Footsteps at Tanasbourne

Last inspection

March 5, 2024

Inspections

4, 23 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

8

Regulatory actions

1

Fines assessed

$250.00 (1 violation)

Current owner since

March 1, 2013

• Every deficiency from the March 5, 2024 inspection was corrected by May 4, 2024

License conditions and other regulatory actions

• September 6, 2023 to November 15, 2023: License Condition, Failed to use an ABST RCFCD23-01113; incident: CALMS - 00046541
  The facility failed to implement an acuity based staffing tool (ABST) that met the regulation.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• March 5, 2024: 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 May 4, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected May 4, 2024
• October 4, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 1, scope L1 Pattern
  • C0270: Change of Condition and Monitoring severity level 1, scope L1 Pattern
• August 2, 2023: Validation, 17 deficiencies cited report
  • C0000: Comment severity level 0
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected October 3, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected October 3, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 3, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 3, 2023
  Show all 19

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected October 3, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected October 3, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected October 3, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected October 3, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected February 11, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected February 11, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 0, corrected February 11, 2024
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected October 3, 2023
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected October 3, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 11, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected February 11, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected October 3, 2023
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected February 11, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected October 3, 2023
• February 16, 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 April 3, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected April 3, 2023

Substantiated abuse or neglect

• September 7, 2025: Failed to provide inservice 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); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Alleged Perpetrator #2 (AP2) works at the facility as a caregiver, according to training records. There is no indication that AP2 was trained as a medication technician. On or about September 7, 2025, Alleged Perpetrator #2 (AP2) administered medications to the Alleged Victim (AV), however, AP2 had already administered AV's medications earlier. The medication was administered to AV accidentally, as AV was not sitting in his/her assigned seat, and the resident the medications were intended for looked similar to AV. AV was sent to the hospital and diagnosed with overdose of medication, causing altered mental status, low blood pressure and non-communicative and sleepy. AP2's actions were found to be inconclusive after investigation. Respondent failed to ensure staff were properly trained to carry out resident services for passing medication. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

Substantiated licensing violations

• March 13, 2026: 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); 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 16, 2026, Alleged Perpetrator #2 (AP2), advised the Alleged Victim (AV) it was time for bed. When AV refused, AP2 enlisted subordinate staff members to put AV to bed. When staff refused, AP2 wheeled AV into AV's bedroom and began changing AV into their pajamas for bed. AV became physically combative, kicking, biting and screaming to resist, and in the process, cut his/her finger open on AP2's key chain lanyard. AV was transported to the hospital where he/she received stitches. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The Respondent failed to ensure facility staff treated residents with respect and honored their rights, which is a violation of Oregon Administrative Rules.

• September 7, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complainant the facility gave a resident another resident medication which led to the resident having to go to the hospital and was hospitalized with bradycardia, which is a violation of Oregon Administrative Rules.

• September 1, 2024: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Facility failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse in accordance with OAR 411-054-0028(2)(b); per complaint that the facility did not immediately report and incident.

• August 4, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to follow physician orders. An investigation determined a licensing violation or abuse occurred.

• March 8, 2023: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. An investigation determined a licensing violation or abuse occurred.

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 12 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.