Print Violation: 00395727-AP-346416

Provider Information

Willow Creek Memory Care

175 NE 16TH STREET
Madras, OR 97741

Date: 4/12/2025
Report number: 00395727-AP-346416
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) 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) relied on the facility for care and assistance with their medications. AV is prescribed a medicated pain patch, and every 72 hours staff are required to take off the old patch when a new one is placed. On or about April 12, 2025, AV was found with two (2) pain patches on their skin. According to an investigation, this was the second time the AV was found with two patches on at the same time and AV appeared more tired than usual. The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered, which is considered neglect of care and constitutes abuse.
Sanction: RCFCP26-00333 $500.00 fine assessed