Fox Chase Rehabilitation And Nursing Center

F-F883) were recited as noncompliant.

On 5/29/2025 at 12:38 PM, an interview was conducted with the facility ' s Director of Nursing (DON) and Nursing Home Administrator (NHA). When asked who was in charge of the facility ' s QAPI committee and program, they stated that no one person was in charge but that there was a QAPI committee that met to discuss the facilities issues and performance improvement.

When asked how they were tracking to ensure that the facility was in compliance with the plan of correction from the annual survey, they stated that initial and follow up audits were conducted.

The survey team expressed concern with the QAPI committee ' s inability to provide documentation that would reflect the implementation of the facility ' s plan of correction for the deficiencies cited in the annual survey. The survey team discussed the 10 Federal regulations that were going to be recited due to the facility's current noncompliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 215197 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215197 B. Wing 03/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fox Chase Healthcare 2015 East-West Highway Silver Spring, MD 20910

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 50504 potential for actual harm Based on record review and interview, it was determined that the facility failed to have an Infection Residents Affected - Few Preventionist (IP) participate in the facility's Quality Assessment and Assurance (QAA) committee meetings.

This was evident in 9 of the 11 months of attendance records reviewed for the Quality Assurance Improvement Program.

The findings include:

The Quality Assessment and Assurance (QAA) committee is responsible for identifying and addressing quality deficiencies, developing and implementing corrective actions, and monitoring the effectiveness of those actions to ensure quality care and quality of life for residents.

On 03/07/25 at 10:41AM a review of the monthly QAA sign-in sheets from January 2024 through September 2024 failed to reveal that an IP participated in the facility's QAA meetings. The dates of the meetings were 1/23/24, 02/20/24, 03/19/24, 04/23/24, 05/28/24, 06/25/24, 07/23/24,08/20/24, and 09/24/24.

On 03/08/25 at 1:06PM in an interview, the findings were brought to the Administrator's attention. The Administrator reviewed the sign-in sheets and stated that she believed one of the QAA committee members was an IP.

On 03/08/25 at 1:30PM the Director of Nursing (DON) informed the surveyor that she served as IP from April 2024 to September 2024 and attended the QAA meetings. The surveyor requested DON's IP credentials from the Administrator.

The Administrator failed to provide DON's IP credentials at the time of exit on 03/10/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 215197 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215197 B. Wing 03/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fox Chase Healthcare 2015 East-West Highway Silver Spring, MD 20910

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 49815 potential for actual harm Based on observation, interview, and record review it was determined the facility failed to use appropriate Residents Affected - Some infection control practices for 1) conducting ongoing surveillance for infections and 2) urinary catheter maintenance and ensuring that staff observed appropriate practices for enhanced barrier precautions during

a high contact care for residents with indwelling urinary catheters and with pressure ulcer. This was found to be evident on the tour of the laundry department, during a record surveillance for infections and for 3 (Resident #48, #58 and #272) of 44 residents reviewed for infection control during the recertification survey

The findings include:

1) On 03/05/25 at 06:56 AM the surveyor toured the laundry department in the basement of the facility with

the Environmental Services Director (EVSD) #16 and the Laundry Aide #17.

During this tour of the laundry department with EVSD #16 and Laundry Aide #17 the surveyor observed the following: staff personal items in clean laundry area (coat on chair, water bottle, bottle of tea and coffee cup

on folding table), cardboard box of socks directly on the floor in clean laundry area, and a small refrigerator with staff personal items in the clean laundry area. Additionally, in an area directly adjacent to the clean and dirty laundry rooms the surveyor observed the following: cardboard box of personal protective equipment on top of a linen cart against a water pipe, 4 plastic bags of personal clothing directly on the floor and personal clothing in a barrel next to a maintenance paint cart. The EVSD #16 acknowledged the surveyor and stated, thank you for bringing these concerns to my attention and that he would take care of these concerns.

The surveyor at 07:55 AM on 03/05/25 conveyed to the Nursing Home Administrator (NHA) several of the findings that were observed in the laundry department.

On follow-up to the laundry department at 08:15 AM on 03/05/25 the surveyor observed the EVSD #16 and

the laundry aide #17 addressing the identified concerns from the initial tour of the laundry department.

On 03/05/25 at 09:15 AM the surveyor reviewed the Infection Prevention & Control Program dated 2001 and

the Surveillance for Infections Policy which was dated 2001 and revised 2017.

