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)
W0262 PROGRAM MONITORING & CHANGE
CFR(s): 483.440(f)(3)(i)

The committee should review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights.


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 Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen, and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home.

Findings include:

Review of the facility's undated policy titled, Human Right Committee Procedures" revealed, ". . . The Human Rights Committee (HRC) is charged with the responsibility and duty to safeguard the rights of residents of [Facility Name] . . ."

Review of the facility's undated document titled, "What is a Rights Restriction?" revealed, "Restriction means anything that limits or prevents an individual from freely exercising his/her rights and privileges. Something is usually considered restrictive if it impedes the enjoyment of general liberties that are available to all citizens. Rights restrictions include (but are not limited to) such things as: Limitation on access to personal possessions (. . . phone . . .), to food or drink . . . Limitations to movement . . . Door/Window alarms and other environmental restrictions . . . The Committee also protects against violations to Alabama-specific rights and personal freedoms for people with development disabilities receiving supports. For the residential program, these include: . . . Exercise freedom of movement within physical environments . . ."

Review of the facility's policy titled, "Individual Rights and Grievance Procedure," revised 08/2022, revealed, ". . . It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] and to responsible others acting on their behalf, to exercise the same human and legal rights guaranteed all persons by the U.S. Constitution unless the individual has been specifically determined to be incompetent by judicial proceedings or otherwise legally restricted. Without regard to competency or legal restrictions, [Name of Facility] recipients have the right to provision of services within an environment that is safe, humane, and abuse free . . . In addition . . . residents have the right to appropriate quality treatment, services, and habilitation specifically designed to maximize their developmental potential within the least restrictive setting . . . HUMAN TREATMENT AND CIVIL RIGHTS. A home-like atmosphere shall be provided. A written policy concerning resident's rights shall be posted in a conspicuous location, and residents on admission shall be informed of their rights orally and in writing in plain and simple language . . ."

Review of the facility's "Individual Rights Handbook," revised 08/2022, revealed, ". . . This handbook tells you about the rights, privileges and responsibilities you have while you are receiving services in programs ...you, your family and friends can be certain that every . . . employee wants to protect your rights. While you are residing and/or receiving services . . . the Human Rights Committee and the [Facility Name] Employees will guard your rights. All of these people want to assist you and to preserve your rights . . . As a recipient of services available from [Facility Name] you have all the rights listed in this handbook the following: 1. You have the right to be treated as an adult and exercise your rights without being punished for doing it . . . 4. You have all the rights as an U.S. citizen and of the state of Alabama, unless your rights have been limited by a judge. This is only done for very good reasons. This includes the right to be considered competent until a court orders otherwise . . . 11. You should be told of your Person Centered Plan (PCP) or Individual Program Plan (IPP) and any restrictions to your rights. Sometimes, some of your rights might be restricted. You may ask your Program Director for a review of this decision if you do not agree with it . . . 25. You have the right not to be unnecessarily restrained, (physically or chemically), or isolated unless for your safety or the safety of others . . ."

Review of the facility's policy titled, "Personal Care and House Rules," dated 08/2008, revealed, ". . . to establish a home that enables the residents to progress or be maintained in the least restrictive environment. The effectiveness in providing adequate support services is to provide as much independence as possible and not provide personal care elements that are not needed . . . staff shall provide observation and precautionary measures to provide safety and protection from residents ' falling, wandering, and harm . . ."

1. During an interview on 09/30/25 at 4:23 PM, when asked how clients accessed their kitchen, Cook (CK) 1 stated the clients were not allowed in the kitchen here.

Observation on 09/30/25 at 4:25 PM of the dining room revealed signage on the wall by the door to the kitchen of "Only dietary staff permitted in the kitchen . . . Kitchen door to be locked and shut at all times . . ."

During an interview on 09/30/25 at 4:47 PM, when asked if clients of the home were able to access their kitchen, the Food Service Director (FSD) stated staff would assist the clients if they needed or wanted anything that was in the kitchen. The FSD stated normally the kitchen door was only unlocked during normal business hours.

