14145 SW 105th Avenue, Tigard, OR 97224 (opens Google Maps) · Washington County · (503) 639-1144· 112 certified beds · avg 66 residents/day · certified since Apr 1, 2006 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
SFF Candidate
What Special Focus status means →
Part of chain: SAPPHIRE HEALTH SERVICES (8 facilities, chain avg rating 1.9★)
New to these records? How to read an inspection report →
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →
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 quality measures from resident assessments and claims.
▲ Immediate jeopardy, pattern · 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): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 9, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 9, 2026 (Deficient, Provider has date of correction)
Showing the latest 3 of 44 inspection findings. Open the full record below to read every finding.
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. F-0880
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 F-0689
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. F-0658
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 11, 2026 | ▲ K · Immediate jeopardy, pattern | 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. · F-0880 |
| May 11, 2026 | ▲ J · Immediate jeopardy, isolated | 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 · F-0689 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | 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. · F-0761 |
| May 11, 2026 | E · Potential for more than minimal harm, pattern | 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. · F-0812 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0605 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0656 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0688 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0757 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883 |
| May 11, 2026 | D · Potential for more than minimal harm, isolated | 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. · F-0887 |
| Nov 17, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0684 |
| Nov 17, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0686 |
| Nov 17, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0755 |
| Jul 18, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0600 |
| Jan 17, 2025 | F · Potential for more than minimal harm, widespread | 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. · F-0812 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · F-0552 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0576 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0656 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | 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 · F-0684 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730 |
| Oct 10, 2024 | D · Potential for more than minimal harm, isolated | 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 · F-0557 |
| May 3, 2024 | D · Potential for more than minimal harm, isolated | 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 · F-0600 |
| Apr 11, 2024 | D · Potential for more than minimal harm, isolated | 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 · F-0684 |
| Dec 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0689 |
| Dec 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0740 |
| Aug 11, 2023 | F · Potential for more than minimal harm, widespread | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730 |
| Aug 11, 2023 | F · Potential for more than minimal harm, widespread | 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 · F-0812 |
| Aug 11, 2023 | F · Potential for more than minimal harm, widespread | 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 · F-0868 |
| Aug 11, 2023 | F · Potential for more than minimal harm, widespread | 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 · F-0880 |
| Aug 11, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| Aug 11, 2023 | E · Potential for more than minimal harm, pattern | 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 · F-0759 |
| Aug 11, 2023 | E · Potential for more than minimal harm, pattern | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint · F-0804 |
| Aug 11, 2023 | E · Potential for more than minimal harm, pattern | The facility did not dispose of garbage and refuse properly. · from a complaint · F-0814 |
| Aug 11, 2023 | E · Potential for more than minimal harm, pattern | 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 · F-0947 |
| Aug 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0553 |
| Aug 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0578 |
| Aug 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0582 |
| Aug 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0684 |
| Aug 11, 2023 | D · Potential for more than minimal harm, isolated | 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 · F-0689 |
| Aug 11, 2023 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842 |
Citations from standard inspections increased between the last two inspection cycles (7 → 13).
All bars start at zero. Exact values and supporting details remain below.
| 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.
How to file a complaint about care →
3 fines totaling $69,509.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| May 11, 2026 | Fine | $14,175 |
| May 11, 2026 | Fine | $19,620 |
| Apr 18, 2025 | Fine | $35,714 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| 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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (5.08 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Tigard Rehabilitation and Care. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
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 |
All 10 owning or managing parties CMS has on file are shown — none excluded.
CMS lists this facility under the chain Sapphire Health Services — 8 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| 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 →
CMS records place this facility in Washington, OR — 9 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 385272.
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