The confrontation at Creekside Health and Rehabilitation Center occurred while federal inspectors were investigating a complaint about dignity violations. They watched staff enter Resident B's room without knocking, then witnessed the medication aide's harsh response when he asked about his oxycodone prescription.
Resident B suffers from depression and moderate cognitive impairment. His quarterly assessment from August 5 indicated he had "severe signs and symptoms of depression," though a psychological note from August 12 showed he remained oriented to person and place with only mild thought process impairment.
On August 21 at 12:40 p.m., inspectors observed Resident B sitting in his wheelchair beside his bed with the room door closed. Certified Nurse Aide 2 opened the door without knocking, asked if he was okay and had his call light, then left when he said he was fine.
After she left, Resident B told inspectors that staff frequently entered his room without knocking and it bothered him. He wished they would knock before coming in.
As he began discussing his pain medications with inspectors, saying staff didn't administer them correctly, Qualified Medication Aide 3 knocked and entered the room. She sternly told Resident B "No we don't" in response to his comments about incorrect medication administration.
QMA 3 had brought his routine methadone dose. When Resident B asked about having his oxycodone, she responded in what inspectors described as a "sharp tone," informing him he had received oxycodone earlier that day. She then asked if he wanted his methadone, adding that if not, she would mark it as refused and throw it away.
Resident B indicated he would take the methadone, which QMA 3 administered before leaving the room.
The resident became tearful after the medication aide left. He told inspectors that staff spoke to him "that way all the time" and he felt it was disrespectful. Staff would talk to him "like there was something wrong with him" and respond as if he didn't know what he was talking about.
When interviewed an hour later, CNA 2 acknowledged she was "sorry for busting in the door without knocking." She said she had been worried Resident B didn't have his call light and should have knocked before entering.
QMA 3 told inspectors that Resident B asked about his pain medications every day and thought he was getting the wrong medications. She said she educated him about his medications before giving them.
The facility's Director of Nursing and Executive Director told inspectors the next day that they expected staff to knock before entering rooms and to treat residents with dignity and respect.
The nursing home's Resident Rights Policy, implemented March 5, 2024, states that "the resident has a right to be treated with respect and dignity."
Federal inspectors cited the facility for failing to ensure residents are treated with dignity and respect, finding minimal harm with potential for actual harm to few residents.
The violation stems from a complaint investigation conducted on August 22. Creekside Health must submit a plan of correction to continue participating in Medicare and Medicaid programs.
Resident B's experience illustrates how daily interactions between staff and vulnerable residents can violate basic dignity rights. His tearful response to being spoken to sharply about legitimate medication questions reveals the emotional impact of disrespectful treatment on residents already struggling with depression and cognitive impairment.
The facility's policy clearly states residents' rights to respectful treatment, yet staff actions directly contradicted these standards during the federal inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creekside Health and Rehabilitation Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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