Inspection Reports for The Ackerly at Reed‘s Crossing
7267 SE Circuit Dr, Hillsboro, OR 97123, USA, OR, 97123
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Original Licensing
Capacity: 66
Deficiencies: 18
Mar 26, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2024-02 to 2025-03 with deficiency history
Findings
Across two inspections, the facility demonstrated multiple deficiencies including failure to comply with food sanitation rules, inadequate administrative oversight, failure to monitor and document resident conditions and medication administration properly, incomplete staff training and competency verification, and failure to conduct fire drills according to code. Some deficiencies were repeated and several plans of correction were implemented but not fully corrected at the time of visits.
Deficiencies (18)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules including cleaning and food storage issues |
| C0000 - Comment: Multiple deficiencies documented during initial licensure and re-visit surveys related to compliance with OARs 411 Division 54 and 004 |
| C0150 - Facility Administration: Operation: Failed to ensure adequate administrative oversight of facility operations and staff supervision/training |
| C0270 - Change of Condition and Monitoring: Failed to monitor and document short-term changes of condition for multiple residents as required |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to ensure outside service providers left written information and updated service plans appropriately |
| C0300 - Systems: Medications and Treatments: Failed to ensure adequate professional oversight for safe medication and treatment administration system |
| C0302 - Systems: Tracking Control Substances: Failed to have accurate system for tracking controlled substances administered to residents |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed for sampled residents |
| C0304 - Systems: Medication and Treatment Review: Failed to ensure registered pharmacist or nurse reviewed medications and treatments every 90 days |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medication or treatment |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs including medication pass times, reasons for use, and resident-specific parameters |
| C0340 - Restraints and Supportive Devices: Failed to ensure thorough assessment and documentation of supportive devices with restraining qualities prior to use |
| C0361 - Acuity-Based Staffing Tool: Failed to implement acuity-based staffing tool addressing all required ADLs and staff time needed |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to maintain training program including competency evaluation and documentation for direct care staff |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure all pre-service orientation and dementia training completed prior to staff job duties |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to verify and document direct care staff competency within 30 days of hire |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills in accordance with Oregon Fire Code including documentation and resident participation |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
Report Facts
Inspections on page: 2
Total deficiencies: 17
Total licensed beds: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | General Manager | Named in multiple findings and acknowledgments related to administrative oversight and deficiency findings |
| Staff 2 | Health & Wellness Director/RN | Named in multiple findings and acknowledgments related to clinical oversight, medication administration, and training |
| Staff 3 | Business Office Manager | Named in training and competency documentation findings |
| Staff 16 | Caregiver | Interviewed regarding fire drill knowledge |
| Staff 22 | Health and Wellness Coordinator | Named in findings related to resident monitoring and documentation |
| Staff 23 | Health and Wellness Coordinator | Named in findings related to resident monitoring and documentation |
| Staff 24 | Opal Manager Memory Care | Named in findings related to acuity-based staffing tool |
| Staff 25 | General Manager | Named in findings related to resident monitoring and documentation |
| Staff 26 | Health and Wellness Director/RN | Named in findings related to resident monitoring and documentation |
| Staff 27 | General Manager | Named in fire drill findings and plan of correction |
| Staff 28 | Plant Operations Supervisor | Named in fire drill findings and plan of correction |
| Witness 1 | Consultant RN | Interviewed and acknowledged findings related to medication administration and supportive devices |
Loading inspection reports...