At 09:45 AM on 03/05/25 in an interview with the Director of Nursing (DON) and the Infection Preventionist (IP) #2 who were responsible for the Infection Control Program, specifically the surveillance for infections revealed that the facility did not have a system in place for conducting ongoing surveillance for infections. Additionally, there was no documentation for gathering surveillance data, data collection and recording, calculating infection rates, and interpreting surveillance data for the year 2024. The surveyor asked the DON and IP for monthly infection surveillance for the 3 months (January, February and March) of 2025. The DON stated that she was working on that but was unable to print the reports.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 215197 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215197 B. Wing 03/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fox Chase Healthcare 2015 East-West Highway Silver Spring, MD 20910

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 On follow-up interview with the Director of Nursing (DON) at 03:00 PM on 03/06/25 the surveyor asked again for the monthly infection surveillance for 2025. The DON presented the surveyor with a 2-page computer Level of Harm - Minimal harm or generated list of Residents with antibiotic orders for the past year totaling 16 orders and a 1-page written log potential for actual harm titled monthly infection surveillance for this year (2025) totaling 7 infections which was incomplete. The surveyor asked the DON for the monthly infection surveillance for 2024, and the DON acknowledged that Residents Affected - Some there were no monthly infection surveillance logs for 2024.

No further information was provided by the facility at the time of exit.

50502

2) An indwelling urinary catheter is a thin, flexible tube inserted into the bladder through the urethra to collect and drain urine. It remains in place for an extended period, typically days or weeks.

Per Centers for Disease Control (CDC), Enhanced Barrier Precautions (EBP)are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).

2a) On 3/03/25 at 9:01 AM, the catheter drainage bag of Resident #48 was observed on the floor. Licensed Practical Nurse (LPN #1) was made aware and confirmed that the drainage bag should be off the floor.

On 3/03/25 at 9:08 AM, an EBP sign was observed posted outside Resident #48's room, however, there was no cart for Personal Protective Equipment (PPE). LPN #1 confirmed that the EBP sign was for foley catheter use and that he/she had not seen the PPE cart.

On 3/06/25 at 6:50 PM, a review of Resident #48's medical record revealed a care plan initiated on 5/11/2023 which indicated Indwelling Catheter: Neurogenic bladder, however, the active physician orders revealed no evidence that an EBP order was written.

2b) On 3/03/25 at 9:32 AM, a review of Resident #58's active physician orders revealed an order written on 11/20/2024 which read, Maintain foley or suprapubic catheter for Neurogenic bladder. The care plan that was initiated on 11/21/2024 also indicated has Indwelling Catheter for Neurogenic bladder, however, Resident #58 had no EBP order, no EBP sign and no PPE cart outside his/her room.

On 3/03/25 at 9:40 AM, the Unit Manager (UM) stated that the facility is expected to put up EBP signs and ensure that PPE carts were placed outside the residents' rooms when caring for residents with indwelling medical devices and wounds. The UM was notified that Resident #48 had no PPE cart outside the room and Resident #58 had no PPE cart as well as no EBP sign.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 215197 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215197 B. Wing 03/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fox Chase Healthcare 2015 East-West Highway Silver Spring, MD 20910

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 On 3/03/25 at 9:44 AM, Geriatric Nurse Assistant (GNA #3) was observed placing a PPE cart outside Resident #48's room. He/she stated that if there was an EBP sign outside the room, he/she would only wear Level of Harm - Minimal harm or mask and gloves when providing close contact care to the residents, however, he/she added that he/she potential for actual harm would wear gown, gloves and mask if a contact isolation (a medical practice used to prevent the spread of infections that can be transmitted through direct or indirect with a patient or environment) sign was up. Residents Affected - Some

On 3/03/25 at 9:47 AM, the UM was observed putting up an EBP sign outside the room of Resident #58.

On 3/03/25 at 10:26 AM, in an interview with Resident #58, he/she confirmed that the staff were not wearing gown when giving direct contact care to him/her. He/she added that the nursing staff would only wear gloves and sometimes would wear masks.

2c) On 3/3/2025 at 9:27 AM, the surveyor observed no EBP sign and PPE cart outside Resident #272's room.

On 3/03/25 10:03 AM, the UM was observed putting up an EBP sign and PPE cart outside Resident #272's room. The UM confirmed that the EBP sign was for Resident #272's wounds.

On 3/06/25 at 9:40 AM, a review of the wound visit dated 3/6/25 confirmed that Resident #272 had a stage 3 pressure ulcer to the buttocks which resolved on 3/6/25 and a surgical wound of the right groin.

