Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
W0127 PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(5)

The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment.


This STANDARD is not met as evidenced by:
Based on record review, interview, and review of the facility's policy, 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 the facility only identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed ". . . Abuse" Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results. Assault used in this definition implies intent. Physical injury, as used herein, is defined as impairment of physical condition or substantial pain . . . Neglect: Failure to carry out a duty through reckless conduct, carelessness, inattention, or disregard of duty whereby the individual served is exposed to harm or risk of harm, and includes, but is not limited to: failing to appropriately supervise individuals or otherwise leaving individuals served unattended, failing to ensure that an individual's basic needs for safety, nutrition, medical care and personal attention are met, failing to provide treatment in accordance with the individual support plan/person directed planning or failing to develop a program plan, and utilizing treatment techniques, restraints (unless authorized with express written consent to promote an individual's safety), seclusion (unless as. part of a behavior support plan and reviewed by the Human Rights

Committee), etc., in violation of standards, whether or not injury results . . ." The policy did not identify one client hitting another as peer to peer abuse.

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C2's "Therap (name of electronic medical record system) Communication Log (T-Log)," dated 11/13/24 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "While assisting resident to bathroom [he/she] was walking towards toilet and went to head-butt padded area on wall, [he/she] missed the pad and head-butted wall hard and resident stated 'ouch.' Nurse notified."

Review of C2's "T-Log," dated 12/20/24 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] came out [his/her] room with [his/her] breakfast plate and [Resident Aide (RA) 1's name] told [him/her] to go back in [his/her] room and [he/she] did not then [he/she] saw me and I told [him/her] to go back into [his/her] room and walked past [him/her] to go help [RA1's name] and then [he/she] throws [his/her] breakfast plate towards my back and it fell into the floor."

Review of C2's "T-Log," dated 12/22/24 and located in the client's EMR under the "T-Log" tab, revealed, "Approximately around 2:30pm I was telling resident to go back into [his/her] room per quarantine instructions. While trying to re-direct resident to [his/her] room [he/she] managed to throw [himself/herself] on the floor by another residents [sic] room where [his/her] head caught the edge of the metal piece in the corner where [he/she] received a laceration. Charge nurse was notify [sic]."

Review of C2's "T-Log," dated 12/23/24 and located in the client's EMR under the "T-Log" tab, revealed, "Resident returned to facility at 8:10 P.M. from the emergency room, [he/she] was alert and good spirits. Resident received eleven staples to the back of [his/her] head."

Review of C2's "T-Log," dated 03/26/25 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] was being sent to the living/dining area to wait for breakfast, while the aid made [his/her] bed and cleaned [his/her] room. The resident became upset because [he/she] wanted to lay down instead of going to breakfast. [C2's name] proceeded to bang [his/her] head against the wall repeatedly until the nurse and aid intervened. Nurse was notified."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab revealed "Staff reported resident head- banged wall while in bathroom, no evident injury

