Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Hills Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to follow required hygiene and food safety protocols, including not wearing proper hair restraints, neglecting hand hygiene, and not labeling or discarding undated food items in kitchen and unit refrigerators. Additionally, ice machines were found with mold, slime, and improper drainage, and were used to serve residents. Staff acknowledged these ongoing issues and inconsistent responsibilities for food and equipment sanitation.
A resident with spinal stenosis was found with a cup of multiple medications left on the bedside table without an assessment for safe self-administration, contrary to facility policy. The resident reported waiting for someone to identify the medications, and staff confirmed the medications were left after the resident was not present during the medication pass. The DNS acknowledged that no assessment had been completed and medications should not have been left in the room.
The facility did not obtain or maintain documentation of advance directives for three residents with complex medical conditions, despite care plans and conference notes indicating these directives were in effect or reviewed. Residents were either unsure about their advance directive status or confirmed the facility did not have a copy, and staff interviews revealed that necessary follow-up to secure these documents was not performed.
A facility failed to provide necessary training for a resident on self-administering an anticoagulant medication before discharge. Despite the resident's care plan requiring education on medication administration, there was no documentation of such training. Staff confirmed the lack of documentation and training, acknowledging the facility's responsibility to ensure residents are prepared for medication administration post-discharge.
A resident with hypothyroidism and hypertension did not receive their prescribed levothyroxine and spironolactone due to a failure in medication administration procedures. An LPN was unaware of the medication schedule and did not report the missed doses to the RCM, DNS, or physician. The DNS confirmed the oversight and highlighted the responsibility of oncoming nurses to review previous medication passes.
The facility failed to ensure sufficient dietary staff, resulting in meals being served late and sometimes cold. Staff and the Resident Council President confirmed ongoing issues with meal timeliness, particularly on weekends, due to staffing shortages.
A resident with encephalopathy and dementia was given a hot cup of tea without proper supervision, resulting in a first-degree burn. The care plan required one-to-one supervision during meals, but the assigned agency staff was not present at the time of the incident.
The facility failed to ensure meals were served in a palatable and appetizing manner, leading to multiple complaints from residents and staff. Issues included cold, tasteless food, inconsistent portions, and poor food quality, as confirmed by a test tray and various interviews.
Deficient Food Safety and Sanitation Practices in Kitchen and Ice Machines
Penalty
Summary
Facility staff failed to adhere to proper personal hygiene and food safety protocols in the kitchen and unit food storage areas. Observations included kitchen staff preparing meals without appropriate hair and beard restraints, and staff failing to perform hand hygiene after glove changes or before food handling. Despite signage reminding staff of hand hygiene requirements, these practices were not consistently followed. Additionally, food items in the kitchen refrigerator and unit refrigerators were found to be undated or improperly labeled, including raw chicken, sliced tomatoes, banana cream pie, sushi, and other unidentifiable foods. Staff provided conflicting information regarding responsibility for discarding undated food, and acknowledged that undated items should be discarded but were not consistently removed. Further deficiencies were observed in the maintenance and sanitation of facility ice machines. One ice machine was found draining into a container of dirty water that also contained a sealed food item, and the interior of the machine had visible black spotting. Another ice machine had drain pipes covered in dark, slimy substances and black mold, with pink mold present where ice was dispensed. Staff were observed using these machines to provide ice to residents. Maintenance and dining services staff confirmed the presence of debris, mold, and slime, and acknowledged responsibility for cleaning the machines, but the issues persisted at the time of survey.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the safe self-administration of medications, as required by its own policy. The policy states that a resident may only self-administer medications after the interdisciplinary team determines which medications can be safely self-administered. However, a review of the resident's record showed no assessment had been completed for self-administration of medications. During observations, the resident was found alone in their room with a cup containing multiple medications on the bedside table. The resident stated they were waiting for someone to tell them what the medications were. Staff confirmed that the medications had been left in the resident's room after the resident was not present during the medication pass. The Director of Nursing Services also confirmed that the resident had not been assessed for self-administration and that medications should not have been left in the room.
Failure to Obtain and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to obtain and maintain documentation of advance directives and health care decisions for three residents with significant medical conditions, including chronic inflammatory demyelinating polyneuritis, sepsis with metabolic encephalopathy, and stroke. For each resident, care plans and care conference notes indicated that advance directives were in effect or had been reviewed, but no actual advance directive documents were found in the clinical records. Interviews with the residents revealed that they either had not completed an advance directive, were unsure if one was completed, or believed the facility did not have a copy. Staff interviews confirmed that there was no advance directive on file for any of the three residents, and the Social Services Coordinator acknowledged that follow-up to obtain or confirm these documents had not occurred. In one case, documentation indicated that a power of attorney (POA) was to be contacted, but there was no evidence this was done. The Executive Director stated that blank advance directive forms were provided at admission, but follow-up and documentation were not consistently completed.
