Rocket City Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Rocket City Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF656Feb 26, 2023

  Based on observations, interviews, resident record review, and review of a facility policy titled Comprehensive Care Plans, the facility failed to develop and implement a care plan with person-centered safety interventions addressing Resident Identifier (RI) #27's noncompliance with the facility's non-smoking policy, including smoking and vaping inside the facility unsupervised in his/her room from 11/15/2022 through 02/13/2023. Facility staff did not know what to do or how to respond on occasions when RI #27 was found using a vape or smoking in his/her room. This failure affected RI #27, one of 23 sampled residents for whom care plans were reviewed. […]

• Immediate jeopardy, widespreadF689Feb 26, 2023

  Based on interviews, record review, review of the facility's RESIDENT HANDBOOK & (and) ADMISSION DOCUMENTS, review of an article published by the United States Food and Drug Administration titled E-Cigarettes, Vapes, and Other Electronic Nicotine Delivery Systems (ENDS), and review of two reports to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System, the facility failed to develop, implement, and revise effective person-centered safety interventions for Resident Identifier (RI) #27, a resident found to have multiple documented episodes of noncompliance with the facility's non-smoking policy dating back to 11/15/2022, including smoking inside the facility unsupervised and falling asleep with ENDS, also known as vapes, in his/her hand. […]

• Immediate jeopardy, widespreadF867Feb 26, 2023

  Based on interviews, review of a policy titled Quality Assurance/Performance Improvement (QAPI) Program Policy, and review of the facility's 12/23/2022 and 01/25/2023 QUALITY PERFORMANCE/PEER REVIEW FACILITY PLAN OF ACTION/CONTINUOUS QUALITY IMPROVEMENT, the facility's QAPI committee failed to thoroughly implement the 12/23/2021 and 01/25/2023 action plans, which included an action item for laundry staff to monitor residents clothing to evaluate for burn holes, soot, and evidence of smoking. This failure placed all 109 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death, due to the ongoing resident safety risk and fire hazard. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2023

  Based on observation, interview, the facility's policies for Staff Attire, Food Preparation, and Food Storage: Cold Foods, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure food safety by: 1.) Employee Identifier (EI) #7 not wearing a beard covering over his mustache while serving the breakfast meal on [DATE], 2.) keeping boiled eggs with a use by date of [DATE] in the Walk-in Cooler on [DATE], 3.) keeping Temperature Control for Safety (TCS) food in the Station #2 resident refrigerator at 53 (degrees) Fahrenheit (F) and the freezer at 15 F on [DATE], and 4.) the Station #1 resident refrigerator having no thermometer for staff to monitor the temperature on [DATE] and [DATE]. […]

• No harm, potential for more than minimal, isolatedF550Feb 26, 2023

  Based on interviews, record reviews and review of a facility policy titled, Contraband Discovery Policy, the facility failed to ensure staff did not search Resident Identifier (RI) #27's room on 12/07/2022 without first obtaining RI #27's consent. This deficient practice affected RI #27, one of one sampled resident reviewed for for improper room searches. Findings include: A facility policy titled Contraband Discovery Policy, revised 10/18/2022, documented: .Use for conducting inspections and searches, with consent, of current residents and residents' rooms under circumstances where there is reasonable suspicion that the resident may be concealing contraband. For purposes of this policy . non-compliant use of tobacco products as per the facility smoking policy is considered contraband. […]