Observation on 09/30/25 at 4:50 PM at the front door of the home (main entrance) revealed the door was equipped with delayed egress hardware and had a sign which stated if the bar was pushed for 15 seconds (consistently) the door would open. The door required a code to get out the door without a 15 second delay.

Observation on 09/30/25 at 5:06 PM revealed when this writer attempted to exit the home by pushing on the exit bar, an audible alarm sounded until the bar was released.. The door did not open, and a key code was required to exit the home.

During an interview on 10/01/25 at 7:53 AM, Resident Aide (RA) 1 stated he/she had worked at the facility for almost three years. When asked if the clients had access to their home's kitchen, RA1 stated, "No, but the clients would ask staff if they wanted a snack or a drink." RA1 also stated clients were not "allowed" to go into the kitchen.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed at the facility for five years. RA3 stated clients were not allowed to go into the kitchen and had not been able to go into the kitchen since he/she had been employed due to safety reasons.

During an interview on 10/01/25 at 8:17 AM, the Program Coordinator (PC), who was also a Licensed Practical Nurse (LPN) stated he/she was responsible for overseeing everything in the home. The PC stated clients who lived in the home could not go into the kitchen because of safety reasons.

During an interview on 10/01/25 at 9:47 AM, when asked about the clients not having access to their own kitchen, the Qualified Intellectual Disability Professional (QIDP) stated the clients should have been able to have access to the kitchen of their home; however, the direct care staff did not allow the clients to have access because of safety reasons.

2. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). Continued review of the CFA revealed it was identified that C1 understood all of his/her rights and how to advocate, as well as the grievance process, but would feel afraid or uncomfortable doing so.

Review of C1's "Individual Program Plan (IPP)," dated 05/2025 and provided by the facility, revealed, ". . . QIDP reviewed C1's Rights Restrictions and [C1's family names] were in agreement with [his/her] restrictions. As the QIDP began talking about the goals that were formulated for [C1's Name] [he/she] went into detail about [his/her] goals and stated that [he/she] agreed with [his/her] plan . . . [C1's Name] looks forward to being challenged and especially focusing on [his/her] bracelet business and having the freedom to travel throughout the [Facility Name] community . . . [C1's Name] family is very interested in creating 'lanes' for [C1's Name] to drive [his/her] wheelchair throughout the community [facility campus] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, individual program planning, and alternate placement . . . Why is this limitation being recommended? [C1's name] is included in the decisions concerning [him/her]. [He/She] is able to make most decisions for [himself/herself]. [He/She] may receive some guidance from [his/her] parents . . . 7. The right to freedom from the use of unnecessary medications and mechanical, chemical, or physical restraints. Why is this limitation being recommended? [C1's Name] uses bedrails on [his/her] bed and seat belts in [his/her] wheelchair and shower chair . . ." Continued review revealed the IPP identified that C1's right to freedom of movement in the home, campus grounds, and off campus grounds were not restricted. C1's IPP did not include any type of behavior plan or a plan to restore the client's rights that had been restricted. There was no documented evidence HRC had reviewed the identified restrictions.

During an interview on 10/01/25 at 12:25 PM, C1 stated living an independent life was very important to him/her. C1 stated he/she was 26 years old and wanted to visit his/her friends who lived on campus at the other houses. C1 stated he/she can independently use his/her wheelchair and has a cell phone he/she could independently use; however, at this time he/she is not allowed to make that choice. C1 stated he/she could not even independently go sit on the front porch of the home because the door stays locked by a keypad. C1 further stated he/she nor other clients were allowed to access the home's kitchen.

