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F0550
D

Failure to Ensure Resident Dignity and Respect

Garfield Heights, Ohio Survey Completed on 10-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with multiple medical conditions, including transient cerebral ischemic attack, heart failure, atrial fibrillation, and anxiety disorder, was not treated with respect and dignity by facility staff. The resident, who was cognitively intact as indicated by a perfect BIMS score, was subjected to derogatory language by a care partner. The responsible party for the resident reported observing staff calling the resident 'fat' on video footage, and further review of another video showed the care partner referring to the resident as 'Big Mama' while alone in the resident's room. The resident expressed feeling that staff could be mean to her, and specifically felt disrespected and offended by the term 'Big Mama.' Interviews with facility leadership and the care partner confirmed that the care partner had previously been counseled not to use derogatory or potentially offensive terms with the resident. Despite prior counseling and disciplinary action, the care partner continued to use language that the resident found disrespectful. Facility policy states that residents are to be free from discrimination and reprisal, but this policy was not upheld in the interactions with the resident.

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