Fox Chase Healthcare: Care Plan Failures After Fall - MD
Inspectors visiting Fox Chase Healthcare, a nursing home at 2015 East-West Highway in Silver Spring, cited the facility in April 2026 for failing to update the care plan of a resident who had fallen in January. The violation was classified as causing minimal harm or potential for actual harm.
The resident, identified in inspection records only as Resident #2, had lived at the facility since July 2022. Their medical history included osteoarthritis of the knee, reduced mobility, difficulty walking, and a history of falls. A quarterly assessment completed in late January 2026 found the resident had moderate cognitive impairment.
On January 9, 2026, while sitting in the activity room, the resident leaned to the left, tipped their wheelchair, and fell to the floor. A progress note written that afternoon documented the fall and listed one immediate response: staff placed a gel cushion in the resident's wheelchair to help prevent another fall.
That note existed. The cushion existed. On April 15, 2026, an inspector observed the resident seated in their wheelchair with the gel cushion still in place.
What didn't exist was any mention of the cushion in the care plan.
The care plan included a section, initiated on March 9, 2026, that identified the resident as being at risk for falls due to poor safety awareness related to cognitive impairment. It listed no intervention directing staff to use a gel cushion. For anyone consulting that document to understand how to keep the resident safe, the cushion wasn't there.
The gap between what staff were actually doing and what the official record said to do stretched across more than three months.
A registered nurse at the facility told inspectors during a telephone interview that the process was straightforward: if a resident fell, the nurse caring for that resident was supposed to add a new intervention to the care plan right away, and unit managers were responsible for making sure the care plan was updated.
The Director of Nursing said the same thing in different words. Nurses were expected to put interventions in place at the time of a fall, and supervisors were responsible for adding those interventions to the care plan.
Both described a system with clear expectations. Neither could explain why, in this case, the system didn't produce a result.
The care plan is the document other staff rely on when they don't know a resident's history. A nurse covering a different unit, an aide working a weekend shift, a physical therapist consulting the record before a session — all of them would have found a fall risk notation and no instruction about the cushion. Whether any of them would have thought to check the chair, or known to ask, the inspection record doesn't say.
Resident #2 had moderate cognitive impairment, meaning they couldn't reliably advocate for themselves or explain to staff what interventions had already been tried. The care plan is supposed to carry that information forward. In this case, it didn't.
Fox Chase Healthcare is a Medicare and Medicaid-certified facility. The inspection was conducted as a complaint survey, meaning someone had raised concerns about care at the facility before inspectors arrived. The inspection was completed April 24, 2026.
The resident was observed in their wheelchair, cushion in place, more than three months after the fall. The plan of care still said nothing about it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fox Chase Healthcare from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
FOX CHASE HEALTHCARE in SILVER SPRING, MD was cited for violations during a health inspection on April 24, 2026.
The violation was classified as causing minimal harm or potential for actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.