Footsteps at Carman Oaks

Last inspection

June 26, 2025

Inspections

7, 21 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

0

Regulatory actions

1

Fines assessed

$982.00 (4 violations)

Current owner since

October 1, 2019

License conditions and other regulatory actions

• August 18, 2023 to September 26, 2023: License Condition, Failed to meet the scheduled and unscheduled needs of residents RCFCD23-00966; 3 incidents: OR0004179502, OR0004179501, OR0004179500
  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training); 411-054-0200 (Residential Care Facility Building Requirements)

Inspections

• June 26, 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 5, 2025: Complaint Investig., 2 deficiencies cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0320: Systems: Medication & Treatment-General severity level 2, scope L2 Isolated
• May 30, 2024: State Licensure, 0 deficiencies cited report
  • Z0000: General Comments severity level 0
• August 9, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 6, 2023: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• August 2, 2022: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated, corrected August 18, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected August 18, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected August 18, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected August 18, 2022
  Show all 13

  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected August 18, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 18, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected August 18, 2022
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Pattern, corrected August 18, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 18, 2022
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected August 18, 2022
  • Z0164: Activities severity level 2, scope L2 Isolated, corrected August 18, 2022
  • Z0176: Resident Rooms severity level 2, scope L2 Widespread, corrected August 18, 2022
• July 21, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 4, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 4, 2022

Substantiated abuse or neglect

• March 12, 2026: 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); 411-054-0030 (Resident Services)
  State’s findings

  On or about March 12, 2026, the Alleged Victim (AV) eloped from the secured unit through the facility courtyard gate. Staff were unaware that the courtyard gate was left open or that AV had exited through the gate. A passerby saw AV in the parking lot looking confused and returned AV to the facility. AV was not harmed; however, AV was placed at risk for serious harm. Respondent failed to ensure AV's safety for failing to provide necessary oversight to prevent AV from leaving the secured facility. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

• January 24, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) fall history which led to an unwitnessed fall. On or about January 24, 2025, at approximately 0500, the AV was found on the floor in their room. The AV has had multiple falls in the past and was noted to be a high fall risk. The facility did not properly care plan interventions to prevent falls. The AV suffered multiple bruises to their face, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 15, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to care plan for Witness 1’s (W1) known sexualized behaviors, resulting in emotional distress for the Alleged Victim (AV). On or about January 15, 2025, W1 exposed their genitalia to the AV which caused the AV to repeatedly say “Bad [specific gender] bad [specific gender].” While reaching for their groin. W1 has a history of sexualized behaviors towards other residents but their service plan does not provide any intervention to prevent the behavior. The facility failed to update W1 service plan causing emotional distress to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 19, 2023: Failed to assure resident was safe Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $169.00; 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

  According to the documentation, the Alleged Victim (AV) exited the memory care facility’s secured courtyard without assistance or anyone knowing. The failure resulted in the AV leaving the facility unassisted for approximately two (2) hours and required law enforcement to be called to aid in searching for the resident. When found, the AV sustained bruises and skin tears and was taken to the hospital for evaluation which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 16 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.