| 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) |
| W0149 | STAFF TREATMENT OF CLIENTS CFR(s): 483.420(d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. This STANDARD is not met as evidenced by: Based on interview and review of the facility's abuse policy, 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. 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 client as peer to peer abuse. During an interview on 10/02/25 at 1:07 PM, the facility Director stated the facility did not consider a client being physically aggressive with another client as abuse. The facility considered it aggression towards others, which they deemed a behavior. The facility Director confirmed the facility's current abuse policy did not include peer to peer abuse as an example or in the definition of abuse. Based on interview and review of the facility's abuse policy, 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. 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 client as peer to peer abuse. During an interview on 10/02/25 at 1:07 PM, the facility Director stated the facility did not consider a client being physically aggressive with another client as abuse. The facility considered it aggression towards others, which they deemed a behavior. The facility Director confirmed the facility's current abuse policy did not include peer to peer abuse as an example or in the definition of abuse. |