noted, [Name of C2's Attending Physician] made aware, neuro checks initiated, neuro intact at this time, care ongoing."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While showering [C2's initials] [he/she] got very agitated and when going to wash [his/her] legs [he/she] started kicking the wall. Then the aid moved so [he/she] would not get hit but when the aid went back to trying to wash the resident [he/she] hit the aid on the side of the head. The aid moved and told [C2's initials] to stop. The aid moved and the resident began hitting [himself/herself] in the face. The aid then washed off [C2's initials] and started to dry [him/her] and the resident kicked the aid in the shin. Next, the aid started to dress [C2's initials] and [he/she] hit the aid in the hand and squeezed the aids [sic] hand. The aid reported it to the nurse."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "I happened to notice [C2's name] became irritated at lunch because [his/her] ice cream was still frozen and [he/she] could not get it out of the cup. I took [his/her] ice cream cup which had [his/her] spoon in it to the kitchen to soften it for [him/her]. When I came back [he/she] was irritated and eating [his/her] cake with [his/her] hands. At some point [he/she] had put [his/her] hands on [his/her] head and got icing in [his/her] hair and on the side of [his/her] face. [He/She] finished a little before 12pm and started to [his/her] room when I saw [his/her] face and hands covered in cake. I stopped [him/her] to wipe [his/her] hands and face and [he/she] showed discontent at first. I tried to keep [his/her] attention but [he/she] screamed and started to hit [himself/herself] in the face and got [sic] made contact a couple of times. I began to redirected [sic] [his/her] hand and [he/she] stopped for a second. Then, [he/she] started hitting [his/her] right side. I began to wipe that hand of the icing to distract [him/her] and [he/she] screamed again. I wiped [his/her] face and [he/she] continued to [his/her] room."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident was in bed and appeared to be sleep during 10pm rounding. By the time staff returned to the desk, [he/she] come out of [his/her] bedroom with a big smile. [He/She] said something to staff and when staff could not understand [him/her] and asked [him/her] to repeat what [he/she] said, [he/she] put [his/her] head as if looking at the floor and hands over [his/her] ears. Staff came closer to try to understand. [He/She] attempted to repeat [himself/herself] then appear frustrated. [He/She] hit [his/her] forehead and nose with the back of [his/her] hand and stomped [his/her] foot. Then [he/she] reached onto the nurses [sic] cart and grabbed a cup with spoons in it off the nursing cart. Resident put the spoons back on the cart and took the cup into [his/her] room. Approx. 10 minutes later [he/she] returned the cup to the cart. Cup which was once dry now had drips of water inside and out. Staff said keep it but [he/she] insisted on putting it back. Then [he/she] returned to [his/her] room."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "This morning when the aids went into [C2's initials] room to get [him/her] up and showered [C2's initials] hit [himself/herself] in the face eleven times, bit [himself/herself] three times, hit [his/her] head on the wall three times, pinched the aid, and screamed four times. All happened while showing and clothing [him/her]. Will continue to monitor behavior."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "Before lunch aide was cleaning [his/her] face, [C2's initials] hit [himself/herself] in the face as well as bit [his/her] arm multiple times. After lunch, [C2's initials] was transported to the bathroom during that duration [he/she] bit [himself/herself] three times and hit [himself/herself] multiple times."

Review of C2's "T-Log," dated 07/09/25 and located in the client's EMR under the "T-Log" tab revealed "While getting [C2's initials] up to take [him/her] to the bathroom and shower [him/her], [he/she] was aggressive with the aide multiple times, would not comply with the aide and then had an incontinent void in the bed, bit [himself/herself] multiple times, hit [his/her] head on the wall multiple times, punched [himself/herself] in the face multiple times, kicked the wall three times, squeezed the aide's hand three times, tried to punch the aide in the face twice, and tried to head-butt the aide twice. The aide and [C2's initials] have no sign of injuries. Will continue to document behavior."

Review of C2's "T-Log," dated 07/14/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident displayed SIB numerous ways this morning while assisting with getting up, showered, and dressed. Biting wrist approx. [approximately] 10 times. Striking face approx. 20 times. Striking top on head approx. 10 times. Kicking wall in shower approx 10 times.

Review of C2's "T-Log," dated 09/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident with toileting resident was sitting on toilet and leaned backwards and started banging head on bathroom wall, nurse notified."

During an interview on 10/01/25 at 3:50 PM, the Qualified Intellectual Disability Professional (QIDP) stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge.

During an interview on 10/01/25 at 5:10 PM, Resident Aide (RA) 1 stated it was normal for C2 to engage in multiple and repetitive episodes of SIB each day. RA1 stated when they wake him/her up in the morning, he/she will bite himself/herself, hit himself/herself in the face, and headbang the wall. When asked if there was anything to follow when he/she did engage in SIB or if he/she had received any training on how to prevent or respond to the behaviors such as intervening, the RA stated they were instructed when C2 had SIB to make a note in the client's T-Log. The RA stated he/she had been trained in the facility's Crisis Prevention Intervention (CPI) program where he/she was taught to ignore the behaviors, especially "junk behaviors." When asked what junk behaviors were, the RA stated that was basically attention seeking behaviors. RA1 stated they do not intervene when C2 engages in SIB including headbanging as this was the client's normal behavior. Continued interview with RA1 revealed on 12/22/24, C2 was being redirected back to his/her room due to the home being on quarantine precautions when C2 did not want to go back to his/her room and when the RA attempted to guide the C2, C2 purposely threw himself/herself to the floor where the client had to go to the emergency room and get stitches.

