| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01G011 | (X3) Date Survey Completed 10/04/2025 |
| Name of Provider or Supplier Rainbow Omega, Inc, | Street Address, City, State 202 Hope Drive, Eastaboga, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| W0122 | CLIENT PROTECTIONS CFR(s): 483.420(a) The facility must ensure the rights of all clients. Therefore the facility must This CONDITION is not met as evidenced by: Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the protection of client rights for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8.) The violation of client rights placed all 15 clients of the facility at risk of living in a restrictive and unsafe environment. All clients who resided in the home were restricted from their kitchen and access to their front doors (freedom of movement) without due process. C2 was neglected by staff and by the interdisciplinary team who were aware of the incidents that constituted neglect. C3 and C4 were victims of a peer to peer abuse. The families of the clients who were victims of abuse were not notified of the abuse; and the State Survey Agency was not notified. On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the protection of client rights constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 07/14/23. The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM. The facility's removal plan included: 1. The facility revised their policy to include peer to peer aggression constituted abuse. The facility began training staff on the revised policy and stated all staff would be training prior to working their next shift. 2. The facility educated all staff on intervening during episodes of client self-injurious behavior (SIB) and failure to intervene was neglect. Through interview and record review, the survey team was able to validate all components of the plan of removal were implemented, and the Immediate Jeopardy was removed on 10/02/25 at 6:15 PM. Findings include: 1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W125. 2. The facility failed to ensure three of eight clients (Client (C) 2, C3, and C 4) were free from abuse and neglect. C2 engaged in frequent and repetitive Self-Injurious Behavior (SIB) and staff neglected to intervene to protect the resident. Additionally, C3 and C4 were not protected from peer to peer abuse that facility identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment. Cross Reference: W127. 3. The facility failed to ensure video/audio live feed monitoring and/or recording was not used in place of staff supervision for one of eight sampled clients (Client (C) 5). C5 had a live feed video monitor in his/her bedroom which violated the client's right to privacy. Cross Reference: W129. 4. The facility failed to ensure staff encouraged and trained clients to use age-appropriate materials and not reinforce childlike socialization for one of eight sampled clients (Client (C) 8). C8 commonly had with him/her a babydoll; however, staff engaged in social interaction with the adult client in a childlike manner. This failure placed the client at risk for stigmatization and diminished opportunity for growth. Cross Reference: W137. 5. The facility failed to ensure parents and/or guardians were notified of abuse or allegations of abuse for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; however, notifications of the abuse were not made to the family/guardian. Cross Reference: W148. 6. The facility failed to ensure their abuse policy identified instances of peer to peer aggression as abuse to prohibit client abuse. This failure had the potential to affect all 15 clients who resided at the facility. Cross Reference: W149. 7. The facility failed to ensure allegations and/or instances of abuse were immediately reported to the facility's Director and to the State Survey Agency (SSA) for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; the facility's Director was not immediately notified nor was the SSA notified within 24 hours of the allegation/abuse. These failures place all 15 clients of the facility at risk for action not to be taken to prevent further abuse. Cross Reference: W153. 8. The facility failed to ensure allegations and/or instances of abuse were investigated for two of eight sampled clients (Client (C) 3 and C4). It was witnessed that C3 was abused by his/her peer; and C4 made an allegation that a peer hit him/her; however, neither of these instances were investigated as abuse. These failures place all 15 clients of being victims of abuse with no corrective action due to the facility not completing the investigations. Cross Reference: W154. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the protection of client rights for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8.) The violation of client rights placed all 15 clients of the facility at risk of living in a restrictive and unsafe environment. All clients who resided in the home were restricted from their kitchen and access to their front doors (freedom of movement) without due process. C2 was neglected by staff and by the interdisciplinary team who were aware of the incidents that constituted neglect. C3 and C4 were victims of a peer to peer abuse. The families of the clients who were victims of abuse were not notified of the abuse; and the State Survey Agency was not notified. On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the protection of client rights constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 07/14/23. Findings include: 1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W125. 2. The facility failed to ensure three of eight clients (Client (C) 2, C3, and C 4) were free from abuse and neglect. C2 engaged in frequent and repetitive Self-Injurious Behavior (SIB) and staff neglected to intervene to protect the resident. Additionally, C3 and C4 were not protected from peer to peer abuse that facility identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment. Cross Reference: W127. 3. The facility failed to ensure video/audio live feed monitoring and/or recording was not used in place of staff supervision for one of eight sampled clients (Client (C) 5). C5 had a live feed video monitor in his/her bedroom which violated the client's right to privacy. Cross Reference: W129. 4. The facility failed to ensure staff encouraged and trained clients to use age-appropriate materials and not reinforce childlike socialization for one of eight sampled clients (Client (C) 8). C8 commonly had with him/her a babydoll; however, staff engaged in social interaction with the adult client in a childlike manner. This failure placed the client at risk for stigmatization and diminished opportunity for growth. Cross Reference: W137. 5. The facility failed to ensure parents and/or guardians were notified of abuse or allegations of abuse for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; however, notifications of the abuse were not made to the family/guardian. Cross Reference: W148. 6. The facility failed to ensure their abuse policy identified instances of peer to peer aggression as abuse to prohibit client abuse. This failure had the potential to affect all 15 clients who resided at the facility. Cross Reference: W149. 7. The facility failed to ensure allegations and/or instances of abuse were immediately reported to the facility's Director and to the State Survey Agency (SSA) for two of eight sampled clients (Client (C) 3 and C4). Both C3 and C4 were victims of abuse from their peers; the facility's Director was not immediately notified nor was the SSA notified within 24 hours of the allegation/abuse. These failures place all 15 clients of the facility at risk for action not to be taken to prevent further abuse. Cross Reference: W153. 8. The facility failed to ensure allegations and/or instances of abuse were investigated for two of eight sampled clients (Client (C) 3 and C4). It was witnessed that C3 was abused by his/her peer; and C4 made an allegation that a peer hit him/her; however, neither of these instances were investigated as abuse. These failures place all 15 clients of being victims of abuse with no corrective action due to the facility not completing the investigations. Cross Reference: W154. ********************** The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM. The facility's removal plan included: 1. The facility revised their policy to include peer to peer aggression constituted abuse. The facility began training staff on the revised policy and stated all staff would be training prior to working their next shift. 2. The facility educated all staff on intervening during episodes of client self-injurious behavior (SIB) and failure to intervene was neglect. Through interview and record review, the survey team was able to validate all components of the plan of removal were implemented, and the Immediate Jeopardy was removed on 10/04/25. |