| 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) |
| W0154 | STAFF TREATMENT OF CLIENTS CFR(s): 483.420(d)(3) The facility must have evidence that all alleged violations are thoroughly investigated. This STANDARD is not met as evidenced by: 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 alleged that a peer hit him/her. Neither of these instances were investigated as abuse. These failures place all 15 clients at risk of being victims of abuse with no corrective action due to the facility not completing the investigations. Findings include: Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed, ". . . 3. The Program Manager/QDDP will direct the Safety Committee to thoroughly investigate the allegations pursuant to [Facility's Name] Policy on Significant Incidents . . . 7. The Investigation Report must be submitted to the CEO [Chief Executive Office] and the Program Manager/QDDP [Qualified Developmental Disability Professional] within five (5) working days following the incident . . ." Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating . . . 3. The Program Director will report the suspected incident to the Chief Operating Officer Human Resources Director (COO/HRD) who will report the suspected incident to the Chief Executive Officer (CEO) and direct the Quality Enhancement Director to immediately conduct an investigation of the reported incident and to thoroughly investigate the allegations pursuant to the ROI Policy on Significant Incidents . . . 5. The Investigation Report must be submitted to the CEO, COO/HRD and the Program Director within five (5) working days following the incident. 6. The Program Director will report the results of the investigation to the ADMTI/DD [Admissions/Direct Supports for Individuals with Mental Illness/Developmental Disabilities] . . ." 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 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 of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client and 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 investigate the incidents as abuse. 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 alleged that a peer hit him/her. Neither of these instances were investigated as abuse. These failures place all 15 clients at risk of being victims of abuse with no corrective action due to the facility not completing the investigations. Findings include: Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment, revised 03/08/22, revealed, ". . . 3. The Program Manager/QDDP will direct the Safety Committee to thoroughly investigate the allegations pursuant to [Facility's Name] Policy on Significant Incidents . . . 7. The Investigation Report must be submitted to the CEO [Chief Executive Office] and the Program Manager/QDDP [Qualified Developmental Disability Professional] within five (5) working days following the incident . . ." Review of the facility's "Abuse, Neglect, Mistreatment and Exploitation Training Document," revised 03/28/22, revealed, ". . . Procedures for Reporting and Investigating . . . 3. The Program Director will report the suspected incident to the Chief Operating Officer Human Resources Director (COO/HRD) who will report the suspected incident to the Chief Executive Officer (CEO) and direct the Quality Enhancement Director to immediately conduct an investigation of the reported incident and to thoroughly investigate the allegations pursuant to the ROI Policy on Significant Incidents . . . 5. The Investigation Report must be submitted to the CEO, COO/HRD and the Program Director within five (5) working days following the incident. 6. The Program Director will report the results of the investigation to the ADMTI/DD [Admissions/Direct Supports for Individuals with Mental Illness/Developmental Disabilities] . . ." 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 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 of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client and 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 investigate the incidents as abuse. |