Tigard Rehabilitation and Care
14145 Sw 105th Avenue · Tigard, OR · 97224 · 5036391144
112 certified beds For profit - Limited Liability company Chain: Sapphire Health Services
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
100% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 5.39 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.44 | 0.55–0.75 |
| Weekend hours / resident-day | 5.09 | ≈ weekday level |
| Nursing turnover / year | 100% | median 45% |
| Fines (3-yr window) | 1 · $35,714 |
Inspection citations (43 in the current record)
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Potential for harm · D November 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 17, 2025 · Quality of Life and Care
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Potential for harm · D November 17, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 17, 2025 · Quality of Life and Care
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Potential for harm · D November 17, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 1, 2025 · Pharmacy Service
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Potential for harm · D July 18, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 20, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 17, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected March 3, 2025 · Resident Rights
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Potential for harm · D January 17, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected March 3, 2025 · Resident Rights
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Potential for harm · D January 17, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · F January 17, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 3, 2025 · Nutrition and Dietary
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Potential for harm · D January 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 3, 2025 · Quality of Life and Care
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Potential for harm · D January 17, 2025 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected March 3, 2025 · Quality of Life and Care
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Potential for harm · D January 17, 2025 · found via complaint
Observe each nurse aide's job performance and give regular training.
Corrected March 3, 2025 · Nursing and Physician Services
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Potential for harm · D October 10, 2024 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected November 5, 2024 · Resident Rights
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Potential for harm · D May 3, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 4, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 11, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 14, 2024 · Quality of Life and Care
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Potential for harm · D December 11, 2023 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 16, 2024 · Quality of Life and Care
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Potential for harm · D December 11, 2023 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected January 16, 2024 · Quality of Life and Care
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Potential for harm · D August 11, 2023 · found via complaint
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected September 19, 2023 · Resident Rights
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Potential for harm · D August 11, 2023 · found via complaint
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.
Corrected September 19, 2023 · Resident Rights
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Potential for harm · D August 11, 2023 · found via complaint
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected September 19, 2023 · Resident Rights
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Potential for harm · E August 11, 2023 · found via complaint
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.
Corrected September 19, 2023 · Resident Rights
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Potential for harm · D August 11, 2023 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 19, 2023 · Quality of Life and Care
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Potential for harm · D August 11, 2023 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 19, 2023 · Quality of Life and Care
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Potential for harm · F August 11, 2023 · found via complaint
Observe each nurse aide's job performance and give regular training.
Corrected September 19, 2023 · Nursing and Physician Services
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Potential for harm · E August 11, 2023 · found via complaint
Ensure medication error rates are not 5 percent or greater.
Corrected September 19, 2023 · Pharmacy Service
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Potential for harm · E August 11, 2023 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected September 19, 2023 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 18, 2025 | Fine | $35,714 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385272 · certified since April 1, 2006. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.