During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had been employed at the facility for five years. When asked about C2, RA2 stated the client engaged in SIBs of headbanging, hitting himself/herself in the mouth, and biting himself/herself really aggressively. RA2 stated on 12/22/24 the clients were quarantined to their rooms due to COVID protocols. RA2 stated the staff from the prior shift told him/her they had to redirect C2 back to his/her room. RA2 stated C2 was out of his/her room so he/she verbally redirected the client. RA2 stated he/she put his/her arms out like a wall so it would better direct C2 when he/she verbally redirected the client to the room. RA2 stated when he/she verbally redirected C2 back to his/her room, C2 purposefully threw himself/herself to the floor where he/she hit his/her head on the outside corner of the wall. RA2 stated the client had to be transported to the ER to receive stitches.

During an interview on 10/02/25 at 1:07 PM, when asked about the multiple documented incidents of C2 engaging in repetitive SIB of headbanging with no staff intervention and what that could be viewed as, the facility Director stated "neglect." When asked why C2 did not have any behavior supports such as a behavior plan, the facility Director stated it has been over a year but the last time the team consulted with a BCBA, the team was told a plan was not needed. The facility Director stated he/she was not sure a plan would have prevented any injury because if C2 wanted to hurt himself/herself, he/she was going to hurt himself/herself.

During an interview on 10/02/25 at 4:07 PM, the Psychiatrist (Psych) stated he/she knew C2 well. The Psych stated he/she consulted with a provider who had treated C2 prior to him/her treating the client and discovered that the client had engaged in SIB for years. The Psych stated he/she had attempted different antipsychotic medications to assist in improving the client's behavior; however, the risk of the side effects outweighed the benefits, and the medications were considered failed attempts; however, these were additional antipsychotics that C2 was already on for his/her schizoaffective disorder. When asked about his/her expectation as to staff managing C2's behaviors, the Psych stated medications were not going to improve C2's behavior. The Psych stated the BCBA (Board Certified Behavior Analysis) could develop a plan with interventions. The Psych stated with the C2's autism diagnosis, he/she could benefit from a sensory room. The Psych stated when C2 was asked to do a task, and then engages in SIB, he/she believed the function of the behavior would be "escape." The Psych stated C2 worked with a BCBA at one time; however, it may be more beneficial to C2 if they attempted to find a BCBA who works with intellectual disabilities with clients who have dual diagnoses (Intellectual Disability/Developmental Disability and mental illness). The Psych stated it was his/her expectation when C2 engaged in SIB, especially the headbanging, staff would have been trained on keeping the client safe. The Psych also stated staff having the proper training from the appropriate discipline such as a BCBA would make the client more comfortable and give the client more autonomy.

2. a. Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab revealed "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

b. Review C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA telling resident to go to room. Upon entering the dining room

resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/01/25 at 3:50 PM, the QIDP stated he/she had not been trained that a client hitting another client was considered abuse. The QIDP stated he/she had not been trained on reporting abuse. When asked if he/she became aware of an allegation of abuse or witnessed abuse, who would he/she report that to, the QIDP stated when he/she had a concern about a client's behavior and/or a concern about staff treatment of the clients, he/she must get the facility Director's approval before reporting or educating the staff.

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility staff had not been educated that a client hitting another client was abuse.

Based on record review, interview, and review of the facility's policy, 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 the facility only identified as peer to peer aggressive behavior. These failures place the client at risk of living in an unsafe environment.

Findings include:

Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed ". . . Abuse" Physical: Any assault by an employee upon an individual served and includes, but not limited to: hitting, kicking, pinching, slapping, or otherwise striking an individual or using excessive force regardless of whether an injury results. Assault used in this definition implies intent. Physical injury, as used herein, is defined as impairment of physical condition or substantial pain . . . Neglect: Failure to carry out a duty through reckless conduct, carelessness, inattention, or disregard of duty whereby the individual served is exposed to harm or risk of harm, and includes, but is not limited to: failing to appropriately supervise individuals or otherwise leaving individuals served unattended, failing to ensure that an individual's basic needs for safety, nutrition, medical care and personal attention are met, failing to provide treatment in accordance with the individual support plan/person directed planning or failing to develop a program plan, and utilizing treatment techniques, restraints (unless authorized with express written consent to promote an individual's safety), seclusion (unless as. part of a behavior support plan and reviewed by the Human Rights

Committee), etc., in violation of standards, whether or not injury results . . ." The policy did not identify one client hitting another as peer to peer abuse.

