Map showing the location of TIGARD REHABILITATION AND CARE in TIGARD, Oregon
14145 SW 105TH AVENUE, TIGARD, OR, 97224

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • OregonLowest tier among peers127 rated homes · average 3.0★
  • Washington CountyLowest tier among peers9 rated homes · average 3.8★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs OR avg
  • StaffingCan add or remove a star3★−0.7 vs OR avg
  • Quality measuresCan add or remove a star1★−2.5 vs OR avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 18% of peersOR avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 13% of peersOR avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersOR avg3.5★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.06hrsAbove 55% of peersOR avg4.95Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.47hrsAbove only 25% of peersOR avg0.68Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is betterNo dataOR avg49%RN turnover
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$35,714Above only 29% of peersOR avg$32,647Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
48citations
10inspection dates
0actual harm (G–I)
1immediate jeopardy (J–L)
Nov 17, 2025most recent

Citations by monthJun 2022 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 17, 20253 citationsCycle 1worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Apr 1, 2025
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Dec 17, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Dec 17, 2025
Jul 18, 20251 citationCycle 1worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 20, 2025
Jan 17, 20257 citationsCycle 1worst F · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 3, 2025
  2. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Mar 3, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 3, 2025
  4. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Mar 3, 2025
  5. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Mar 3, 2025
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 3, 2025
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Mar 3, 2025
Oct 10, 20241 citationCycle 2worst D · no actual harm
  1. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Nov 5, 2024
May 3, 20241 citationCycle 2worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 4, 2024
Apr 11, 20241 citationCycle 2worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 14, 2024
Dec 11, 20232 citationsCycle 3worst D · no actual harm
  1. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Jan 16, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 16, 2024
Aug 11, 202315 citationsCycle 2worst F · no actual harm
  1. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Sep 19, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 19, 2023
  3. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Sep 19, 2023
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Sep 19, 2023
  5. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Sep 19, 2023
  6. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Sep 19, 2023
  7. F578Honor 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.Resident RightsD · isolatedCorrected Sep 19, 2023
  8. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Sep 19, 2023
  9. F584Honor 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.Resident RightsE · patternCorrected Sep 19, 2023
  10. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 19, 2023
  11. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Sep 19, 2023
  12. F814Dispose of garbage and refuse properly.Nutrition and DietaryE · patternCorrected Sep 19, 2023
  13. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Sep 19, 2023
  14. F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationF · widespreadCorrected Sep 19, 2023
  15. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Sep 19, 2023
May 17, 20235 citationsCycle 3worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 16, 2023
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 16, 2023
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 16, 2023
  4. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Jun 16, 2023
  5. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 16, 2023
Jun 16, 202212 citationsCycle 3worst K · immediate jeopardy
  1. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Jul 28, 2022
  2. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Jul 28, 2022
  3. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Jul 28, 2022
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jul 28, 2022
  5. F880Provide and implement an infection prevention and control program.Infection ControlK · patternCorrected Jul 28, 2022
  6. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jul 28, 2022
  7. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Jul 28, 2022
  8. F887Educate 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.Infection ControlD · isolatedCorrected Jul 28, 2022
  9. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jul 28, 2022
  10. F578Honor 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.Resident RightsD · isolatedCorrected Jul 28, 2022
  11. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jul 28, 2022
  12. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 28, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.06hrsAbove 55% of peers+0.11 vs OR avg
  • Registered nursesRN hours only0.47hrsAbove only 25% of peers−0.21 vs OR avg
  • Licensed practical nursesLPN hours1.01hrs
  • Nurse aidesCNA hours3.58hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.66hrs
  • Oregon average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is betterOR avg 49%
  • RN turnoverRegistered nurses onlyNot ranked by CMS
  • Administrators who leftIn the past year
  • Occupancy112 certified beds · ~65 residents a day58%Above only 31% of peersOR avg 69%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $35,714In fines
  • 1Fine
  • 0Payment denials
  • $32,647OR avg in fines
Above only 29% of peersFewer fines than 29% of rated homes in Oregon

Actions on record

  1. Apr 18, 2025Civil money penalty$35,714

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Sapphire Health Services8 facilities in the chain1.8★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Andy Becker
  • Lisa Hilty
  • Bryan Morris
  • Kevin Ricker
Operational or managerial control
  • Andy Becker
Corporate officers
  • Tyler Nelson

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 385272 · 14145 SW 105TH AVENUE, TIGARD, OR, 97224.
  • Percentiles compare this facility with every rated nursing home in Oregon and Washington County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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