Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tigard Rehabilitation And Care during CMS and state inspections, most recent first.
A resident admitted with heart failure and diabetes was found to have a blister on the left knee during the admission assessment. Although the care plan noted impaired skin integrity, staff did not implement monitoring or complete further assessments of the wound, and the required documentation and alert charting were not initiated.
A resident with osteomyelitis developed new pressure ulcers that were not comprehensively assessed or treated in a timely manner. After a CNA reported an open sore, an LPN cleaned and covered the wound but did not measure it, obtain provider orders, or document treatment. Wound care orders and comprehensive assessment were delayed by two days, and wound care was not provided until the following day, contrary to facility protocol and national guidelines.
The facility did not maintain accurate records or account for all controlled drugs, resulting in missing narcotic medication for two residents. Staff interviews confirmed knowledge of the missing medication, but the facility was unable to determine its whereabouts, indicating a failure to follow required procedures for reconciling and documenting controlled substances.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to monitor refrigerator temperatures and label food items properly, risking foodborne illnesses. Observations showed that temperatures were recorded only once, and food items lacked dates or names. Staff interviews revealed a lack of awareness and adherence to the facility's policy, leading to the deficiency.
A resident with limited English proficiency was not provided with important documents in their preferred language, Spanish, despite needing an interpreter. This included critical documents like POLST and Medicare notices. Staff confirmed the resident's language needs, but the facility failed to ensure communication was in a language the resident could understand.
The facility did not deliver resident mail on Saturdays, contrary to its policy requiring mail delivery within 24 hours, including weekends. Residents reported this issue during a council meeting, and the Activities Director confirmed that mail was only distributed Monday through Friday. The Administrator acknowledged that mail should be delivered on the same day it arrives.
A facility failed to create a comprehensive care plan for a resident with diabetes and chronic suicidal ideation. Despite assessments and progress notes indicating mood issues, depression, and behavioral problems, these concerns were not included in the care plan. Staff interviews revealed a lack of awareness and monitoring of the resident's mood, with some staff acknowledging the resident's expressions of wanting to die. The DNS expected these issues to be addressed, but the Social Services Director did not perceive them as significant enough for the care plan.
A resident with a diabetic foot ulcer and venous ulcers did not receive timely wound care upon admission. Despite being aware of the wounds, the facility failed to obtain treatment orders for over a month, leading to a delay in care. This oversight was confirmed by staff, highlighting a significant lapse in the facility's wound management protocol.
A resident with malnutrition and type 1 diabetes experienced significant weight loss, dropping from an average of 205.5 pounds to 174.6 pounds. Despite this, the facility delayed a reweigh and did not implement new nutritional interventions or review the resident in the Nutritional at Risk group in a timely manner. The RD acknowledged these delays, which placed the resident at risk for continued weight loss.
The facility did not conduct annual performance reviews for four CNAs, as confirmed by the DNS and Staffing Coordinator. This oversight placed residents at risk of receiving care from potentially incompetent staff.
A facility failed to ensure resident dignity and respect when a verbal altercation between two residents resulted in one resident spitting in the other's face. The incident, witnessed by staff, occurred over a borrowed wheelchair. Despite one resident's denial, staff confirmed the spitting incident, and both residents were placed on safety monitoring.
A resident with a history of inappropriate sexual behavior was found with their hand inside another resident's brief while the latter was asleep. Both residents had severe cognitive impairments, and the incident was witnessed by a staff member. The facility's records indicated prior knowledge of the offending resident's behavior, yet the incident occurred, placing residents at risk for repeat abuse.
A facility failed to provide wound care for a diabetic resident as per physician orders. The resident's orders required specific wound care procedures, including cleaning, applying AD ointment, and securing with bordered foam, to be performed three times weekly. However, no wound care was documented for over two weeks, as confirmed by the DNS.
Failure to Monitor Non-Pressure Skin Wound
Penalty
Summary
The facility failed to monitor a non-pressure skin wound for one resident who was admitted with diagnoses including heart failure and diabetes. Upon admission, a clinical progress note documented redness and a small healing blister on the resident's front left knee. The care plan identified impaired skin integrity due to the blister and immobility. However, a review of the medical record and treatment administration record (TAR) showed no assessment or monitoring of the wound during the resident's stay. Staff confirmed that although the blister was identified during the admission assessment, monitoring was not implemented, and no further assessments were completed. Facility leadership stated that the expected protocol for skin impairments was not followed, as the blister was not documented for ongoing monitoring or alert charting.
Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified pressure ulcer wounds were comprehensively assessed and that wound care orders were obtained and implemented for a resident with a diagnosis of osteomyelitis of the vertebrae. After admission, a CNA notified an LPN of an open sore on the upper part of the resident's buttock. The LPN observed, cleaned, and covered the wound, and initiated a Skin Integrity Report, but did not measure the wound, obtain provider orders, document wound treatment, or initiate any wound care protocol on the Treatment Administration Record (TAR) at that time. There was no evidence in the health record of a comprehensive wound assessment, including measurement, location, stage, or other characteristics, between the initial identification of the wound and two days later. Wound care orders were not obtained until two days after the wound was first identified, and wound care was not provided until the following day. The Director of Nursing Services confirmed that the wound was not comprehensively assessed and measured until two days after it was first identified, and that there was no evidence of wound care being provided during that period. This lapse in timely assessment and intervention did not follow the facility's protocol or national guidelines for pressure ulcer care.
Failure to Maintain Accurate Narcotic Drug Records
Penalty
Summary
The facility failed to ensure that narcotic drug records were properly maintained and that an accurate account of all controlled drugs was kept for one of three narcotic books reviewed. According to the facility's policy, nursing staff are required to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses reconciling and documenting the count, and reporting any discrepancies to the Director of Nursing Services (DNS). However, a review of records revealed that narcotic medication for two residents was missing and unaccounted for, and the facility was unable to determine what happened to the missing medication. Staff interviews confirmed awareness of the missing narcotic medication but did not provide information on its whereabouts. The deficiency was identified when a former DNS discovered two missing narcotic cards during a review of the facility's narcotic books. Subsequent investigation and staff interviews indicated that the required procedures for reconciling and documenting controlled substances were not followed, resulting in the loss of narcotic medication. The lack of proper record-keeping and reconciliation placed residents at risk for drug diversion.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor and Label Food Storage
Penalty
Summary
The facility failed to ensure proper monitoring and labeling of food storage in two refrigerators, which placed residents at risk for potential foodborne illnesses. Observations revealed that the refrigerator used to store resident food items in the dining room had a temperature log, but temperatures were only recorded once on 1/10/25. Additionally, food items in the refrigerator were found without dates or names. Staff interviews indicated a lack of awareness and adherence to the facility's policy, which required daily temperature checks and proper labeling of food. The Dietary Manager was unaware of the monitoring process for the resident foods refrigerator, and a CNA was unsure of the labeling policy. This lack of compliance with the facility's policy led to the deficiency.
Failure to Provide Language-Appropriate Communication
Penalty
Summary
The facility failed to ensure that a resident, who primarily spoke Spanish and required an interpreter, received communication in a language they could understand. The resident was admitted with a diagnosis of diabetes and had a care plan indicating a preference for Spanish. Despite this, several important documents, including Portable Orders for Life-Sustaining Treatment (POLST), Notices of Medicare Non-Coverage, and SNF Discharge Instructions, were provided to the resident in English only. Interviews with staff confirmed the resident's limited English proficiency and the need for translation services, yet the facility did not provide documents in Spanish, leading to a lack of involvement in the resident's care.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that resident mail was delivered on Saturdays, as required by their Mail and Electronic Communication policy revised in 2017. This policy mandates that mail and packages be delivered to residents within twenty-four hours of delivery to the premises, including Saturdays. During a resident council meeting, residents reported that their mail was not delivered on Saturdays. Staff 20, the Activities Director, confirmed that mail was only delivered to residents from Monday through Friday, and any mail received on Saturdays was not distributed until the following Monday. Staff 1, the Administrator, acknowledged that resident mail should be delivered on the same day it arrives at the facility.
