| 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) |
| W0266 | CLIENT BEHAVIOR & FACILITY PRACTICES CFR(s): 483.450 The facility must ensure that specific client behavior and facility practices requirements are met. This CONDITION is not met as evidenced by: Based on interview and record review the facility failed to have a policy and procedure that governed the management of inappropriate client behavior. Client (C) 2 engaged in a high frequency of inappropriate behavior including self-injurious behavior. The facility's failure to have a policy led to neglect and actual harm to the client. This failure placed all 15 clients of the facility at risk for their current behaviors or behaviors which could be manifested to not be appropriately managed. On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 11/13/24 when C2 was noted to have self-injurious behaviors, and the facility did not have a policy to address those behaviors. The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM. The facility's removal plan included: 1. The facility developed a policy that governed the management of inappropriate behaviors. 2. The facility began training staff on the developed policy and all staff will be trained prior to working their next shift. Through interview and record review, the survey team was able to validate the facility began implementation of the removal plan, and the Immediate Jeopardy was lifted on 10/04/25 at 6:15 PM. Findings include: 1. The facility failed to develop written policies and procedures that govern the management of inappropriate behavior. This systemic failure affected all 15 clients who resided at the facility. Cross Reference: W274. 2. The facility failed to ensure a fully enclosed barred bed which could prevent a client from leaving the bed was not used without documented behavioral assessments which clearly stated why the enclosure was necessary, the risks of using the enclosure versus not using the enclosure, and what less restrictive measures had been attempted for one of eight sampled clients (Client (C) 5). Cross Reference: W307. Based on interview and record review the facility failed to have a policy and procedure that governed the management of inappropriate client behavior. Client (C) 2 engaged in a high frequency of inappropriate behavior including self-injurious behavior. The facility's failure to have a policy led to neglect and actual harm to the client. This failure placed all 15 clients of the facility at risk for their current behaviors or behaviors which could be manifested to not be appropriately managed. On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 11/13/24 when C2 was noted to have self-injurious behaviors, and the facility did not have a policy to address those behaviors. Findings include: 1. The facility failed to develop written policies and procedures that govern the management of inappropriate behavior. This systemic failure affected all 15 clients who resided at the facility. Cross Reference: W274. 2. The facility failed to ensure a fully enclosed barred bed which could prevent a client from leaving the bed was not used without documented behavioral assessments which clearly stated why the enclosure was necessary, the risks of using the enclosure versus not using the enclosure, and what less restrictive measures had been attempted for one of eight sampled clients (Client (C) 5). Cross Reference: W307. *********************** The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM. The facility's removal plan included: 1. The facility developed a policy that governed the management of inappropriate behaviors. 2. The facility began training staff on the developed policy and all staff will be trained prior to working their next shift. Through interview and record review, the survey team was able to validate the facility began implementation of the removal plan, and the Immediate Jeopardy was lifted on 10/04/25 at 6:15 PM. |