Footsteps at Lake Oswego

Last inspection

July 1, 2026

Inspections

8, 20 deficiencies cited

Substantiated abuse

13

Substantiated licensing violations

11

Regulatory actions

0

Fines assessed

$5,554.00 (13 violations)

Current owner since

April 2, 2026

Inspections

• July 1, 2026: Change of Owner, 3 deficiencies cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Isolated
• January 21, 2026: 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
• April 21, 2025: Complaint Investig., 2 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• January 28, 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
• May 29, 2024: Complaint Investig., 3 deficiencies cited report
  • C0155: Facility Administration: Records severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• September 2, 2024: 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)
  State’s findings

  According to the documentation, the facility failed to properly care plan interventions for Witness 1’s (W1) history of physical altercations with other residents. on or about September 02, 2024, W1 and the Alleged Victim (AV) were involved in a physical altercation. W1 and AV have been involved in physical altercations with each other before. W1 has a known history of physical altercations with other residents of the facility. There was no documented evidence of the facility implementing interventions to prevent future altercation with other residents, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 13, 2024: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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 to have safety precautions in place for the Alleged Victim’s (AV) known fall risk. On or about August 13, 2024, the AV was found on the ground suffering an unwitnessed fall. When staff found the AV on the ground, their walker was not in proximity to the AV who needs the walker to safely ambulate. The results of the fall were a nasal fracture and laceration, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 6, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $338.00; 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 Witness 1’s (W1) known aggressive behavior starting in the afternoon. According to an assessment, W1 is known to have sundowning behavioral issues in the afternoon but did not specify what kind of behaviors for staff to be aware of. On or about august 06, 2024, staff heard screaming coming from the Alleged Victim’s (AV) room. As staff entered the room, staff witnessed W1 straddling the AV, their hands around the AV’s neck and was strangling them. Local law enforcement was called, and they took W1 to the hospital on a police officer hold and deemed W1 a danger to other residents. There were no interventions on W1 service plan or signs to look for to prevent a resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 3, 2024: 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

  According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) by ensuring the resident couldn’t exit the secured facility unsupervised. On or about August 03, 2024, a visitor opened the secured door, the AV pushed it open and exited the facility. The AV wandered about the unsecured facility for approximately 20 minutes before staff in another unit called the secured facility and notified them a resident had exited the secured unit. The staff were unaware the AV had exited the facility placing the AV at risk at harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 21, 2024: Failed to properly plan care 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 properly care plan for the Alleged Victim’s (AV) known history of wandering and getting into resident-to-resident altercations. On or about May 19, 2024, the AV wandered into Witness 1’s (W1) room and caused a resident-to-resident altercation. The incident left the AV with a new skin tear on their left arm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 21, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.

• April 11, 2025: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• March 14, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7).

• March 6, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.

• June 3, 2024: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.

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 24 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.