Print Violation: 00463891-AP-416189

Provider Information

Willow Creek Memory Care

175 NE 16TH STREET
Madras, OR 97741

Date: 3/13/2026
Report number: 00463891-AP-416189
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) relies on the facility for his or her care and medication management. On or about March 13, 2026, AV was released from the hospital with an antibiotic prescription. According to an investigation, the medication was received by the facility, but was not given to AV until approximately March 16, 2026, placing AV at risk for worsening infection. The facility failed to provide a safe medication administration system, which is a violation of resident rights is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(ii).