3. 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.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . Rights Assessment: It has been assessed that [he/she] does not understand them and didn't really want to hear them at this time. [He/She] was unable to state who [he/she] would tell if [he/she] felt [his/her] rights were violated . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of restrictive behavior and/or medical procedures . . . 9. The right to have access to, to keep, and to spend personal money. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds, and off [facility name] grounds . . . A reduction in the rights restraints will occur when [C2's name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident . . . [His/Her] rights will be reviewed annually . . ." There was no documented evidence of a behavior plan addressing these restrictions nor a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

4. Review of C3's "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. The IPP also revealed, ". . . Rights Assessment: [C3's Name] does understand some of [his/her] rights but needs assistance with others. [His/Her] rights will be reviewed with [his/her] annual. The QIDP asked whom [he/she] would feel comfortable talking to if [he/she] felt [he/she] was being mistreated and [he/she] [identified persons] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds . . ." There was no documented evidence the restrictions were documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

5. Review of 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 C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . Rights Assessment: [C4's Name] had [his/her] rights reviewed with [him/her] and it has been assessed that [he/she] does have limited understanding of [his/her] rights and how to report concerns . . . Any recommendations for goals retaining to rights: None at this time . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . ." The IPP indicated C4's right to freedom of movement in the home, vocational center, and on the facility's campus was not restricted and documented ". . . [C4's name] has freedom of movement at the health and wellness center and in the ICF. [He/She] has supervision when outdoors . . . as a safety precaution . . ." There was no documented evidence the restrictions were documented in a behavior plan nor was there a plan to restore the restricted rights. Additionally, the IPP failed to identify C4's freedom of movement was restricted in his/her home as he/she could not access his/her home's kitchen and the front door of his/her home was equipped with a delayed egress locking system.

6. Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides. [He/She] has a seatbelt, a chest strap, and thigh/trunk guides on [his/her] wheelchair . . . 8. The right to wear, to keep, to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C5's Name] hygiene items are kept in a safe place where staff can access them. [He/She] is not able to read or understand about the hazards of various substances and may ingest harmful ones. [He/She] is physically unable to use [his/her] hygiene products on [his/her] own . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C5's Name] has no safety awareness and requires supervision on an off [Facility Name] grounds . . . " There was no documented evidence of a behavior plan to address the right restrictions nor any evidence of a restoration plan to restore these rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

7. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . it was assessed that [C6's] name does not understand [his/her] rights . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C6's Name] uses bedrails on [his/her] bed and seatbelts on [his/her] wheelchair and shower chair to prevent falls and a gait belt when walking. There are wheelchair and bed alarms to alert staff if [he/she] is in need of assistance . . . 11. The right to privacy. Why is this limitation being recommended? [C6's Name] requires standby assistance with all areas of hygiene due to seizure precautions, and therefore [his/her] right to privacy is limited for medical reasons. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C6's Name] has supervision when [he/she] is on or off [Facility Name] property. [He/She] requires help with transportation and ambulation . . . The reduction in [C6's Name] rights is congruent with [his/her] care needs. If at anytime it is shown that [C6's Name] is able to exercise these rights safely without restrictions or when [he/she] is no longer a resident, these restrictions will be removed . . . " There was no documented evidence of a behavior plan nor a restoration plan to restore the client's rights restrictions. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

8. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . It has been assessed that [R7's Name] does not understand the rights and responsibilities due to [his/her] speech and disability . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement. Why is the limitation recommended? [C7's Name] does not understand some aspects of [his/her] care, finances, and/or legal issues. [He/She] has legal guardians to help [him/her] with decisions . . . 5. The right to make and to receive confidential phone calls. Why is the limitation recommended? [C7's Name] still has the right to make and receive phone calls in private. [His/Her] sisters who are [his/her] guardians have asked that [he/she] not have [his/her] cell phone until after the evening meal . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [He/She] [C7] uses bedrails and bed alarms due to a seizure disorder. [He/She] has a restricted wheelchair seatbelt and shower chair belt due to [his/her] seizure disorder. 8. The right to wear, to keep, and to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C7's Name] is kept at the nurse's station to prevent [him/her] from calling people in the middle of the night. [He/She] has agreed with [his/her] sisters on this issue . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? To protect [him/her] from exploitation and to ensure safety, [he/she] is accompanied by a staff if [he/she] is outside or off the property . . . A reduction in the rights restrictions will occur when [C7's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] no longer is a resident of the facility . . ." There was no documented evidence the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

