Nursing home report card · Tigard, OR
Tigard Rehabilitation and Care
14145 SW 105th Avenue, Tigard, OR 97224
Call this home: (503) 639-1144
View this home on Medicare.gov ↗
Quick summary
This home is listed for extra oversight
Status: SFF Candidate. Special Focus Facility homes have a history of serious quality problems and get extra oversight.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- May 11, 2026
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Among the lowest Medicare ratings
Based on problems found during health inspections.
Among the lowest Medicare ratings
Based on staffing levels and related measures.
About average for U.S. nursing homes
Based on reported health and care results.
Below-average Medicare rating
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 385272
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Immediate danger to residents · isolated case
May 11, 2026 · Inspection rule 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate danger to residents · pattern case
May 11, 2026 · Inspection rule 0880
Provide and implement an infection prevention and control program.
Could have caused harm · pattern case
May 11, 2026 · Inspection rule 0761
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.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 28 minutes per resident per day
about 5 hr 5 min per resident per day
about 18 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 1 stars
- Health inspection rating: 1 stars
- Staffing rating: 3 stars
- Registered nurse time per resident: 0.47 hours/day
- Total nurse time per resident: 5.08 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; Oregon averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Immediate danger to residents2 citations
- Could have caused harm42 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 44
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Limited Liability company.
- We do not have individual owner names for this home.
Other homes in this group: All Sapphire Health Services nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
May 11, 202613 findings
- Infection Control problemsImmediate danger to residents · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code K
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsImmediate danger to residents · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code E
Ensure services provided by the nursing facility meet professional standards of quality.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code 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.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0605 · code D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0688 · code 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.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0757 · code D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0842 · code D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0883 · code D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0887 · code 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.
November 17, 20253 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
July 18, 20251 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
January 17, 20257 findings
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0552 · code D
Ensure that residents are fully informed and understand their health status, care and treatments.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0576 · code D
Ensure residents have reasonable access to and privacy in their use of communication methods.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code D
Provide enough food/fluids to maintain a resident's health.
- Nursing and Physician Services problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0730 · code D
Observe each nurse aide's job performance and give regular training.
October 10, 20241 finding
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0557 · code D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
May 3, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
April 11, 20241 finding
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
December 11, 20232 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0740 · code D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
August 11, 202315 findings
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0730 · code F
Observe each nurse aide's job performance and give regular training.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Administration problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0868 · code F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- Infection Control problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code F
Provide and implement an infection prevention and control program.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code 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.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code E
Ensure medication error rates are not 5 percent or greater.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0804 · code E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0814 · code E
Dispose of garbage and refuse properly.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0947 · code E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0553 · code D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0578 · code 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.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0582 · code D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0842 · code D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · May 11, 2026$14,175
- Fine · May 11, 2026$19,620
- Fine · Apr 18, 2025$35,714
Other homes in this chain
Sapphire Health Services · other locations in Oregon
- Belmont Care and Rehabilitation · Portland1 of 5 · 47 problems
- Myrtle Point Rehabilitation & Care · Myrtle Point1 of 5 · 71 problems
- Gresham Post Acute Care and Rehabilitation · Gresham2 of 5 · 51 problems
- Rivers Edge Rehabilitation and Care · Sheridan2 of 5 · 36 problems
- Fernhill Rehabilitation and Care · Portland2 of 5 · 60 problems
- Cedar Crossings · Portland3 of 5 · 57 problems
- Gateway Care and Retirement · Portland3 of 5 · 34 problems
Related topics
Questions about Tigard Rehabilitation and Care
What is Tigard Rehabilitation and Care's Medicare star rating?
Has Tigard Rehabilitation and Care been fined?
Does Tigard Rehabilitation and Care have a Medicare abuse warning?
How does Tigard Rehabilitation and Care compare with other nursing homes in Oregon?
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