Tigard Rehabilitation and Care
14145 Sw 105th Avenue, Tigard, OR 97224
Tigard Rehabilitation and Care is a nursing home in Tigard, Oregon. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionMay 11, 2026 (6 months ago)
- Health citations since August 11, 202344 (Oregon average 34)
- Fines in the past three years3, $57,681 in total
- CMS flagsSpecial Focus Facility candidate
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of October 8, 2026
Fine
CMS changed the fine from May 11, 2026 from $19,620 to $12,753.
Fine
CMS changed the fine from May 11, 2026 from $14,175 to $9,214.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of June 24, 2026
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on May 11, 2026
13 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
6 of 128 Oregon homes (5%) got a citation at the immediate jeopardy level in 2026.
CMS fine of $12,753 on May 11, 2026.
CMS fine of $9,214 on May 11, 2026.
Show the 13 citations
Citation F0880. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 9, 2026.
CMS has cited this home for F0880 2 times since 2023.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 9, 2026.
CMS has cited this home for F0689 3 times since 2023.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on May 18, 2026.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 18, 2026.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 18, 2026.
CMS has cited this home for F0812 3 times since 2023.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on May 18, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 18, 2026.
CMS has cited this home for F0656 2 times since 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 18, 2026.
CMS has cited this home for F0684 5 times since 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 18, 2026.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 18, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on May 18, 2026.
CMS has cited this home for F0842 2 times since 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 18, 2026.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 18, 2026.
Fire safety inspection on May 11, 2026
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on June 16, 2026.
CMS has cited this home for E0039 2 times since 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 16, 2026.
CMS has cited this home for K0712 4 times since 2023.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on June 16, 2026.
CMS has cited this home for K0741 2 times since 2025.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 3 of 5.
CMS update of February 25, 2026
Staffing
Total nurse staffing reported to CMS went from 5.7 to 5.1 hours per resident per day.
CMS update of January 14, 2026
Fine
CMS changed the fine from April 18, 2025 from $54,945 to $35,714.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on November 17, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 17, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 17, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 1, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on July 18, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 20, 2025.
CMS has cited this home for F0600 2 times since 2024.
CMS update of June 25, 2025
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
Fire safety inspection on April 18, 2025
4 citationsCMS lists this as a complaint inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
6 of 128 Oregon homes (5%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $35,714 on April 18, 2025.
Show the 4 citations
Citation K0741. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on May 5, 2025.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on May 15, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 15, 2025.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on May 15, 2025.
CMS update of February 26, 2025
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Health inspection on January 17, 2025
7 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 7 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 3, 2025.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on March 3, 2025.
Citation F0576. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on March 3, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 3, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 3, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 3, 2025.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on March 3, 2025.
CMS has cited this home for F0730 2 times since 2023.
Fire safety inspection on January 17, 2025
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0020. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures including evacuation.
CMS lists it as corrected on February 13, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 3, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 3, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 13, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 21, 2025.
CMS has cited this home for K0918 2 times since 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 13, 2025.
CMS update of December 20, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on October 10, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on November 5, 2024.
CMS update of September 26, 2024
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 1 of 5 to 3 of 5.
Health inspection on May 3, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 4, 2024.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on April 11, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 14, 2024.
CMS update of March 28, 2024
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
CMS update of December 21, 2023
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Health inspection on December 11, 2023
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 16, 2024.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on January 16, 2024.
Health inspection on August 11, 2023
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation F0730. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on September 19, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 19, 2023.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on September 19, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 19, 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 19, 2023.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 19, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on September 19, 2023.
Citation F0814. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on September 19, 2023.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on September 19, 2023.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on September 19, 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 19, 2023.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on September 19, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 19, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 19, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 19, 2023.
Fire safety inspection on August 11, 2023
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on September 19, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 19, 2023.
Citation K0912. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on September 19, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 19, 2023.
Citation K0325. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on September 19, 2023.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 19, 2023.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 19, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (503) 639-1144
- Last standard health inspection
- May 11, 2026 (6 months ago)
- Certified beds
- 112
- Residents per day, on average
- 66.3
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Sapphire at Tigard Rehab LLC
- Chain
- Sapphire Health Services
- Takes part in
- Medicare and Medicaid
More health citations than the Oregon average (44 vs 34).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BECKER, ANDREW5% or greater direct ownership interest · 30% · since 12/13/2022
- HILTY, LISA5% or greater direct ownership interest · 25% · since 12/13/2022
- MORRIS, BRYAN5% or greater direct ownership interest · 5% · since 12/13/2022
- RICKER, KEVIN5% or greater direct ownership interest · 40% · since 12/13/2022
- SAPPHIRE HEALTHCARE SRVS.Operational/managerial control · not applicable · since 08/01/2023
Show 2 more
- LARSON, DAVIDOperational/managerial control · not applicable · since 09/01/2023
- ZHENG, JEFFREYOperational/managerial control · not applicable · since 09/10/2024
Questions
When was Tigard Rehabilitation and Care last inspected?
CMS lists May 11, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Tigard Rehabilitation and Care have?
CMS lists 44 health citations since August 11, 2023. CMS also calls these deficiencies.
Has Tigard Rehabilitation and Care been fined?
CMS lists 3 fines in the past three years, $57,681 in total.
What is the CMS star rating of Tigard Rehabilitation and Care?
Its CMS overall star rating is 1 of 5.
Is Tigard Rehabilitation and Care a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.