Fox Chase Nursing Home: Infection Control Failures MD
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.
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 March 10, 2025.
When surveyors requested monthly infection surveillance reports for 2025, nursing staff initially could not provide the documentation.
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.