Failure to Provide Medication Administration Training Before Discharge
Penalty
Summary
The facility failed to provide necessary education and training for the self-administration of an anticoagulant subcutaneous medication prior to the discharge of a resident. The facility's discharge planning policy required the development and implementation of an effective discharge planning process, which included evaluating the resident's discharge needs and providing continuous education to the resident and their family. However, the facility did not adhere to this policy for a resident who was admitted with a left femur fracture and stroke and was receiving subcutaneous injectable anticoagulant therapy. The resident's care plan included interventions for training and education on medication administration, but there was no documentation indicating that the resident or their representative received this training before discharge. The resident was discharged with the prescription still in active use, and staff members confirmed the lack of documentation and training. The LPN responsible for discharge planning and the RNCM both acknowledged the absence of documentation and training, and the DNS confirmed the facility's responsibility to ensure residents are trained on medication administration prior to discharge.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was not administered their prescribed medications. The resident, who had diagnoses of hypothyroidism and hypertension, was ordered to receive levothyroxine and spironolactone at 6 AM before meals. However, a review of the resident's December Medication Administration Record (MAR) revealed that these medications were not administered as ordered. Staff 6, an LPN, confirmed that the resident did not receive their thyroid or blood pressure medications and admitted to being unaware of the timing for the administration of these medications. Staff 6 also stated that it was not her responsibility to review previous medication passes to ensure completion by the last shift and did not report the missed medication administration to the Resident Care Manager (RCM), Director of Nursing Services (DNS), or the physician. The DNS confirmed that the oncoming nurse failed to review the previous medication pass and emphasized that it is the facility's expectation for any nurse discovering a medication error to report it and file an incident report.
Dietary Staffing Shortages Lead to Late Meal Service
Penalty
Summary
The facility failed to ensure sufficient dietary staff were available to deliver food service in a timely manner, which placed residents at risk for unmet nutritional needs. A public complaint was made to the state agency alleging that all meals were served late daily, and this issue had persisted for several months. The Resident Council President confirmed that meals were always served late and sometimes cold. Staff interviews revealed that the dining room was served first, followed by different halls, with the skilled hall being served last. Staff members, including a cook and CNAs, acknowledged ongoing staffing shortages, particularly in the dietary department, which resulted in meals being served up to 45 minutes late, especially on weekends. The facility's Administrator also acknowledged the issue and mentioned the process of hiring a new Dietary Manager.
Failure to Implement Supervision for Resident with Dementia
Penalty
Summary
The facility failed to implement care plan interventions to ensure adequate supervision was provided to prevent accidents for a resident with encephalopathy and dementia. The resident's care plan required one-to-one supervision during meals and specified that staff should not leave cups in front of the resident without supervision. However, on one occasion, the resident was given a hot cup of tea without proper supervision, resulting in the resident dropping the cup and sustaining a first-degree burn on the left thigh. Staff interviews revealed that an agency staff member was assigned to supervise the resident but was not present at the time of the incident. A CNA observed the resident about to throw the cup but left the dining room for about 30 seconds, during which the incident occurred. The DNS confirmed that the resident sustained a first-degree burn with no blisters as a result of the liquid spill.
Failure to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure meals were served in a palatable and appetizing manner for two sampled residents, leading to unmet nutritional needs. The facility's Food Temperature policy, revised in August 2023, stated that food should be transported quickly to maintain appropriate temperatures. However, multiple complaints were documented, including from the Resident Council notes in March 2024, which indicated that food was always cold, tasteless, and portions were inconsistent. Resident 105, admitted in 2022 with acute cystitis and weakness, reported that the food was terrible, often resorting to peanut butter and jelly sandwiches and oatmeal. Resident 106, admitted in 2023 with transverse myelitis and Hepatitis B, stated that the food quality had declined after menu changes, leading them to eat mostly salads due to poor food quality. The Resident Council President and several CNAs corroborated these complaints, noting that food was often late, cold, too salty, overcooked, and generally unpalatable. A test tray sampled on May 7, 2024, revealed that the shrimp was lukewarm and not fully cooked, the rice was bland, and the sautéed vegetables were mushy and unappetizing. The National Culinary Director acknowledged the complaints and mentioned that the company was in the process of hiring a new dietary manager. The facility administrator also acknowledged the multiple complaints about the food and confirmed efforts to hire a new dietary manager. These observations and interviews indicate a systemic issue with food quality and temperature, affecting the residents' nutritional intake and overall satisfaction with their meals.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Vermont Hills | 1 mi | ★★★★★ | 2 | 0 |
| Robison Jewish Health Center | 1.3 mi | ★★★★★ | 23 | 0 |
| Marquis Autumn Hills Memory Care | 1.3 mi | ★★★★★ | 7 | 0 |
| Avamere Crestview Of Portland | 1.6 mi | ★★★★★ | 11 | 0 |
| Beaverton Post Acute Care Of Cascadia | 3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.