Federal inspection record · CMS data as of October 1, 2026
Tigard Rehabilitation And Care
14145 Sw 105th Avenue, Tigard, OR · (503) 639-1144
- Special Focus Facility
- Certified beds
- 112
- Residents per day
- 66
- Ownership
- For-Profit
- Chain
- Sapphire Health Services
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 1, 2006
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Oregon.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Oregon homes
Tigard Rehabilitation And Care carries 198.25 inspection points. That is fewer than 2% of Oregon's 126 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Oregon: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–41 pts
- 3★ 41–65 pts
- 2★ 65–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in Oregon by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
44 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
K
Provide and implement an infection prevention and control program.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care11D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 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.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights7E
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- 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.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- 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.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Assessment and Care Planning5E
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Nutrition and Dietary5F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Dispose of garbage and refuse properly.
Pharmacy Service4E
- 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.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
Freedom from Abuse, Neglect, and Exploitation3D
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Infection Control3F
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 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.
- F
Provide and implement an infection prevention and control program.
Nursing and Physician Services3F
- D
Observe each nurse aide's job performance and give regular training.
- F
Observe each nurse aide's job performance and give regular training.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Administration1F
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspection history
2026-05-11
16 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2025-01-17
9 health deficiencies · 10 fire-safety deficiencies
Top issue: Resident Rights (3 deficiencies)
2023-08-11
19 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 25 min of nursing staff time a day, 31 min of it from a registered nurse.
This home
5 h 25 min
Oregon average
5 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 36% of nursing staff and 70% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$57,681 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-05-11 | Fine | $9,214 |
| 2026-05-11 | Fine | $12,753 |
| 2025-04-18 | Fine | $35,714 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.4 pts better | 98.7% | 95.3% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.6 pts better | 96.6% | 94.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.6 pts worse | 4.0% | 2.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms8.7 pts worse | 13.6% | 4.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight9.3 pts worse | 13.9% | 4.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication4.3 pts better | 7.9% | 12.2% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication1.3 pts worse | 15.6% | 14.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened7.1 pts better | 11.5% | 18.6% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.5 pts better | 11.7% | 14.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.2 pts worse | 1.5% | 1.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection3 pts worse | 5.0% | 2.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6.8 pts better | 14.0% | 20.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.2 pts worse | 7.8% | 5.6% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.3 pts better | 89.1% | 85.8% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts worse | 2.8% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine8.8 pts better | 89.7% | 80.9% | 80.1% |
·
Who owns and runs it
10 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Ricker, Kevin | 5% Or Greater Direct Ownership Interest · Individual | 40% | 8 facilities |
| Becker, Andrew | 5% Or Greater Direct Ownership Interest · Individual | 30% | 8 facilities |
| Hilty, Lisa | 5% Or Greater Direct Ownership Interest · Individual | 25% | 8 facilities |
| Morris, Bryan | 5% Or Greater Direct Ownership Interest · Individual | 5% | 8 facilities |
| Larson, David | Operational/Managerial Control · Individual | 0% | 14 facilities |
| Larson, David | Adp Of The SNF · Individual | 0% | 14 facilities |
| Sapphire Healthcare Srvs. | Operational/Managerial Control · Organization | 0% | 8 facilities |
| Sapphire Healthcare Srvs. | Adp Of The SNF · Organization | 0% | 8 facilities |
| Zheng, Jeffrey | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Zheng, Jeffrey | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
20 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Miscellaneous6F
- 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.
- F
Provide a written emergency evacuation plan.
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems6F
- D
Meet requirements for the use of electrical equipment.
- 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
Have power receptacles that are properly grounded.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Have proper medical gas storage and administration areas.
Emergency Preparedness3F
- F
Conduct testing and exercise requirements.
- F
Establish policies and procedures including evacuation.
- F
Conduct testing and exercise requirements.
Smoke3F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
Egress1D
- 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.
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Other homes nearby
-
Avamere Rehabilitation Of King City
Tigard, OR · Avamere
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 40 min
- Fines
- $0
-
Marquis Tualatin Post Acute Rehab
Tualatin, OR · Marquis Companies
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 23 min
- Fines
- $0
-
The PEARL AT KRUSE WAY
Lake Oswego, OR · Avamere
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 49 min
- Fines
- $0