Print Violation: 00335228-AP-286264

Provider Information

Willow Creek Memory Care

175 NE 16TH STREET
Madras, OR 97741

Date: 5/26/2024
Report number: 00335228-AP-286264
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to administer medication as ordered
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) relies on the facility for care, which includes medication administration. On or about May 26, 2024, AV was only given a partial dose of their insulin that controls blood sugar, due to the facility running out. The facility took multiple days to get AV's insulin refilled, due to it being a holiday. AV had higher CBG levels during the days they missed the insulin dosage but did not show symptoms of hyperglycemia or hypoglycemia. While waiting for the insulin to be refilled, the Alleged Perpetrator 2 (AP2) gave AV a different type of blood sugar medication, in error. An investigation determined no abuse occurred by the Alleged Perpetrator 2 (AP2). The facility failed to provide services to AV, to include a safe medication system to ensure medications were available and to ensure physician orders were followed, placing AV at risk for harm, which is a violation of resident’s rights is neglect of care and constitutes abuse.
Sanction: RCFCP25-01383 $250.00 fine assessed