| 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) |
| W0137 | PROTECTION OF CLIENTS RIGHTS CFR(s): 483.420(a)(12) The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients have the right to retain and use appropriate personal possessions and clothing. This STANDARD is not met as evidenced by: Based on observation, interview, record review, and review of the facility's policy, 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. Findings include: Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed, "It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] . . . Individual Rights Assessment . . . 1.Right to be treated as an adult and not be discriminated against based on race, religion, sex, age, or disability . . ." Review of C8's "Comprehensive Functional Assessment (CFA)," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities. Review of C8's "Individual Program Plan (IPP)," dated 02/20/25 and provided by the facility, revealed no documented evidence of any program objective encouraging age-appropriate socialization. During an observation on 09/30/25 at 1:35 PM at the Health and Wellness Center, C8 was sitting in his/her wheelchair at the end of a table with peers. The client was not engaged in any meaningful activity and was holding a child's babydoll. During an interview on 10/01/25 at 9:47 AM, when asked about C8 having a children's babydoll with him/her throughout the day, the Qualified Intellectual Disability Professional (QIDP) stated the client usually gets upset if it was taken away from him/her. The QIDP stated it was like his/her child and the babydoll's name was Butterly. The QIDP stated he/she saw the babydoll as an emotional support for the client. The QIDP stated it was not incorporated in C8's Individual Program Plan (IPP) to promote an age-appropriate environment and socialization as he/she saw C8 having the babydoll as emotionally supportive. When asked if there was anything in the client's IPP to support the rational of emotional support or that other more age-appropriate alternatives had been attempted, the QIDP stated "no." During an observation on 10/03/25 at 3:11 PM of C8's medication administration, C8 was in the living area of the home with no other clients in the living area. C8 was in his/her wheelchair, reclined, and had two child toys, one being a babydoll and the other a red stuffed animal, and sitting in front of the television watching a cartoon (Sponge Bob). Licensed Practical Nurse (LPN) 3 took the red stuffed animal lying on C2's chest and started playing and interacting with the client in a child-like manner. The LPN talked in a baby/child voice during the interaction. During an interview on 10/03/25 at 3:25 PM, when asked about his/her interaction with C8, LPN3 stated he/she had only been employed by the facility for two days and he/she was not aware that interacting with C8 and playing with the client was not appropriate. During an interview on 10/03/25 at 3:44 PM, Resident Aide (RA) 4 stated he/she had been employed at the facility for one year. The RA stated C8 carried his/her babydolls around all of the time and had a bunch in his/her room. When asked how old C8 was, RA4 stated the client was 34 years old. When asked if it was age appropriate for staff to interact and promote the use of children's toy when interacting with a 34 year old adult client, RA4 stated he/she had worked in a nursing home where it was common to see residents having babydolls. RA4 also stated if it made C2 happy, then the client should have the babydolls. RA4 further stated he/she was the person who turned the cartoons on for C8. RA4 stated he/she asked C8 if he/she wanted to watch cartoons, and C8 stated "yes." When asked if the client liked tv programs that were not cartoons, the RA stated yes and named some adult tv shows C8 enjoyed. During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation staff would have discouraged C8 from childlike socialization. The Director stated he/she had addressed this with the home's staff before; however, they did not understand not to encourage things that were not age appropriate for the client. Based on observation, interview, record review, and review of the facility's policy, 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. Findings include: Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed, "It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] . . . Individual Rights Assessment . . . 1.Right to be treated as an adult and not be discriminated against based on race, religion, sex, age, or disability . . ." Review of C8's "Comprehensive Functional Assessment (CFA)," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities. Review of C8's "Individual Program Plan (IPP)," dated 02/20/25 and provided by the facility, revealed no documented evidence of any program objective encouraging age-appropriate socialization. During an observation on 09/30/25 at 1:35 PM at the Health and Wellness Center, C8 was sitting in his/her wheelchair at the end of a table with peers. The client was not engaged in any meaningful activity and was holding a child's babydoll. During an interview on 10/01/25 at 9:47 AM, when asked about C8 having a children's babydoll with him/her throughout the day, the Qualified Intellectual Disability Professional (QIDP) stated the client usually gets upset if it was taken away from him/her. The QIDP stated it was like his/her child and the babydoll's name was Butterly. The QIDP stated he/she saw the babydoll as an emotional support for the client. The QIDP stated it was not incorporated in C8's Individual Program Plan (IPP) to promote an age-appropriate environment and socialization as he/she saw C8 having the babydoll as emotionally supportive. When asked if there was anything in the client's IPP to support the rational of emotional support or that other more age-appropriate alternatives had been attempted, the QIDP stated "no." During an observation on 10/03/25 at 3:11 PM of C8's medication administration, C8 was in the living area of the home with no other clients in the living area. C8 was in his/her wheelchair, reclined, and had two child toys, one being a babydoll and the other a red stuffed animal, and sitting in front of the television watching a cartoon (Sponge Bob). Licensed Practical Nurse (LPN) 3 took the red stuffed animal lying on C2's chest and started playing and interacting with the client in a child-like manner. The LPN talked in a baby/child voice during the interaction. During an interview on 10/03/25 at 3:25 PM, when asked about his/her interaction with C8, LPN3 stated he/she had only been employed by the facility for two days and he/she was not aware that interacting with C8 and playing with the client was not appropriate. During an interview on 10/03/25 at 3:44 PM, Resident Aide (RA) 4 stated he/she had been employed at the facility for one year. The RA stated C8 carried his/her babydolls around all of the time and had a bunch in his/her room. When asked how old C8 was, RA4 stated the client was 34 years old. When asked if it was age appropriate for staff to interact and promote the use of children's toy when interacting with a 34 year old adult client, RA4 stated he/she had worked in a nursing home where it was common to see residents having babydolls. RA4 also stated if it made C2 happy, then the client should have the babydolls. RA4 further stated he/she was the person who turned the cartoons on for C8. RA4 stated he/she asked C8 if he/she wanted to watch cartoons, and C8 stated "yes." When asked if the client liked tv programs that were not cartoons, the RA stated yes and named some adult tv shows C8 enjoyed. During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation staff would have discouraged C8 from childlike socialization. The Director stated he/she had addressed this with the home's staff before; however, they did not understand not to encourage things that were not age appropriate for the client. |