The Ackerly at Reed's Crossing Memory Care

Last inspection

September 24, 2026

Inspections

3, 25 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

12

Regulatory actions

1

Fines assessed

$1,251.00 (5 violations)

Current owner since

June 14, 2023

License conditions and other regulatory actions

• August 12, 2026: License Condition, RCFCD26-00712; incident: CALMS - 00120498
  The facility failed to comply with Oregon Administrative Rules, posing a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)

Inspections

• September 24, 2026: Re-Licensure, 9 deficiencies cited report
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  • C0361: Acuity Based Staffing Tool - Elements severity level 2, scope L2 Widespread
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  Show all 9

  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Isolated
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Isolated
• January 29, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• February 26, 2024: Initial Licensure, 14 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated, corrected April 28, 2024
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected September 14, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected December 26, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected December 26, 2024
  Show all 17

  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected December 26, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected September 14, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected September 14, 2024
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected April 28, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected April 28, 2024
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Pattern, corrected April 28, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected December 26, 2024
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Pattern, corrected April 28, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 14, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected April 28, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected December 26, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected April 28, 2024

Substantiated abuse or neglect

• March 31, 2026: Failed to provide medical treatment as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, on or about March 31, 2026, Alleged Perpetrator 2 (AP2) did not follow proper procedure for the application of a topical patch, ensuring the old patch was removed, resulting in the AV having two medical patches in place for approximately twelve hours. The AV experienced possible side effects of reduced appetite and increased anxiety. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed ensure a safe medication system and to administer AV’s medication as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

• January 1, 2026: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage and administer their medications. The AV has an order for a transdermal patch medication to be applied every 24 hours. According to an investigation, on or about January 1, 2026, it was discovered the AV had multiple transdermal patches left in place on their body, placing the AV at risk of harm of being over medicated. The facility failed to ensure a safe medication system and to administer medications as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

• December 31, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0200 (Residential Care Facility Building Requirements)
  State’s findings

  The Alleged Victim (AV) had a history of wandering and exit seeking behaviors. AV is care planned for staff to redirect AV away from the doors when AV is. exit seeking. According to an investigation, on or about December 31, 2025, the lock to the secured memory care door was not operating, the exit door alarm did not alert staff, and the AV eloped from the secured unit around 3:30 pm, The AV was observed in the facility parking lot, placing AV at risk for serious harm. The facility's failure to ensure a safe environment is a violation of resident rights, is considered neglect of care, and constitutes abuse.

• July 8, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  The Alleged Victim (AV) has a history of exit seeking and wandering. The AV required frequent redirection and orienting. According to an investigation, on or about July 8, 2025, a member of the community notified the facility the AV was in the parking lot of a nearby apartment complex, placing the AV at risk of harm. The facility was unaware of the AV's elopement or how they had left the building. The facility failed to ensure a safe environment for the AV, which is a violation of resident rights, is considered neglect of care, and constitutes abuse.

• July 13, 2024: Failed to provide service Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her needs, including incontinence care, and has a history of falls. According to an investigation, on or about July 13, 2024, AV was found on the floor with an injury to the head and near the eye. AV's service planned interventions were for staff to provide safety checks and toileting if awake in bed. Prior to the fall, AV had been approached for incontinence care but refused. AV was not re-approached for incontinence care the following shift util found on the floor. When AV was found with injuries to the head and eye, medical treatment was not provided timely. Emergency services were not called until several hours after the injuries were discovered. The facility failed to provide incontinence care, placing AV at risk of standing without assistance and having a fall and resulting in injury and bruising. The facility failed to provide timely care and medical treatment, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Substantiated licensing violations

• August 11, 2026: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections)
  State’s findings

  The facility failed to ensure the resident's right to be given informed choice and the opportunity to select or refuse service, which is a violation of Oregon Administrative Rules.

• August 2, 2026: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to ensure the service plan must reflect the resident's needs in accordance with OAR411-054-0036(2). Per complainant, the resident has had increased agitation and aggression and falls within the last sixty days which has caused injury to resident. In current service plan there is no behavioral care planning, which is a violation of Oregon Administrative Rules.

• August 2, 2026: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0004
  State’s findings

  The facility failed to ensure If a resident experiences a significant change of condition, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan and the ABST in accordance with OAR 411-054-00040(1)(c). Per complainant, there was a resident-to-resident altercation on 08/02/26 with injuries. Resident has increased agitation and aggression and falls within the last 60 days. Facility does not have behavioral care planning and or interventions in place for resident behaviors, which is a violation of Oregon Administrative Rules.

• April 10, 2026: Failed to hire according to administrative rules Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0065 (Administrator Qualifications and Requirements)
  State’s findings

  Based on observation and interview, the facility failed to ensure the administrator must be scheduled to be on-site in the facility at least 40 hours per week. The facility’s failure is a violation of Oregon Administrative Rules.

• April 9, 2026: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on interview and record review, the facility failed to ensure an accurate Medication Administration Record (MAR) must be kept of all medications. The facility’s failure is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 28 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.