9. Review of C8's "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 "IPP," dated 02/20/25 and provided by the facility, revealed, ". . . Rights Assessment: [C8's Name] were reviewed with [him/her]. It has been assessed that [he/she] does not understand some of [his/her] rights, but is limited to being able to advocate for [himself/herself] if [his/her] rights were violated . . . Limitation of Rights: 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C8's Name] uses bedrails on [his/her] bed and a seatbelt in wheelchair and shower chair and a chest harness . . . 11. The right to privacy. Why is this limitation being recommended? [C8's Name] has a call bell in [his/her] bathroom in order to alert staff if [he/she] needs/wants assistance. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C8's Name] does not always pay attention around traffic and is open to exploitation. [He/She] should be supervised when outside the ICF building in the event [he/she] has a need. [He/She] needs seatbelts on wheelchair and shower and chest harness on wheelchair . . . A reduction in the rights restrictions will occur when [C8's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident of the facility . . ." There was no documented evidence that the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed that the clients not having access to their kitchen and not being able to freely go out the front door due to a delayed egress locking system that required a code to exit were not taken to HRC for approval. The director stated with the design of the home, he/she did not realize the clients were supposed to be able to access the kitchen. The facility Director confirmed all of the restrictions above did not have the required components including restoration plans for their rights.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the Human Rights Committee (HRC) approved all client restrictions before the restrictions were imposed for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The clients did not have freedom of movement to access common areas of their home. Clients were restricted from their kitchen, and the clients' front door to their home was equipped with delayed egress locking hardware and required a key code to exit. These restrictions were not taken before the HRC, and clients were not afforded due process. Additionally, the right restrictions approved by the HRC and identified in the clients' CFA did not include a behavior plan which included a rights restoration plan. These restrictions affected all 15 clients who resided in the home.

Findings include:

Review of the facility's undated policy titled, Human Right Committee Procedures" revealed, ". . . The Human Rights Committee (HRC) is charged with the responsibility and duty to safeguard the rights of residents of [Facility Name] . . ."

Review of the facility's undated document titled, "What is a Rights Restriction?" revealed, "Restriction means anything that limits or prevents an individual from freely exercising his/her rights and privileges. Something is usually considered restrictive if it impedes the enjoyment of general liberties that are available to all citizens. Rights restrictions include (but are not limited to) such things as: Limitation on access to personal possessions (. . . phone . . .), to food or drink . . . Limitations to movement . . . Door/Window alarms and other environmental restrictions . . . The Committee also protects against violations to Alabama-specific rights and personal freedoms for people with development disabilities receiving supports. For the residential program, these include: . . . Exercise freedom of movement within physical environments . . ."

Review of the facility's policy titled, "Individual Rights and Grievance Procedure," revised 08/2022, revealed, ". . . It is the policy of [Facility Name] to provide age appropriate assistance to individuals who are admitted to [Facility Name] and to responsible others acting on their behalf, to exercise the same human and legal rights guaranteed all persons by the U.S. Constitution unless the individual has been specifically determined to be incompetent by judicial proceedings or otherwise legally restricted. Without regard to competency or legal restrictions, [Name of Facility] recipients have the right to provision of services within an environment that is safe, humane, and abuse free . . . In addition . . . residents have the right to appropriate quality treatment, services, and habilitation specifically designed to maximize their developmental potential within the least restrictive setting . . . HUMAN TREATMENT AND CIVIL RIGHTS. A home-like atmosphere shall be provided. A written policy concerning resident's rights shall be posted in a conspicuous location, and residents on admission shall be informed of their rights orally and in writing in plain and simple language . . ."

Review of the facility's "Individual Rights Handbook," revised 08/2022, revealed, ". . . This handbook tells you about the rights, privileges and responsibilities you have while you are receiving services in programs ...you, your family and friends can be certain that every . . . employee wants to protect your rights. While you are residing and/or receiving services . . . the Human Rights Committee and the [Facility Name] Employees will guard your rights. All of these people want to assist you and to preserve your rights . . . As a recipient of services available from [Facility Name] you have all the rights listed in this handbook the following: 1. You have the right to be treated as an adult and exercise your rights without being punished for doing it . . . 4. You have all the rights as an U.S. citizen and of the state of Alabama, unless your rights have been limited by a judge. This is only done for very good reasons. This includes the right to be considered competent until a court orders otherwise . . . 11. You should be told of your Person Centered Plan (PCP) or Individual Program Plan (IPP) and any restrictions to your rights. Sometimes, some of your rights might be restricted. You may ask your Program Director for a review of this decision if you do not agree with it . . . 25. You have the right not to be unnecessarily restrained, (physically or chemically), or isolated unless for your safety or the safety of others . . ."