Failure to Develop Comprehensive Care Plan for Resident with Mood Issues
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident admitted with diagnoses including diabetes and chronic suicidal ideation. Despite multiple assessments and progress notes indicating the resident's mood issues, including depression, suicidal ideation, and behavioral problems such as yelling and combativeness, the facility did not include these concerns in the resident's care plan. Interviews with staff revealed a lack of awareness and monitoring of the resident's mood and behaviors, with some staff members acknowledging the resident's expressions of wanting to die and feelings of helplessness. The Director of Nursing Services expected mood and behavior issues to be addressed in the care plan, yet the Social Services Director did not perceive the resident's mood issues as significant enough to warrant inclusion in the care plan. This oversight placed the resident at risk for unmet needs, as there was no structured plan to monitor or address the resident's mental health and behavioral issues, despite the resident's history and ongoing expressions of distress.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with multiple wounds, including a diabetic foot ulcer and venous ulcers, upon admission. The resident was admitted with a known right foot ulcer, but daily skilled evaluations from early October to early November did not include assessments of this ulcer. Additionally, physician progress notes during this period did not address the ulcer. A skin check assessment in late November revealed additional venous ulcers on the resident's left leg, which were reportedly present since admission, yet no treatment orders were in place. It was not until late November that the facility requested and obtained orders for wound care for the resident's right foot ulcer and newly identified wounds on the left lower extremity and buttocks. Staff confirmed that the facility was aware of the wounds upon admission but failed to secure treatment orders until over a month later. This oversight placed the resident at risk for worsening wounds due to the lack of timely and appropriate care.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was properly assessed after significant weight loss was identified. Resident 34, who was admitted with diagnoses including malnutrition and type 1 diabetes, experienced a notable weight loss from an average of 205.5 pounds to 174.6 pounds over a period of time. Despite the identification of this weight loss on 9/23/24, a reweigh was not conducted until 10/7/24, two weeks after the initial request. During this period, no new nutritional interventions were implemented, and the resident was not reviewed by the Nutritional at Risk (NAR) group until 10/22/24, which was three days after readmission from a hospital stay related to diabetes. Staff 13, the Registered Dietitian (RD), acknowledged that the reweigh recommendation was not completed in a timely manner and that the resident was not reviewed in the NAR group within the expected timeframe. This delay in assessment and intervention placed the resident at risk for continued weight loss. Observations made in January 2025 indicated that the resident was capable of feeding themselves and consumed 100% of their meals, suggesting that earlier intervention might have been beneficial.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, as evidenced by the lack of performance reviews for four randomly selected CNA staff members. On January 14, 2025, the Director of Nursing Services (DNS) was unable to provide the requested performance reviews for the identified CNAs. The following day, the Staffing Coordinator acknowledged that no performance reviews had been completed for these staff members. This deficiency placed residents at risk for receiving care from potentially incompetent staff.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by an incident involving two residents. Resident 2, who was admitted to the facility with hyperlipidemia, was involved in a verbal altercation with Resident 1, who had chronic systolic heart failure. The altercation occurred in the facility parking lot when Resident 2 requested the return of a spare wheelchair borrowed by Resident 1. During the altercation, Resident 1 was observed spitting in the face of Resident 2, which was confirmed by multiple staff witnesses. Staff 3 and Staff 4, who witnessed the incident, intervened to separate the residents and ensure their safety. Resident 2 expressed feeling offended and disrespected by the incident but declined a physical assessment, stating no injuries were sustained. Despite Resident 1's denial of spitting, both staff members confirmed the act occurred. The incident was documented in a Facility Reported Incident, and both residents were placed on safety monitoring to prevent further occurrences.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents with severe cognitive impairments. Resident 1, who has a history of trauma related to domestic violence, was found to have been sexually abused by Resident 2, who has a history of inappropriate sexual behavior. On the evening of April 29, 2024, Resident 2 was discovered with their hand inside Resident 1's brief while Resident 1 was asleep. This incident was witnessed by a staff member, who observed Resident 2 exposing Resident 1's right hip and buttocks. The facility's records indicated that Resident 2 had been previously identified with inappropriate sexual behavior, yet was able to access Resident 1's room and engage in the abusive act. The incident was reported to the police, and it was acknowledged by the facility's administrator and director of nursing services. The failure to prevent this incident placed residents at risk for potential repeat sexual abuse incidents.
Failure to Provide Diabetic Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care treatment according to physician orders for a resident with a diabetic wound. The resident, admitted in May 2023 with a diagnosis of diabetes, had specific physician orders dated October 10, 2023, for the care of a diabetic wound on the right toe. The orders required the wound to be cleaned with wound cleanser, a thin layer of AD ointment to be applied to the wound and periwound, and the wound to be secured with bordered foam. The dressing was to be changed three times per week and as needed. However, a review of the resident's October 2023 Treatment Administration Record (TAR) revealed that no wound care was documented as being performed from October 11, 2023, through October 27, 2023. This lapse in care was confirmed by Staff 2, the Director of Nursing Services (DNS), on April 10, 2024, indicating a failure to adhere to the prescribed wound care regimen.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 453 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tigard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of King City | 1.3 mi | — | 13 | 0 |
| Marquis Tualatin Post Acute Rehab | 3.1 mi | — | 0 | 0 |
| Pearl At Kruse Way, The | 3.4 mi | — | 3 | 0 |
| Beaverton Post Acute Care Of Cascadia | 4 mi | — | 1 | 0 |
| West Hills Health & Rehabilitation | 4.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Tigard Rehabilitation And Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.