Tigard Rehabilitation and Care
14145 Sw 105th Avenue, Tigard, OR 97224 · Washington County · (503) 639-1144
112 certified beds, about 66 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2006
Special Focus Facility candidate Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385272 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on May 11, 2026, inspectors cited 13 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 44 health citations since August 2023, 2 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 3 fines totaling $57,681 in the last three years; the largest was $35,714, and the latest is dated May 11, 2026.
Nurses and nurse aides worked 5.08 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.47 of those hours.
58.6% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Sapphire Health Services, an affiliated group of 8 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1508/23
212/23
104/24
105/24
110/24
701/25
107/25
311/25
1305/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 44 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
8E
5F
Potential for minimal harm
0A
0B
0C
May 11, 2026Standard inspection, Complaint inspection · 13 citations
- K Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the community use glucometer was properly sanitized between resident use for 2 of 2 sampled residents (#s 9 and 53) reviewed for infection control during CBG checks. This failure, determined to be an Immediate Jeopardy (IJ) situation, placed all residents who required CBG checks at significant risk for bloodborne illness. On 5/6/26 the facility was informed of the IJ situation and provided a copy of the IJ template.
- J Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure foods and fluids were served in a manner to prevent accidental choking for 2 of 3 sampled residents (#s 28 and 30) reviewed for accidents. This failure, determined to be an Immediate Jeopardy situation (IJ), resulted in Resident 30 choking after the resident received food of the wrong texture. This failure also placed other residents at risk for choking and lack of oxygen. It was determined the IJ began on 3/26/26. On 5/6/26 the facility was notified of the IJ situation and was provided a copy of the IJ template.
- E Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to disinfection of common use glucometers, following physician orders, unnecessary medications, and infection control during wound care for 1 of 1 licensed nurse (Staff #3) reviewed for infection control and medication administration. This placed residents at risk for bloodborne illness, uncontrolled hypertension, and hypoglycemia.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained, failed to ensure proper labeling of biologicals and failed to ensure a medication cart was properly secured for 1 of 1 medication refrigerator, for 1 of 3 treatment carts and 1 of 4 medication carts reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and unauthorized access to medications.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was the determined the facility failed to ensure staff wore hair restraints for 1 of 1 Staff (#6) reviewed for kitchen. This placed residents at risk for cross contamination.
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review it was determined the facility failed to assess the appropriateness and effectiveness of psychotropic medication use for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for receiving unnecessary psychotropic medications.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care plan interventions were individualized for 1 or 1 sampled resident (#42) reviewed for ADLs. This placed residents at risk for unmet needs and receiving non-individualized care interventions.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to clarify and follow physician orders for 1 of 1 sampled resident (#42) reviewed for Activities of Daily Living (ADLs). This placed residents at risk for unmet needs and uncontrolled hypertension.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in ROM or mobility for 1 of 1 sampled resident (#49) reviewed for positioning and mobility. This placed residents at risk for loss of ROM and mobility.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to administer insulin as ordered for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk of receiving unnecessary medication.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident medical records were kept secured and confidential for 2 of 2 random observations. This placed residents at risk for lack of privacy and confidentiality.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review it was determined the facility failed to offer and obtain consent prior to administration of influenza and pneumococcal vaccinations for 2 of 5 sampled residents (#s 11 and 28) reviewed for immunizations. This placed residents at risk for pneumonia and being uninformed of the risks and benefits of vaccination.
- D Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were offered the COVID-19 vaccine for 2 of 5 sampled residents (#s 11 and 62) reviewed for immunizations. This placed residents at risk for COVID-19 illness.
November 17, 2025Complaint inspection · 3 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure non-pressure skin wounds were monitored for 1 of 3 sampled residents (#6) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds and delays in treatment.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure newly identified pressure ulcer wounds were comprehensively assessed and wound care orders were obtained and implemented for 1 of 3 sampled residents (#7) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure narcotic drug records were in order and an account of all controlled drugs was maintained for 1 of 3 narcotic books reviewed for medication administration. This placed residents at risk for drug diversion.
July 18, 2025Complaint inspection · 1 citation
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse.
January 17, 2025Standard inspection, Complaint inspection · 7 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food storage. This placed residents at risk for potential foodborne illnesses. A review of the facility policy Refrigerator and Freezer policy revealed refrigerator and freezer temperatures were to be checked daily and all food items were to be marked with dates. Responsibility for implementating the policy was assigned to supervisors or their designee. On 1/13/25 at 8:25 AM the refrigerator used to store resident food items, located in the resident dining room, was observed to have a temperature recording log, however, the temperature was only recorded on 1/10/25. [...]
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavior. This placed residents at risk for lack of involvement in care.