Review of the facility's policy titled, "Personal Care and House Rules," dated 08/2008, revealed, ". . . to establish a home that enables the residents to progress or be maintained in the least restrictive environment. The effectiveness in providing adequate support services is to provide as much independence as possible and not provide personal care elements that are not needed . . . staff shall provide observation and precautionary measures to provide safety and protection from residents ' falling, wandering, and harm . . ."

1. During an interview on 09/30/25 at 4:23 PM, when asked how clients accessed their kitchen, Cook (CK) 1 stated the clients were not allowed in the kitchen here.

Observation on 09/30/25 at 4:25 PM of the dining room revealed signage on the wall by the door to the kitchen of "Only dietary staff permitted in the kitchen . . . Kitchen door to be locked and shut at all times . . ."

During an interview on 09/30/25 at 4:47 PM, when asked if clients of the home were able to access their kitchen, the Food Service Director (FSD) stated staff would assist the clients if they needed or wanted anything that was in the kitchen. The FSD stated normally the kitchen door was only unlocked during normal business hours.

Observation on 09/30/25 at 4:50 PM at the front door of the home (main entrance) revealed the door was equipped with delayed egress hardware and had a sign which stated if the bar was pushed for 15 seconds (consistently) the door would open. The door required a code to get out the door without a 15 second delay.

Observation on 09/30/25 at 5:06 PM revealed when this writer attempted to exit the home by pushing on the exit bar, an audible alarm sounded until the bar was released.. The door did not open, and a key code was required to exit the home.

During an interview on 10/01/25 at 7:53 AM, Resident Aide (RA) 1 stated he/she had worked at the facility for almost three years. When asked if the clients had access to their home's kitchen, RA1 stated, "No, but the clients would ask staff if they wanted a snack or a drink." RA1 also stated clients were not "allowed" to go into the kitchen.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed at the facility for five years. RA3 stated clients were not allowed to go into the kitchen and had not been able to go into the kitchen since he/she had been employed due to safety reasons.

During an interview on 10/01/25 at 8:17 AM, the Program Coordinator (PC), who was also a Licensed Practical Nurse (LPN) stated he/she was responsible for overseeing everything in the home. The PC stated clients who lived in the home could not go into the kitchen because of safety reasons.

During an interview on 10/01/25 at 9:47 AM, when asked about the clients not having access to their own kitchen, the Qualified Intellectual Disability Professional (QIDP) stated the clients should have been able to have access to the kitchen of their home; however, the direct care staff did not allow the clients to have access because of safety reasons.

2. Review of C1's "Comprehensive Functional Assessment (CFA)," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD). Continued review of the CFA revealed it was identified that C1 understood all of his/her rights and how to advocate, as well as the grievance process, but would feel afraid or uncomfortable doing so.

Review of C1's "Individual Program Plan (IPP)," dated 05/2025 and provided by the facility, revealed, ". . . QIDP reviewed C1's Rights Restrictions and [C1's family names] were in agreement with [his/her] restrictions. As the QIDP began talking about the goals that were formulated for [C1's Name] [he/she] went into detail about [his/her] goals and stated that [he/she] agreed with [his/her] plan . . . [C1's Name] looks forward to being challenged and especially focusing on [his/her] bracelet business and having the freedom to travel throughout the [Facility Name] community . . . [C1's Name] family is very interested in creating 'lanes' for [C1's Name] to drive [his/her] wheelchair throughout the community [facility campus] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, individual program planning, and alternate placement . . . Why is this limitation being recommended? [C1's name] is included in the decisions concerning [him/her]. [He/She] is able to make most decisions for [himself/herself]. [He/She] may receive some guidance from [his/her] parents . . . 7. The right to freedom from the use of unnecessary medications and mechanical, chemical, or physical restraints. Why is this limitation being recommended? [C1's Name] uses bedrails on [his/her] bed and seat belts in [his/her] wheelchair and shower chair . . ." Continued review revealed the IPP identified that C1's right to freedom of movement in the home, campus grounds, and off campus grounds were not restricted. C1's IPP did not include any type of behavior plan or a plan to restore the client's rights that had been restricted. There was no documented evidence HRC had reviewed the identified restrictions.

