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)
W0153 STAFF TREATMENT OF CLIENTS
CFR(s): 483.420(d)(2)

The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.


This STANDARD is not met as evidenced by:
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.

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 . . . Procedures for reporting and investigating: 1. All suspected incidents of abuse (physical or sexual), neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Manager/QDDP [Qualified Developmental Disability Professional] or to your immediate supervisor . . ."

Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating. All suspected incidents of abuse, neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Director and/or your Direct Supervisor and/or the Chief Operating Officer Human Resources Director (COO/HRD) . . . The Program Director and COO/HRD will immediately report the allegations to the Alabama Department of Mental Health Development Disabilities Division (ADMFVDD) and to the Alabama Department of Human Resources (ADHR). All abuse and neglect which is criminal in nature, must also be reported as soon as possible, to local law enforcement. (i.e., Talladega Sheriff Department) . . ."

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 the 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 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 on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's " Therap (name of electronic medical record system) Communication Log (T-Log)," note dated 09/09/25 and located in the client's electronic medical record (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."

2. 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 [Resident Aide] 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 10/02/25 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 did not report the incidents as abuse to the SSA or other required entities.

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.

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 . . . Procedures for reporting and investigating: 1. All suspected incidents of abuse (physical or sexual), neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Manager/QDDP [Qualified Developmental Disability Professional] or to your immediate supervisor . . ."

Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating. All suspected incidents of abuse, neglect, exploitation, or mistreatment, including all injuries of unknown sources, must be reported IMMEDIATELY to the Program Director and/or your Direct Supervisor and/or the Chief Operating Officer Human Resources Director (COO/HRD) . . . The Program Director and COO/HRD will immediately report the allegations to the Alabama Department of Mental Health Development Disabilities Division (ADMFVDD) and to the Alabama Department of Human Resources (ADHR). All abuse and neglect which is criminal in nature, must also be reported as soon as possible, to local law enforcement. (i.e., Talladega Sheriff Department) . . ."

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 the 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 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 on 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities.

Review of C2's " Therap (name of electronic medical record system) Communication Log (T-Log)," note dated 09/09/25 and located in the client's electronic medical record (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."

2. 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 [Resident Aide] 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 10/02/25 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 did not report the incidents as abuse to the SSA or other required entities.