Footsteps at Mill Creek

Last inspection

July 9, 2025

Inspections

4, 16 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

2

Regulatory actions

0

Fines assessed

$357.00 (2 violations)

Current owner since

March 1, 2017

Inspections

• July 9, 2025: Re-Licensure, 3 deficiencies cited report
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• August 29, 2024: 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
• September 25, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• March 28, 2022: Validation, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected August 13, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 28, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected August 13, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected August 13, 2022
  Show all 13

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected May 28, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected May 28, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 28, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected August 13, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 13, 2022
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected August 13, 2022
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected May 28, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected May 28, 2022

Substantiated abuse or neglect

• November 2, 2023: 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 history of exit seeking behaviors and elopement. The failure resulted in the AV to leave the enclosed memory care courtyard and enter the assisted living courtyard where they fell and could not get up until facility staff found them after approximately four and a half hours, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 23, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) and Witness #1 (W1) have had previous altercations. On or about August 23. 2022, AV and W1 engaged in an altercation where W1 hit AV on the arm, leaving a red mark. AV and W1 have had 2 previous altercations within the prior 2 months. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 27, 2025: Failed to follow care plan 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 the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the care plan for the Alleged Victim (AV) by utilizing a two-person transfer. On or about January 25, 2025, Ap2 attempted to self transfer the AV. The AV’s care plan was updated on or about December 23, 2024, to use two persons for assist for the AV. In an interview with the AP2, AP2 admitted they were unaware the AV was a 2-person transfer. During the self-transfer, the AV suffered a fall and sustained a laceration on their leg which required stitches. The failure to follow the care plan caused the AV to fall, leading to an injury which required medical attention and stitches, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.

• October 16, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-020-0002 (Definitions)
  State’s findings

  According to the documentation, the Alleged Perpetrator (AP2) failed to provide a safe medication administration system. The failure resulted in the Alleged Victim (AV) to receive the wrong medication due to the AP2 not following facility medication protocol, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system 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 25 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.