During an interview on 10/01/25 at 12:25 PM, C1 stated living an independent life was very important to him/her. C1 stated he/she was 26 years old and wanted to visit his/her friends who lived on campus at the other houses. C1 stated he/she can independently use his/her wheelchair and has a cell phone he/she could independently use; however, at this time he/she is not allowed to make that choice. C1 stated he/she could not even independently go sit on the front porch of the home because the door stays locked by a keypad. C1 further stated he/she nor other clients were allowed to access the home's kitchen.

3. 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.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . Rights Assessment: It has been assessed that [he/she] does not understand them and didn't really want to hear them at this time. [He/She] was unable to state who [he/she] would tell if [he/she] felt [his/her] rights were violated . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of restrictive behavior and/or medical procedures . . . 9. The right to have access to, to keep, and to spend personal money. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds, and off [facility name] grounds . . . A reduction in the rights restraints will occur when [C2's name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident . . . [His/Her] rights will be reviewed annually . . ." There was no documented evidence of a behavior plan addressing these restrictions nor a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

4. Review of C3's "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. The IPP also revealed, ". . . Rights Assessment: [C3's Name] does understand some of [his/her] rights but needs assistance with others. [His/Her] rights will be reviewed with [his/her] annual. The QIDP asked whom [he/she] would feel comfortable talking to if [he/she] felt [he/she] was being mistreated and [he/she] [identified persons] . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds . . ." There was no documented evidence the restrictions were documented in a behavior plan nor a plan to restore the restricted rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

5. Review of 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 C4's "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . Rights Assessment: [C4's Name] had [his/her] rights reviewed with [him/her] and it has been assessed that [he/she] does have limited understanding of [his/her] rights and how to report concerns . . . Any recommendations for goals retaining to rights: None at this time . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . ." The IPP indicated C4's right to freedom of movement in the home, vocational center, and on the facility's campus was not restricted and documented ". . . [C4's name] has freedom of movement at the health and wellness center and in the ICF. [He/She] has supervision when outdoors . . . as a safety precaution . . ." There was no documented evidence the restrictions were documented in a behavior plan nor was there a plan to restore the restricted rights. Additionally, the IPP failed to identify C4's freedom of movement was restricted in his/her home as he/she could not access his/her home's kitchen and the front door of his/her home was equipped with a delayed egress locking system.

6. Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . Right Assessment: It has been assessed that [C5's Name] does not understand [his/her] rights and would not be able to advocate for [himself/herself] in the event [his/her] rights were violated in some way . . . Any recommendations for goals relating to rights: none at this time . . . Limitations of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is the limitation being recommended? [C5's Name] uses a specialized bed with high bedrails on all four sides. [He/She] has a seatbelt, a chest strap, and thigh/trunk guides on [his/her] wheelchair . . . 8. The right to wear, to keep, to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C5's Name] hygiene items are kept in a safe place where staff can access them. [He/She] is not able to read or understand about the hazards of various substances and may ingest harmful ones. [He/She] is physically unable to use [his/her] hygiene products on [his/her] own . . . 11. The right to privacy. Why is this limitation being recommended? [C5's Name] has a live time monitor in [his/her] room to monitor for safety due to brittle bones-to help staff be aware of [his/her] safety needs . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C5's Name] has no safety awareness and requires supervision on an off [Facility Name] grounds . . . " There was no documented evidence of a behavior plan to address the right restrictions nor any evidence of a restoration plan to restore these rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

7. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . it was assessed that [C6's] name does not understand [his/her] rights . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C6's Name] uses bedrails on [his/her] bed and seatbelts on [his/her] wheelchair and shower chair to prevent falls and a gait belt when walking. There are wheelchair and bed alarms to alert staff if [he/she] is in need of assistance . . . 11. The right to privacy. Why is this limitation being recommended? [C6's Name] requires standby assistance with all areas of hygiene due to seizure precautions, and therefore [his/her] right to privacy is limited for medical reasons. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C6's Name] has supervision when [he/she] is on or off [Facility Name] property. [He/She] requires help with transportation and ambulation . . . The reduction in [C6's Name] rights is congruent with [his/her] care needs. If at anytime it is shown that [C6's Name] is able to exercise these rights safely without restrictions or when [he/she] is no longer a resident, these restrictions will be removed . . . " There was no documented evidence of a behavior plan nor a restoration plan to restore the client's rights restrictions. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

8. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," dated 07/10/25 and provided by the facility, revealed, ". . . Rights Assessment: . . . It has been assessed that [R7's Name] does not understand the rights and responsibilities due to [his/her] speech and disability . . . Limitation of Rights: 1. The right to make informed decisions regarding medical treatment, financial matters, Individual Program Planning, and alternate placement. Why is the limitation recommended? [C7's Name] does not understand some aspects of [his/her] care, finances, and/or legal issues. [He/She] has legal guardians to help [him/her] with decisions . . . 5. The right to make and to receive confidential phone calls. Why is the limitation recommended? [C7's Name] still has the right to make and receive phone calls in private. [His/Her] sisters who are [his/her] guardians have asked that [he/she] not have [his/her] cell phone until after the evening meal . . . 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [He/She] [C7] uses bedrails and bed alarms due to a seizure disorder. [He/She] has a restricted wheelchair seatbelt and shower chair belt due to [his/her] seizure disorder. 8. The right to wear, to keep, and to use own clothing, personal hygiene items, and personal possessions. Why is this limitation being recommended? [C7's Name] is kept at the nurse's station to prevent [him/her] from calling people in the middle of the night. [He/She] has agreed with [his/her] sisters on this issue . . . 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? To protect [him/her] from exploitation and to ensure safety, [he/she] is accompanied by a staff if [he/she] is outside or off the property . . . A reduction in the rights restrictions will occur when [C7's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] no longer is a resident of the facility . . ." There was no documented evidence the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

9. Review of C8's "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 "IPP," dated 02/20/25 and provided by the facility, revealed, ". . . Rights Assessment: [C8's Name] were reviewed with [him/her]. It has been assessed that [he/she] does not understand some of [his/her] rights, but is limited to being able to advocate for [himself/herself] if [his/her] rights were violated . . . Limitation of Rights: 7. The right to freedom from the use of physical, chemical, or mechanical restraints. Why is this limitation being recommended? [C8's Name] uses bedrails on [his/her] bed and a seatbelt in wheelchair and shower chair and a chest harness . . . 11. The right to privacy. Why is this limitation being recommended? [C8's Name] has a call bell in [his/her] bathroom in order to alert staff if [he/she] needs/wants assistance. 12. The right to freedom of movement in the home, vocational center, [facility name] grounds. Why is this limitation being recommended? [C8's Name] does not always pay attention around traffic and is open to exploitation. [He/She] should be supervised when outside the ICF building in the event [he/she] has a need. [He/She] needs seatbelts on wheelchair and shower and chest harness on wheelchair . . . A reduction in the rights restrictions will occur when [C8's Name] is able to demonstrate that [he/she] is able to exercise these rights without supervision or when [he/she] is no longer a resident of the facility . . ." There was no documented evidence that the restrictions were identified in a behavior plan nor was there a plan to restore the client's rights. Additionally, the plan did not address the client being restricted from areas of his/her home such as the kitchen and the front door being locked with delayed egress hardware requiring a code to exit the home.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed that the clients not having access to their kitchen and not being able to freely go out the front door due to a delayed egress locking system that required a code to exit were not taken to HRC for approval. The director stated with the design of the home, he/she did not realize the clients were supposed to be able to access the kitchen. The facility Director confirmed all of the restrictions above did not have the required components including restoration plans for their rights.