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On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 45 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare Special Focus status indicates a history of serious quality problems and heightened oversight. Review the latest inspection records, ask what corrective actions remain open, and visit in person before deciding.
Tigard Rehabilitation and Care presents a highly polarized experience for families, with reviews oscillating between praise for specific staff members during recovery stays and severe allegations of neglect. While some families report positive outcomes and attentive care, multiple reviewers consistently cite dangerous delays in call-light response times, poor hygiene, and inadequate communication regarding patient needs. Potential residents and their families should be aware of these significant inconsistencies in care quality and staffing reliability.
Quality Themes
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Concerns
Rating Trends
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Distribution · 51 analyzed
This facility actively engages with reviewer feedback.
Personalized based on this facility's data
Key Review Excerpts
“My girlfriend who had a stroke and was staying for physical and occupational therapy. When she called for help to the restroom, she was made to wait 40 mjnutes on several occassions. The cleaning staff must have been cut,it was dirty and smelled.”
“She was left in her bed for 5 days with only 1 visit from PT. She was expected to wear a diaper and go in it instead of being helped to a bedside commode because there hadn't been PT approval.”
“The staff kept in touch with me & fortunately were willing & able to fill in all the gaps left by the less than stellar hospice company we initially hired.”
RN hours are below the EveryPlace reference benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
6
measures
5
measures
Residents whose walking got worse
Residents on anti-anxiety or sleep medication
Residents who lost too much weight
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents with pressure sores (bedsores)
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility shows a concerning pattern of recurring deficiencies, particularly around patient safety and abuse prevention, with families filing numerous complaints that triggered inspections. The most frequent problems involve proper treatment and care delivery, nursing staff competency and training, and emergency preparedness/safety systems. While all deficiencies have been corrected, the pattern of repeated issues across multiple surveys and the high number of complaint-triggered inspections (36 out of 74 total deficiencies) suggests ongoing operational challenges families should carefully evaluate.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
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.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Federal Penalties
Fine
May 11, 2026
$14,175
Fine
May 11, 2026
$19,620
Fine
Apr 18, 2025
$35,714
Tigard Rehabilitation and Care
for profit
Sapphire Health Services
8 facilities nationwide
Chain avg rating: 1.8/5 · Rank 8 of 8 (Lowest rating)
Owners
Becker, Andrew
Owner
Hilty, Lisa
Owner
Morris, Bryan
Owner
Ricker, Kevin
Owner
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
45 reviews from families & visitors
Official Website
Visit sapphireattigardrehab.com
Medicare data downloads
Original nursing home datasets
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