West Hills Village Senior Residence

Last inspection

January 27, 2025

Inspections

4, 8 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

10

Regulatory actions

0

Fines assessed

$750.00 (3 violations)

Current owner since

June 15, 1999

Inspections

• January 27, 2025: Complaint Investig., 2 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• January 17, 2025: Re-Licensure, 5 deficiencies cited report
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Widespread
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0540: Heating and Ventilation severity level 2, scope L2 Pattern
• March 20, 2024: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 19, 2024
• March 15, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• April 11, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care. On or about April 11, 2023, at approximately 4:45am, AV was using his/her wheelchair to ambulate in their room. As AV was exiting AV’s bathroom, AV bumped into a door that was leaning against AV’s wall. The door was not secured or attached to a doorframe. When AV bumped into the door, it fell over and hit AV on his/her back. AV fell out of his/her wheelchair onto the floor. As a result, AV was observed to be experiencing severe lower back hip pain. The facility failed to provide a safe environment for AV, by leaving an unhinged door in AV’s room, which is a violation of resident rights, is neglect of care and constitutes abuse.

• February 11, 2023: Failed to provide service Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Alleged Victim (AV) requires full assistance to include transfers, medication, meals, and hygiene care. On or about February 11, 2023, AV did not have his/her call light pendent on his/her person and staff took around one (1) hour to respond to AV’s call. On or about February 24, 2023, AV was left on the bed pan. Staff did not check-in with AV and his/her call light went unanswered for at least 48 minutes. AV screamed for assistance due to not having his/her tray with phone or tablet nearby, and a neighbor had to call 911 for assistance. Staff have often placed AV into uncomfortable or incorrect positions in his/her wheelchair, hoyer lift and bed. On or about March 6, 2023, staff placed two undergarment briefs on AV instead of using one of AV’s provided briefs inserts, making AV uncomfortable. The facility failed to provide service for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• January 29, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 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)
  State’s findings

  Alleged Victim (AV) relies on the facility to administer his/her medications. On or about January 29, 2024, AV was scheduled to receive four (4) pain medications including two (2) opioids at 8:00 PM. However, AV did not receive the schedule pain medications at the required time and as a result, AV suffered a lot of pain and was unable to sleep due to the missed pain medications. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• November 27, 2025: Failed to provide a safe medication administration system 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); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) lives at Respondent’s facility. Facility staff are to order, manage and administer all AV medications. AV is scheduled to be administered a neurological medication at 2:00am each night. The facility had received complaints the week of November 27, 2026, that Alleged Perpetrator 2 (AP2) was not available or helpful. Witness 3 (W3) went to the facility on November 27/25 at 3:15am for a random check-in with staff, found AP2 sleeping on a sofa during their shift. Medication audit discovered AV had several late medication passes when AP2 was working. AP2 did not administer AV's medications timely 12 days in the month of November. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

• March 15, 2025: Failed to assure timely medical treatment 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, on or about March 15, 2025, the Alleged Perpetrator 2 (AP2) did not administer the AV's evening medications medication, resulting in the AV experiencing weakness and increased tremors, causing distress. The AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.

• March 15, 2025: Failed to administer medication as ordered 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, on or about March 15, 2025, the Alleged Perpetrator 2 (AP2) did not administer the AV's evening medications medication, resulting in symptoms preventing the AV from sleeping. The AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.

• March 15, 2025: Failed to administer ordered medication 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, On or about March 15, 2025, the Alleged Perpetrator 2 (AP2) failed to administer the correct dose of ordered medication to the Alleged Victim (AV). After the AV told AP2 they had a medication change that increased their dose of medication, the AP2 spoke rudely to the AV, belittling them and making them feel angry. The AV did not receive their correct dose of medication resulting in the AV having trouble sleeping. The verbal altercation left the AV feeling angry and belittled, causing emotional distress, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide ordered medication to the AV, which is a violation of Oregon Administrative Rules.

• March 14, 2025: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this 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 150 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.