Footsteps at Clackamas Woods

Last inspection

July 29, 2025

Inspections

4, 29 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

3

Regulatory actions

2

Fines assessed

$1,108.00 (5 violations)

Current owner since

October 15, 2012

License conditions and other regulatory actions

• September 8, 2026: License Condition, Failed to provide appropriate staffing RCFCD26-00758; incident: CALMS - 00128110
  The facility failed to implement and maintain an Acuity-Based Staffing Tool in accordance with OAR 411-054-0037(1-7).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
• September 27, 2024 to October 9, 2024: License Condition, Failed to properly plan care RCFCD24-00996; 2 incidents: CALMS - 00062725, CALMS - 00062724
  The facilitys failure to conduct an RN assessment for significant changes of condition, have effective oversight of residents and properly care plan appropriate interventions for unscheduled weight loss by AV, placed the AV at risk for serious harm, which is a violation of the following OARs.
  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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0070 (Staffing Requirements and Training)

Inspections

• July 29, 2025: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
• October 17, 2024: Re-Licensure, 14 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  Show all 14

  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Isolated
  • H1515: Physical Setting: Individual Accessible severity level 2, scope L2 Widespread
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Isolated
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0164: Activities severity level 2, scope L2 Pattern
  • Z0168: Outside Area severity level 2, scope L2 Widespread
• August 24, 2023: 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 September 10, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 10, 2023
• May 9, 2022: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected November 13, 2022
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected November 13, 2022
  Show all 16

  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected November 13, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected November 13, 2022
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected November 13, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected November 13, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected November 13, 2022
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected November 13, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected November 13, 2022
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected August 31, 2022
  • Z0176: Resident Rooms severity level 2, scope L2 Pattern, corrected November 13, 2022

Substantiated abuse or neglect

• June 7, 2024: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to follow Witness 1’s (W1) care plan to implement interventions when they were showing signs of agitation. On or about June 07, 2024, W1 exhibited agitated behaviors as outlined in their service plan. W1 threw a cup in the dining room, then the Alleged Victim (AV) approached W1 and W1 pushed them down. The AV suffered a head injury and one of their teeth were knocked out due to this incident. There is no documented evidence the facility tried to redirect the W1 when exhibiting agitation as outlined in their service plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 28, 2024: Failed to follow care plan 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 follow the care plan by attempting interventions for Witness 1’s (W1) after they displayed known behaviors. On or about March 28, 2024, W1 was pacing down the hallway and yelling for help. W1 is service planned for interventions when W1 displays these behaviors. There is no documented evidence the facility attempted interventions to mitigate the behavior. W1 then sat in a chair in the hallway and as the Alleged Victim (AV) walked by, W1 punched them in the stomach, causing pain and unreasonable discomfort. The facility failed to attempt interventions to mitigate known behaviors displayed by W1 causing a resident-to-resident altercation resulting in pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 9, 2023: Failed to provide safe environment 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); 411-057-0170 (Physical Design, Environment, and Safety)
  State’s findings

  According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) to ensure they could not elope from the secured facility. On or about September 09, 2023, the AV was able to leave the locked facility without staff knowing they left. The AV left the facility and was brought back to the front desk by a family member of another resident. Upon inspection of the back door, the facility found it would not close without additional force, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 13, 2022: Failed to provide or maintain resident care equipment 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); 411-054-0045 (Resident Health Services)
  State’s findings

  According to the documentation, the facility failed to provide the Alleged Victim’s (AV) with appropriate service related to his/her catheter care needs. The failure resulted in the AV using an old catheter bag that had turned black, for an unknown length of time, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 24, 2022: Failed to provide service 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

  The facility failed to provide appropriate services according to the AV's needs. The failure resulted in AV being left on the toilet and attempting to self transfer. The AV experienced a fall causing unreasonable discomfort and a loss of personal dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• August 26, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe environment for the Alleged Victim (AV) by leaving a toxic cleaner in their room unsecured. On or about August 26, 2025, AP2 was using a urine cleaner in the AV’s room. Upon leaving the roo, the AP2 forgot the cleaner and left it unsecured. The AV ingested an unknown amount of the cleaning solution and was sent to the hospital for precaution, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 22, 2024: Failed to protect resident from involuntary seclusion Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to protect the Alleged Victim (AV) from involuntary seclusion by locking them in their room. On or about July 22, 2024, the AV was refusing to go to their room after exhibiting behaviors and refused to be redirected. A video showed the AP3 grabbing the resident around the waist in attempt to take the AV to their room. AP3 was seen pushing the AV into their room and closing the door. AP2 was then seen bringing the AP3 a chair which AP3 placed under the door handle of the AV’s room with the AV inside, locking them in their room. The AP2 and AP3 failed to protect the AV from involuntary seclusion, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect the AV from involuntary seclusion which is a violation of Oregon Administrative Rules.

• December 1, 2021: Failed to protect resident from financial exploitation Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  According to documentation, the Alleged Perpetrator 2 made fraudulent charges on the Alleged Victim's credit card. AP2's actions are considered financial exploitation, which constitutes abuse. The facility failed to protect the AV from theft, which 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 32 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.