The Ackerly at Reed's Crossing

Last inspection

January 29, 2025

Inspections

2, 16 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

6

Regulatory actions

0

Fines assessed

$875.00 (2 violations)

Current owner since

June 14, 2023

Inspections

• January 29, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• February 26, 2024: Initial Licensure, 15 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread, corrected April 28, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected March 8, 2025
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected April 28, 2024
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected April 28, 2024
  Show all 17

  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected September 30, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected September 30, 2024
  • C0304: Systems: Medication and Treatment Review severity level 2, scope L2 Widespread, corrected April 28, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected April 28, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected September 30, 2024
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected September 30, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected September 30, 2024
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Widespread, corrected April 28, 2024
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected April 28, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Widespread, corrected April 28, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected March 8, 2025
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected March 8, 2025

Substantiated abuse or neglect

• November 11, 2025: Failed to administer medication as ordered 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); 411-054-0055 (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 November 7 through 10, 2025, a medication ordered weekly was documented to be administered to the AV daily, Receiving the extra doses of the medication placed the AV at risk of harm. The facility failed to administer AV’s medication as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

• July 5, 2024: Failed to administer ordered medication Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her care and to administer his/her medications. According to an investigation, on or about July 5, 2024, AV was found on the floor of his/her apartment after having an apparent seizure. Over a period of at least three days, AV was not checked on and did not receive any ordered medications, including medication to treat seizures. This resulted in harm to AV and AV being transferred to the hospital for treatment. The facility failed to provide service and failed to administer medication as ordered, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 1, 2025: Failed to cooperate with an investigation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  State’s findings

  Based on interview and, record review, the facility failed to keep resident records for a minimum of three years. The facility’s failure is a violation of Oregon Administrative Rules.

• July 1, 2025: Failed to meet the scheduled and unscheduled needs of residents Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Based on interview and record review, the facility's failure to develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. The facility’s failure is a violation of Oregon Administrative Rules.

• December 23, 2024: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

• December 20, 2024: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

• November 14, 2024: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  State’s findings

  Based on interview and record review, the facility failed to provide qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The facility’s failure is a violation of Oregon Administrative Rules.

• November 14, 2024: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility failed to provide qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. 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 135 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.