1. Review of C2's "Comprehensive Functional Assessment (CFA)," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder. The CFA identified client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB); however, through record review and interview, it was confirmed C2 did not have any type of behavior plan.

Review of C2's "Therap (name of electronic medical record system) Communication Log (T-Log)," dated 11/13/24 and located in the client's electronic medical record (EMR) under the "T-Log" tab, revealed, "While assisting resident to bathroom [he/she] was walking towards toilet and went to head-butt padded area on wall, [he/she] missed the pad and head-butted wall hard and resident stated 'ouch.' Nurse notified."

Review of C2's "T-Log," dated 12/20/24 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] came out [his/her] room with [his/her] breakfast plate and [Resident Aide (RA) 1's name] told [him/her] to go back in [his/her] room and [he/she] did not then [he/she] saw me and I told [him/her] to go back into [his/her] room and walked past [him/her] to go help [RA1's name] and then [he/she] throws [his/her] breakfast plate towards my back and it fell into the floor."

Review of C2's "T-Log," dated 12/22/24 and located in the client's EMR under the "T-Log" tab, revealed, "Approximately around 2:30pm I was telling resident to go back into [his/her] room per quarantine instructions. While trying to re-direct resident to [his/her] room [he/she] managed to throw [himself/herself] on the floor by another residents [sic] room where [his/her] head caught the edge of the metal piece in the corner where [he/she] received a laceration. Charge nurse was notify [sic]."

Review of C2's "T-Log," dated 12/23/24 and located in the client's EMR under the "T-Log" tab, revealed, "Resident returned to facility at 8:10 P.M. from the emergency room, [he/she] was alert and good spirits. Resident received eleven staples to the back of [his/her] head."

Review of C2's "T-Log," dated 03/26/25 and located in the client's EMR under the "T-Log" tab, revealed, "[C2's Name] was being sent to the living/dining area to wait for breakfast, while the aid made [his/her] bed and cleaned [his/her] room. The resident became upset because [he/she] wanted to lay down instead of going to breakfast. [C2's name] proceeded to bang [his/her] head against the wall repeatedly until the nurse and aid intervened. Nurse was notified."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab revealed "Staff reported resident head- banged wall while in bathroom, no evident injury

noted, [Name of C2's Attending Physician] made aware, neuro checks initiated, neuro intact at this time, care ongoing."

Review of C2's "T-Log," dated 04/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While showering [C2's initials] [he/she] got very agitated and when going to wash [his/her] legs [he/she] started kicking the wall. Then the aid moved so [he/she] would not get hit but when the aid went back to trying to wash the resident [he/she] hit the aid on the side of the head. The aid moved and told [C2's initials] to stop. The aid moved and the resident began hitting [himself/herself] in the face. The aid then washed off [C2's initials] and started to dry [him/her] and the resident kicked the aid in the shin. Next, the aid started to dress [C2's initials] and [he/she] hit the aid in the hand and squeezed the aids [sic] hand. The aid reported it to the nurse."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "I happened to notice [C2's name] became irritated at lunch because [his/her] ice cream was still frozen and [he/she] could not get it out of the cup. I took [his/her] ice cream cup which had [his/her] spoon in it to the kitchen to soften it for [him/her]. When I came back [he/she] was irritated and eating [his/her] cake with [his/her] hands. At some point [he/she] had put [his/her] hands on [his/her] head and got icing in [his/her] hair and on the side of [his/her] face. [He/She] finished a little before 12pm and started to [his/her] room when I saw [his/her] face and hands covered in cake. I stopped [him/her] to wipe [his/her] hands and face and [he/she] showed discontent at first. I tried to keep [his/her] attention but [he/she] screamed and started to hit [himself/herself] in the face and got [sic] made contact a couple of times. I began to redirected [sic] [his/her] hand and [he/she] stopped for a second. Then, [he/she] started hitting [his/her] right side. I began to wipe that hand of the icing to distract [him/her] and [he/she] screamed again. I wiped [his/her] face and [he/she] continued to [his/her] room."