- D Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident (#52) reviewed for behavior. This placed residents at risk for unmet needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide care to wounds for 1 of 1 sampled resident (#52) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings Include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. An 10/5/24 hospital progress note revealed Resident 52 had a a right foot ulcer. An 10/8/24 Clinical admission revealed a right lateral (outer edge) foot diabetic foot ulcer was identified. Daily Skilled Evaluations completed 10/9/24 through 10/18/24, 10/20/24 through 11/1/24, 11/4/24, and 11/5/24, identified Resident 52's right lateral foot diabetic ulcer was not evaluated. 10/14/24, 10/17/24, 10/25/24, 11/1/24, and 11/19/24 Physician Progress Notes revealed no information related to Resident 52's right lateral foot diabetic ulcer. [...]
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were assessed after weight loss was identified for 1 of 3 sampled residents (# 34) reviewed for nutrition. This placed residents at risk continued weight loss.
- D Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 randomly selected CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for lack of care by competent staff.
October 10, 2024Complaint inspection · 1 citation
- D Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity and respect. This placed residents at risk for a decrease in their quality of life. Resident 2 admitted to the facility in 11/2023, with diagnoses including hyperlipidemia (a condition caused by high levels of fat in the blood). Resident 1 admitted to the facility in 2/2024, with diagnoses including chronic systolic heart failure. A 7/17/24 Facility Reported Incident indicated Resident 1 was observed having a verbal altercation with Resident 2 in the facility parking lot. It was reported the altercation began after Resident 2 requested Resident 1 to return a spare wheelchair that Resident 1 had borrowed. [...]
May 3, 2024Complaint inspection · 1 citation
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for potential repeat sexual abuse incidents.
April 11, 2024Complaint inspection · 1 citation
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to treat a diabetic wound per physician orders for 1 of 3 sampled residents (#8) reviewed for skin conditions. This placed residents at risk for worsening wounds.
December 11, 2023Complaint inspection · 2 citations
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow resident care plans related to substance use disorder for 1 of 1 sampled resident (# 2) reviewed for safety and coordination of care.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess and develop individualized interventions specific to the expression to continue using illegal substances for 1 of 1 sampled resident (#2) reviewed for behavioral emotional health. This placed residents at risk for a decline in mood and potential risk for reduced quality of life.
August 11, 2023Standard inspection · 15 citations
- F Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete nurse aide training performance reviews every 12 months and provide regular in-service training based on the outcome of these reviews for 1 of 1 CNA (#12) reviewed for annual nurse aide training performance. This placed residents at risk for lack of care by competent staff.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined that the facility failed to prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed residents at risk for foodborne illness.
- F Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review it was determined the facility failed to have the Medical Director or designee attend the QAA (quality assessment and assurance) committee for 2 of 3 quarters reviewed for QAA. This placed residents at risk of not receiving care and services for optimal resident outcomes.
- F Provide and implement an infection prevention and control program.
Inspectors wrote1. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens.
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain a safe environment for 1 of 1 courtyard areas reviewed for environment. This placed residents at risk for accidents.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the medication error rate was less than 5%. There were 28 medication administration opportunities with 8 errors resulting in an error rate of 28%. This placed residents at risk for adverse medication side effects.
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure hot food was served at preferable temperatures for 1 of 1 lunch meal reviewed for food concerns. This placed residents at risk for inadequate food temperatures.
- E Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered for 1 of 1 facility garbage areas reviewed for sanitation. This placed residents at risk for exposure to pests and rodents.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 sampled CNAs (#s 11, 12, 13, 14 and 15) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff.
- D Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review it was determined the facility failed to offer the resident the opportunity to participate in the care planning process for 1 of 4 sampled residents (#19) reviewed for care planning. This placed residents at risk for not being involved in the care planning process.
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an Advance Directives for 1 of 3 sampled residents (#14) reviewed for Advanced Directives. This placed residents at risk for not having their health care preferences honored.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide NOMNC (Notice of Medicare Non Coverage) and SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 2 of 3 sampled residents (#s 247 and 248) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow and implement physician orders and provide bowel medication in a timely manner for 2 of 6 sampled residents (#s 26 and 43) reviewed for medications and tube feeding. This placed residents at risk for medical complications from constipation and adverse side effects of medications.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure elopement interventions were in place for 1 of 3 sampled residents (#26) reviewed for accidents. This placed residents at risk for lack of supervision and increased elopement risk.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure records were complete and accurate for 3 of 6 sampled residents (#s 7, 14 and 44) reviewed for medications and death. This placed residents at risk for inaccurate medical records.
Fire safety inspections
20 fire safety citations on file: 3 on May 11, 2026, 4 on April 18, 2025, 6 on January 17, 2025, 7 on August 11, 2023.
