| 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) |
| W0307 | PHYSICAL RESTRAINTS CFR(s): 483.450(d)(6) Opportunity for motion and exercise must be provided and a record of such activity must be kept. 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 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). Findings include: Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed ". . . 6. Physical restraint and separation shall not be used as a routine therapeutic procedure. It may be used when protecting a resident from personal harm, from harming others, or when as a therapeutic necessity and reviewed as such by the Human Rights Committee . . ." Observation on 10/01/25 at 11:50 AM of C5's bedroom revealed the client's bed was a fully enclosed barred bed. Review of C5's "Individual Program Plan (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: . . . 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 . . . Health and Safety . . . [C5's Name] has brittle bones . . . [he/she] has . . . high bedsides to prevent falls . . . H. Areas of Independence: [C5's Name] can sit up in bed or in [his/her] wheelchair and can reposition [himself/herself] . . ." During an interview on 10/04/25 at 9:15 AM, when asked for documentation to justify the use of C5's enclosed barred bed, the facility Director stated this was approved by the Human Rights Committee (HRC); however, there was no restoration plan or any other documentation including a physical support plan, or other interventions that had been attempted. The Director stated C5's father wanted the enclosed bed. Based on observation, interview, record review, and review of the facility's policy, 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). Findings include: Review of the facility's policy titled, "Board of Directors Policy on Resident Rights," revised 08/2022, revealed ". . . 6. Physical restraint and separation shall not be used as a routine therapeutic procedure. It may be used when protecting a resident from personal harm, from harming others, or when as a therapeutic necessity and reviewed as such by the Human Rights Committee . . ." Observation on 10/01/25 at 11:50 AM of C5's bedroom revealed the client's bed was a fully enclosed barred bed. Review of C5's "Individual Program Plan (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: . . . 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 . . . Health and Safety . . . [C5's Name] has brittle bones . . . [he/she] has . . . high bedsides to prevent falls . . . H. Areas of Independence: [C5's Name] can sit up in bed or in [his/her] wheelchair and can reposition [himself/herself] . . ." During an interview on 10/04/25 at 9:15 AM, when asked for documentation to justify the use of C5's enclosed barred bed, the facility Director stated this was approved by the Human Rights Committee (HRC); however, there was no restoration plan or any other documentation including a physical support plan, or other interventions that had been attempted. The Director stated C5's father wanted the enclosed bed. |