Review of C2's "T-Log," dated 06/29/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident was in bed and appeared to be sleep during 10pm rounding. By the time staff returned to the desk, [he/she] come out of [his/her] bedroom with a big smile. [He/She] said something to staff and when staff could not understand [him/her] and asked [him/her] to repeat what [he/she] said, [he/she] put [his/her] head as if looking at the floor and hands over [his/her] ears. Staff came closer to try to understand. [He/She] attempted to repeat [himself/herself] then appear frustrated. [He/She] hit [his/her] forehead and nose with the back of [his/her] hand and stomped [his/her] foot. Then [he/she] reached onto the nurses [sic] cart and grabbed a cup with spoons in it off the nursing cart. Resident put the spoons back on the cart and took the cup into [his/her] room. Approx. 10 minutes later [he/she] returned the cup to the cart. Cup which was once dry now had drips of water inside and out. Staff said keep it but [he/she] insisted on putting it back. Then [he/she] returned to [his/her] room."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "This morning when the aids went into [C2's initials] room to get [him/her] up and showered [C2's initials] hit [himself/herself] in the face eleven times, bit [himself/herself] three times, hit [his/her] head on the wall three times, pinched the aid, and screamed four times. All happened while showing and clothing [him/her]. Will continue to monitor behavior."

Review of C2's "T-Log," dated 06/30/25 and located in the client's EMR under the "T-Log" tab, revealed, "Before lunch aide was cleaning [his/her] face, [C2's initials] hit [himself/herself] in the face as well as bit [his/her] arm multiple times. After lunch, [C2's initials] was transported to the bathroom during that duration [he/she] bit [himself/herself] three times and hit [himself/herself] multiple times."

Review of C2's "T-Log," dated 07/09/25 and located in the client's EMR under the "T-Log" tab revealed "While getting [C2's initials] up to take [him/her] to the bathroom and shower [him/her], [he/she] was aggressive with the aide multiple times, would not comply with the aide and then had an incontinent void in the bed, bit [himself/herself] multiple times, hit [his/her] head on the wall multiple times, punched [himself/herself] in the face multiple times, kicked the wall three times, squeezed the aide's hand three times, tried to punch the aide in the face twice, and tried to head-butt the aide twice. The aide and [C2's initials] have no sign of injuries. Will continue to document behavior."

Review of C2's "T-Log," dated 07/14/25 and located in the client's EMR under the "T-Log" tab, revealed, "Resident displayed SIB numerous ways this morning while assisting with getting up, showered, and dressed. Biting wrist approx. [approximately] 10 times. Striking face approx. 20 times. Striking top on head approx. 10 times. Kicking wall in shower approx 10 times.

Review of C2's "T-Log," dated 09/04/25 and located in the client's EMR under the "T-Log" tab, revealed, "While assisting resident with toileting resident was sitting on toilet and leaned backwards and started banging head on bathroom wall, nurse notified."

During an interview on 10/01/25 at 3:50 PM, the Qualified Intellectual Disability Professional (QIDP) stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge.

During an interview on 10/01/25 at 5:10 PM, Resident Aide (RA) 1 stated it was normal for C2 to engage in multiple and repetitive episodes of SIB each day. RA1 stated when they wake him/her up in the morning, he/she will bite himself/herself, hit himself/herself in the face, and headbang the wall. When asked if there was anything to follow when he/she did engage in SIB or if he/she had received any training on how to prevent or respond to the behaviors such as intervening, the RA stated they were instructed when C2 had SIB to make a note in the client's T-Log. The RA stated he/she had been trained in the facility's Crisis Prevention Intervention (CPI) program where he/she was taught to ignore the behaviors, especially "junk behaviors." When asked what junk behaviors were, the RA stated that was basically attention seeking behaviors. RA1 stated they do not intervene when C2 engages in SIB including headbanging as this was the client's normal behavior. Continued interview with RA1 revealed on 12/22/24, C2 was being redirected back to his/her room due to the home being on quarantine precautions when C2 did not want to go back to his/her room and when the RA attempted to guide the C2, C2 purposely threw himself/herself to the floor where the client had to go to the emergency room and get stitches.