Every fire safety citation20 citations
- F Conduct testing and exercise requirements.
- F Have simulated fire drills held at unexpected times.
- F Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- L Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F Provide a written emergency evacuation plan.
- F Have simulated fire drills held at unexpected times.
- D Meet requirements for the use of electrical equipment.
- F Establish policies and procedures including evacuation.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure proper usage of power strips and extension cords.
- F Conduct testing and exercise requirements.
- F Have simulated fire drills held at unexpected times.
- F Have power receptacles that are properly grounded.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Have properly installed hallway dispensers for alcohol-based hand rub.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Have proper medical gas storage and administration areas.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 11, 2026 | Fine | $9,214 |
| May 11, 2026 | Fine | $12,753 |
| April 18, 2025 | Fine | $35,714 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.08 | 5.03 | 3.86 |
| Registered nurses | 0.47 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.73 | 4.51 | 3.42 |
| Nurse aides | 3.69 | ||
| Licensed practical nurses | 0.92 | ||
| Nursing staff turnover (share who left in a year) | 58.6% | 47.4% | 45.8% |
| Registered nurse turnover | 70.0% | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.31 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.22 on weekdays and 4.73 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.72 in April to June 2025 to 5.08 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.08 | 0.47 | 5.22 | 4.73 | 2.6% | 0 of 90 | 66 |
| Oct to Dec 2025 | 5.39 | 0.44 | 5.52 | 5.09 | 3.4% | 0 of 92 | 64 |
| Jul to Sep 2025 | 5.06 | 0.47 | 5.22 | 4.66 | 6.8% | 0 of 92 | 65 |
| Apr to Jun 2025 | 5.72 | 0.43 | 5.90 | 5.26 | 11.3% | 1 of 91 | 58 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.7 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.4 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.8 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.8 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.5 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 7.9 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 10.2 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.8 | 13.9 | 15.4 |
Owners and operators
Legal business name: SAPPHIRE AT TIGARD REHAB LLC. CMS links this home to Sapphire Health Services, a group of 8 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Becker, Andrew | 5% or greater direct ownership interest | Individual | 30% | 12/13/2022 |
| Hilty, Lisa | 5% or greater direct ownership interest | Individual | 25% | 12/13/2022 |
| Morris, Bryan | 5% or greater direct ownership interest | Individual | 5% | 12/13/2022 |
| Ricker, Kevin | 5% or greater direct ownership interest | Individual | 40% | 12/13/2022 |
| Sapphire Healthcare Srvs. | Operational/managerial control | Organization | 08/01/2023 | |
| Larson, David | Operational/managerial control | Individual | 09/01/2023 | |
| Zheng, Jeffrey | Operational/managerial control | Individual | 09/10/2024 | |
| Sapphire Healthcare Srvs. | Adp of the SNF | Organization | 05/23/2025 | |
| Larson, David | Adp of the SNF | Individual | 08/01/2023 | |
| Zheng, Jeffrey | Adp of the SNF | Individual | 09/10/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 12 problems in this area, most recently on May 11, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on January 17, 2025: "Ensure that residents are fully informed and understand their health status, care and treatments."
- When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on May 11, 2026: "Ensure services provided by the nursing facility meet professional standards of quality."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 5 problems in this area, most recently on May 11, 2026: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
Other nursing homes nearby
- Avamere Rehabilitation of King City Tigard, 1.3 mi · 4 of 5 stars · 33 citations
- Marquis Tualatin Post Acute Rehab Tualatin, 3.1 mi · 5 of 5 stars · 11 citations
- The Pearl at Kruse Way Lake Oswego, 3.4 mi · 4 of 5 stars · 22 citations
- Beaverton Post Acute Care of Cascadia Beaverton, 4 mi · 5 of 5 stars · 20 citations
- West Hills Health & Rehabilitation Portland, 4.2 mi · 4 of 5 stars · 26 citations
- Marquis Vermont Hills Portland, 5 mi · 5 of 5 stars · 13 citations
- Maryville Beaverton, 5.1 mi · 4 of 5 stars · 15 citations
- Robison Jewish Health Center Portland, 5.3 mi · 2 of 5 stars · 32 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Tigard Rehabilitation and Care's Medicare star rating?
- CMS rates Tigard Rehabilitation and Care 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Tigard Rehabilitation and Care get at its last inspection?
- 13 health deficiencies at the standard inspection on May 11, 2026. The Oregon average is 9.2.
- Has Tigard Rehabilitation and Care been fined?
- Yes. CMS lists 3 fines totaling $57,681 in the last three years.
- Does Tigard Rehabilitation and Care accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Tigard Rehabilitation and Care?
- CMS lists 10 owners and managers, and links the home to Sapphire Health Services. Legal business name: SAPPHIRE AT TIGARD REHAB LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.