Print Violation: 00201380-AP-162024

Provider Information

Willow Creek Assisted Living

175 NE 16TH STREET
Madras, OR 97741

Date: 5/22/2022
Report number: 00201380-AP-162024
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a)
411-054-0027(1)(r)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) is prescribed insulin to control his/her blood glucose. On or about May 22,2022, AV did not receive 3 doses of his/her insulin due to pharmacy error. This is not the first time at AV has missed doses of insulin due to pharmacy error. On May 22, 2022, after not receiving his/her insulin, AV suffered an upset stomach, being tired and overall not well. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP22-01038 $188.00 fine assessed