Tigard Rehabilitation and Care
14145 SW 105th Avenue, Tigard, OR 97224 · Washington County · 112 certified beds · avg 66 residents/day · certified since Apr 1, 2006
SFF Candidate
Part of chain: SAPPHIRE HEALTH SERVICES (8 facilities, chain avg rating 1.9★)
1/5
Health inspection rating (on-site)
2
Serious findings on record
$69,509
Fines, last 3 years
5.88
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · May 11, 2026 · F-0880
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 9, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 11, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 9, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (44)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 11, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 11, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 11, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 11, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 11, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 11, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| May 11, 2026 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 18, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| May 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 11, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 11, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Aug 11, 2023 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Aug 11, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Aug 11, 2023 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint |
| Aug 11, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 17 | 0 | F |
| 2024 | 3 | 0 | D |
| 2025 | 11 | 0 | F |
| 2026 | 13 | 2 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $69,509.
| Date | Type | Amount / length |
|---|---|---|
| May 11, 2026 | Fine | $14,175 |
| May 11, 2026 | Fine | $19,620 |
| Apr 18, 2025 | Fine | $35,714 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.88 | 5.42 | 3.95 | top 19% in Oregon; top 5% in the U.S. |
| Registered Nurse hours | 0.54 | 0.78 | 0.69 | bottom 29% in Oregon; bottom 44% in the U.S. |
| Weekend total nurse staffing | 5.47 | 4.85 | 3.50 | top 13% in Oregon; top 3% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.48 | 0.48 | bottom 22% in Oregon; bottom 30% in the U.S. |
| Total nursing staff turnover (%) | 58.6 | 47.4 | 45.8 | bottom 23% in Oregon; bottom 18% in the U.S. |
| RN turnover (%) | 70.0 | 51.6 | 42.9 | bottom 23% in Oregon; bottom 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.08, RN 0.47, weekend 4.73. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Becker, Andrew | Individual | 5% or Greater Direct Ownership Interest | 30% | 12/13/2022 |
| Hilty, Lisa | Individual | 5% or Greater Direct Ownership Interest | 25% | 12/13/2022 |
| Morris, Bryan | Individual | 5% or Greater Direct Ownership Interest | 5% | 12/13/2022 |
| Ricker, Kevin | Individual | 5% or Greater Direct Ownership Interest | 40% | 12/13/2022 |
| Larson, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Larson, David | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
| Sapphire Healthcare SRVS. | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2023 |
| Sapphire Healthcare SRVS. | Organization | ADP of the SNF | NOT APPLICABLE | 05/23/2025 |
| Zheng, Jeffrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/10/2024 |
| Zheng, Jeffrey | Individual | ADP of the SNF | NOT APPLICABLE | 09/10/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avamere Rehabilitation of King City | 1.4 mi | Tigard, OR | ★★★★☆ | 3/5 | |
| Marquis Tualatin Post Acute Rehab | 3.1 mi | Tualatin, OR | ★★★★★ | 4/5 | |
| The Pearl at Kruse Way | 3.4 mi | Lake Oswego, OR | ★★★★☆ | 4/5 | |
| Beaverton Post Acute Care of Cascadia | 4.0 mi | Beaverton, OR | ★★★★★ | 4/5 | |
| West Hills Health & Rehabilitation | 4.2 mi | Portland, OR | ★★★★☆ | 3/5 | |
| Marquis Vermont Hills | 5.0 mi | Portland, OR | ★★★★★ | 5/5 | |
| Maryville | 5.1 mi | Beaverton, OR | ★★★★☆ | 3/5 | |
| Robison Jewish Health Center | 5.3 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Marquis Autumn Hills Memory Care | 5.3 mi | Portland, OR | ★★★★★ | 4/5 | |
| Avamere Crestview of Portland | 5.6 mi | Portland, OR | ★★★★☆ | 3/5 | |
| Fernwood Supportive Living at Madrona Grove | 6.8 mi | Portland, OR | ★★★★☆ | 3/5 | |
| Willamette View Health Center | 6.8 mi | Milwaukie, OR | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385272.