control protocols puts all residents at increased risk of acquiring dangerous infections.
Medical Significance of Infection Control Failures
These infection control deficiencies pose serious health risks to nursing home residents, who are among the most vulnerable populations for healthcare-associated infections. Urinary tract infections associated with indwelling catheters are among the most common infections in long-term care facilities and can lead to sepsis, kidney complications, and increased mortality rates.
Enhanced Barrier Precautions serve as a crucial defense against multidrug-resistant organisms, which can cause life-threatening infections that are difficult to treat with standard antibiotics. When staff fail to use proper gowns, gloves, and masks during high-contact care activities, they risk spreading these dangerous organisms between residents.
Proper surveillance systems are the foundation of infection prevention in healthcare settings. Without accurate tracking of infection rates and patterns, facilities cannot identify outbreaks early, implement targeted interventions, or evaluate the effectiveness of prevention measures. The absence of surveillance data for an entire year represents a significant gap in resident protection.
Quality Assurance Committee Structure Problems
The facility's Quality Assessment and Assurance committee, responsible for identifying and addressing quality deficiencies, failed to include required infection prevention expertise. Review of meeting attendance records from January through September 2024 showed no documented participation by an Infection Preventionist in monthly committee meetings.
When questioned about this deficiency, the Administrator initially believed committee members included infection prevention staff. The Director of Nursing later claimed to have served as the Infection Preventionist from April through September 2024 and attended meetings, but the facility could not provide credentials documenting the Director of Nursing's infection prevention qualifications at the time of survey exit.
This lack of infection prevention expertise in quality oversight committees undermines the facility's ability to identify, assess, and address infection-related risks systematically. Federal regulations require specific professional expertise on these committees to ensure comprehensive quality monitoring.
Laundry Department Contamination Risks
Inspectors identified additional infection control concerns in the facility's laundry operations, where clean and soiled items were improperly separated. Staff personal items including coats, water bottles, and food containers were observed in clean laundry areas, creating potential contamination sources.
The survey team also found cardboard boxes of supplies stored directly on floors, personal protective equipment stored inappropriately near water pipes, and personal clothing mixed with facility operations. These conditions violate basic infection control principles requiring clear separation between clean and contaminated areas.
Additional Issues Identified
The inspection revealed problems with pneumococcal vaccination documentation for three residents. Medical records showed that residents had not been offered pneumococcal vaccines, with recent assessments indicating vaccines were "not received" and "not offered." Informed consent forms were either missing entirely or indicated residents could not sign due to confusion, with no alternative documentation of vaccine discussions with appropriate representatives.
The facility also demonstrated broader quality assurance program deficiencies, with leadership unable to provide documentation showing implementation of previous survey corrections. When asked about compliance tracking for earlier cited deficiencies, administrators could only reference initial and follow-up audits without producing supporting evidence.
These systemic issues suggest fundamental problems with the facility's approach to quality monitoring and improvement. The inability to demonstrate correction of previously identified problems, combined with new infection control failures, indicates ongoing challenges in maintaining regulatory compliance and protecting resident welfare.
Federal regulations require nursing homes to maintain comprehensive infection prevention programs, conduct regular surveillance, and ensure proper implementation of safety protocols. The violations identified at Fox Chase Rehabilitation and Nursing Center represent significant departures from these standards and highlight the ongoing challenges many facilities face in protecting residents from preventable infections and maintaining quality care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fox Chase Rehabilitation and Nursing Center from 2025-03-10 including all violations, facility responses, and corrective action plans.
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