During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had been employed at the facility for five years. When asked about C2, RA2 stated the client engaged in SIBs of headbanging, hitting himself/herself in the mouth, and biting himself/herself really aggressively. RA2 stated on 12/22/24 the clients were quarantined to their rooms due to COVID protocols. RA2 stated the staff from the prior shift told him/her they had to redirect C2 back to his/her room. RA2 stated C2 was out of his/her room so he/she verbally redirected the client. RA2 stated he/she put his/her arms out like a wall so it would better direct C2 when he/she verbally redirected the client to the room. RA2 stated when he/she verbally redirected C2 back to his/her room, C2 purposefully threw himself/herself to the floor where he/she hit his/her head on the outside corner of the wall. RA2 stated the client had to be transported to the ER to receive stitches.

During an interview on 10/02/25 at 1:07 PM, when asked about the multiple documented incidents of C2 engaging in repetitive SIB of headbanging with no staff intervention and what that could be viewed as, the facility Director stated "neglect." When asked why C2 did not have any behavior supports such as a behavior plan, the facility Director stated it has been over a year but the last time the team consulted with a BCBA, the team was told a plan was not needed. The facility Director stated he/she was not sure a plan would have prevented any injury because if C2 wanted to hurt himself/herself, he/she was going to hurt himself/herself.

During an interview on 10/02/25 at 4:07 PM, the Psychiatrist (Psych) stated he/she knew C2 well. The Psych stated he/she consulted with a provider who had treated C2 prior to him/her treating the client and discovered that the client had engaged in SIB for years. The Psych stated he/she had attempted different antipsychotic medications to assist in improving the client's behavior; however, the risk of the side effects outweighed the benefits, and the medications were considered failed attempts; however, these were additional antipsychotics that C2 was already on for his/her schizoaffective disorder. When asked about his/her expectation as to staff managing C2's behaviors, the Psych stated medications were not going to improve C2's behavior. The Psych stated the BCBA (Board Certified Behavior Analysis) could develop a plan with interventions. The Psych stated with the C2's autism diagnosis, he/she could benefit from a sensory room. The Psych stated when C2 was asked to do a task, and then engages in SIB, he/she believed the function of the behavior would be "escape." The Psych stated C2 worked with a BCBA at one time; however, it may be more beneficial to C2 if they attempted to find a BCBA who works with intellectual disabilities with clients who have dual diagnoses (Intellectual Disability/Developmental Disability and mental illness). The Psych stated it was his/her expectation when C2 engaged in SIB, especially the headbanging, staff would have been trained on keeping the client safe. The Psych also stated staff having the proper training from the appropriate discipline such as a BCBA would make the client more comfortable and give the client more autonomy.

2. a. Review of C3's "Individual Program Plan (IPP)," dated 05/09/25 and provided by the facility revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab, revealed, "This afternoon at approximately 2:45 p.m. during Health and Wellness, [C2's name] exhibited ATO [aggression towards others] behavior and struck a peer on the right arm. The hit was not forceful; however, [C2's name] displayed signs of aggression and agitation."

Revie of C3's "T-Log," note, dated 09/09/25 and located in the client's EMR under the "T-Log" tab revealed "During Health and Wellness, [C3's name] was struck on the right arm by another

peer. [C3's name] did not report or display any signs of pain at the time of the incident. Staff monitored [him/her] and no further concerns were observed."

b. Review C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C3's "T-Log" note, dated 09/18/25 and located in the client's EMR under the "T-Log" tab, revealed, "Overheard RA telling resident to go to room. Upon entering the dining room

resident noted to be agitated and fussing at other resident and staff. Resident was instructed to go to room for cooling off period. Resident attempted to hit me with [his/her] elbow. Resident finally went to [his/her] room. When asked what happened another resident [C4] stated [he/she] [C3] hit me. PD [program director] and PC [program coordinator] notified."

During an interview on 10/01/25 at 3:50 PM, the QIDP stated he/she had not been trained that a client hitting another client was considered abuse. The QIDP stated he/she had not been trained on reporting abuse. When asked if he/she became aware of an allegation of abuse or witnessed abuse, who would he/she report that to, the QIDP stated when he/she had a concern about a client's behavior and/or a concern about staff treatment of the clients, he/she must get the facility Director's approval before reporting or educating the staff.

During an interview on 10/02/25 at 1:07 PM, the facility Director stated he/she was not aware that a client hitting another client would be considered abuse. The Director stated the facility considered and documented that as ATO (aggression towards others). The facility Director confirmed the facility staff had not been educated that a client hitting another client was abuse.