On 3/06/25 at 10:40 AM, a review of the active physician orders revealed treatment to the wounds, however,

an EBP order was not written.

On 3/07/25 at 7:55 AM, in an interview with GNA #13, he/she stated that when an EBP sign was posted outside the resident's room, it meant that the resident was on oxygen and that the staff should put on gloves and mask when care was being given to the resident. He/she added that only when a resident was on contact isolation, that's when the nursing staff were expected to wear gown.

On 3/07/25 at 8:24 AM, in an interview with LPN #1, he/she stated that when residents were placed on EBP for wounds and urinary catheters, nursing staff were expected to wear PPE, such as mask, gown and gloves when providing care.

On 3/07/25 at 8:31 AM, in an interview with the Director of Nursing (DON), she stated that per the facility's policy, residents who had feeding tubes, wounds , foley catheters should be placed on EBP. She added that once the residents were identified, the nursing staff put up EBP signs and placed PPE carts outside the residents' rooms. The DON was made aware of the concerns.

On 3/07/25 at 10:37 AM, a review of the facility's EBP policy indicated the following:

Gloves and gown are applied prior to performing the high contact resident care activity.

EBPs are indicated for residents with wounds and indwelling medical device.

Staff are trained prior to caring for residents on EBPs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 215197 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215197 B. Wing 03/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fox Chase Healthcare 2015 East-West Highway Silver Spring, MD 20910

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 Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Level of Harm - Minimal harm or potential for actual harm PPE is available outside the resident rooms.

Residents Affected - Some Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 215197 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215197 B. Wing 03/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fox Chase Healthcare 2015 East-West Highway Silver Spring, MD 20910

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 49815 potential for actual harm Based on record review and facility staff interviews, it was determined that the facility failed to provide Residents Affected - Few documentation that Residents were offered the pneumococcal vaccine. This was found to be evident in 3 (Resident #27, 54 and 56) of 5 Residents reviewed for pneumococcal immunization.

The findings include:

The surveyor conducted record reviews of Resident #27, 54 and 56's medical records on 03/05/25 at 08:50 AM. Reviews of the medical records revealed that Residents #27, 54 and 56 lacked up to date documentation of the pneumococcal immunization.

The MDS (Minimum Data Set) assessment is a standardized tool used to evaluate the health and functional status of Residents in skilled nursing homes (SNFs) in the United States. The purpose is to provide a comprehensive picture of the Resident's physical, cognitive, social and emotional needs; to guide care planning and ensure that Residents receive appropriate services; and to collect data for quality improvement, research and policymaking.

Further review of the medical records on 3/6/25 at 9:10 AM of Resident #27, 54 and 56 revealed that the Residents had a recent MDS assessments completed which indicated that the pneumococcal vaccination was not up to date, not received and not offered. Resident #27 had an MDS assessment completed 12/20/24 and the MDS indicated that the pneumococcal vaccine not received, state reason not offered. Resident #54 had an MDS assessment completed 01/28/25 and the MDS indicated that the pneumococcal vaccine not received, state reason not offered. Resident #56 had an MDS assessment completed 12/05/25 and the MDS indicated that the pneumococcal vaccine not received, state reason not offered.

The surveyor interviewed the Director of Nursing (DON) and the Infection Preventionist (IP) on 03/06/25 10:45 AM and asked what the expectation was for the documentation of the pneumococcal vaccination. The DON stated that the documentation of the pneumococcal vaccination was in the Resident's medical record.

The surveyor stated that the informed consent sheets and the immunization records for the pneumococcal vaccinations were incomplete for Resident #27, 54 and 56. In addition, the surveyor stated that review of the recent MDS assessments for Residents #27, 54 and 56 indicated that the pneumococcal vaccinations were not up to date, were not received and were not offered.

The surveyor reviewed Resident #27, 54 and 56's medical records specifically the pneumococcal vaccination informed consent forms with the Infection Preventionist (IP) at the nursing unit on 03/06/25 at 12:50 PM. The

review revealed that Resident #27 did not have an informed consent form in the medical record, Resident #54's informed consent form indicated Resident cannot sign due to confusion dated 11/30/23, and Resident #56's informed consent form indicated Resident cannot sign due to confusion dated 2/23/24. The Infection Preventionist (IP) acknowledged that Resident #27 did not have an informed consent form and Resident #54 and #56's pneumococcal vaccination informed consent forms indicated that Residents cannot sign due to confusion. The surveyor requested a copy of these informed consent forms.

At the time of survey exit on 03/10/25 no additional information for pneumococcal immunization was provided by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 215197