Print Violation: 00463901-AP-416195

Provider Information

Willow Creek Memory Care

175 NE 16TH STREET
Madras, OR 97741

Date: 3/6/2026
Report number: 00463901-AP-416195
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(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 their care, including medication management. According to an investigation, on or about March 5, 2026, AV was tested for a UTI and an antibiotic was ordered the next day. AV did not start their antibiotic medication until approximately March 11, 2026, as it could not be located, posing a risk of harm. AV was also seen to be “out of it” and “not aware” and noted to be in pain. The facility failed to provide a safe medication administration system and failed to ensure medication was administered as ordered, which is a violation of resident rights, is neglect of care which constitutes abuse.