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)
W0214 INDIVIDUAL PROGRAM PLAN
CFR(s): 483.440(c)(3)(iii)

The comprehensive functional assessment must identify the client's specific developmental and behavioral management needs.


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 the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency of self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life, and the client was neglected during SIB episodes, which eventually caused actual harm to the client.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

Review of C2's "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. Continued review of the CFA revealed, ". . . Developmental & Behavioral Management Needs. [C2's Name] has a Behavior Support Plan (BSP) in place [inaccurate] . . . Targeted behaviors include: physical aggression, verbal aggression, and self-injury . . . Vocational Skills. [C2's Name] no longer attends the workshop due to [his/her] behavioral issues . . . Recommendations: 1. Continue placement in the ICF/IID [Facility Name] due to needing for help with daily self-care, medical appointments . . . behavioral issues . . ." The CFA did not include any recommendations for any behavioral supports and/or services.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . II. Behavior/Psych Support . . . Is there a behavioral support plan (BSP) in place: NO. Summary: A Behavioral Support Plan was in place for [C2's Name] due to target behaviors such as verbal and physical aggression and self-injurious behaviors. If the previous behaviors began to cause issues they will be tracked and a new BSP might be implemented . . ."

Review of C2's EMR and paper medical records revealed no documented evidence behavioral data was being obtained, collected, monitored, and reviewed at least quarterly.

Review of C2's "Therap [Name of EMR] Communication Log (T-Log)," dated 11/13/24 and located in the client's 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 10/02/25 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. 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 engaged 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 (ID/DD 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.

During an interview on 10/04/25 at 6:41 PM, the facility Administrator stated a Functional Behavioral Assessment had not been completed on C2 in over a year. The Director stated it was his/her expectation when C2 started having an increase in behaviors, the QIDP would have ensured a referral for a functional behavioral assessment would have been made to include in C2's CFA.

Based on observation, interview, record review and review of the facility's policy, the facility failed to ensure the comprehensive functional assessment (CFA) for one of eight clients (Client (C) 2) addressed specific behavioral supports needed to address aggressive behavior towards himself/herself or others. The Qualified Intellectual Disability Professional (QIDP) was aware of C2's high frequency of self-injurious behavior (SIB) and physical aggression towards others; however, the CFA did not include a functional behavioral assessment or a referral for a functional behavioral assessment completed by a qualifying professional. This failure impaired C2's everyday life, and the client was neglected during SIB episodes, which eventually caused actual harm to the client.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 02/17/25, revealed, ". . . Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

Review of C2's "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. Continued review of the CFA revealed, ". . . Developmental & Behavioral Management Needs. [C2's Name] has a Behavior Support Plan (BSP) in place [inaccurate] . . . Targeted behaviors include: physical aggression, verbal aggression, and self-injury . . . Vocational Skills. [C2's Name] no longer attends the workshop due to [his/her] behavioral issues . . . Recommendations: 1. Continue placement in the ICF/IID [Facility Name] due to needing for help with daily self-care, medical appointments . . . behavioral issues . . ." The CFA did not include any recommendations for any behavioral supports and/or services.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . II. Behavior/Psych Support . . . Is there a behavioral support plan (BSP) in place: NO. Summary: A Behavioral Support Plan was in place for [C2's Name] due to target behaviors such as verbal and physical aggression and self-injurious behaviors. If the previous behaviors began to cause issues they will be tracked and a new BSP might be implemented . . ."

Review of C2's EMR and paper medical records revealed no documented evidence behavioral data was being obtained, collected, monitored, and reviewed at least quarterly.

Review of C2's "Therap [Name of EMR] Communication Log (T-Log)," dated 11/13/24 and located in the client's 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 10/02/25 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. 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 engaged 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 (ID/DD 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.

During an interview on 10/04/25 at 6:41 PM, the facility Administrator stated a Functional Behavioral Assessment had not been completed on C2 in over a year. The Director stated it was his/her expectation when C2 started having an increase in behaviors, the QIDP would have ensured a referral for a functional behavioral assessment would have been made to include in C2's CFA.