The Vardell Report.Tigard Rehabilitation and Care

Across 9 inspections from August 2023 to May 2026, state surveyors documented 44 findings at Tigard Rehabilitation and Care; 44 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

9

2023–2026, standard and complaint

Findings

44

Deficiencies cited by state inspectors

Corrected

44

Of 44 findings, with a recorded correction date

Penalties

3

3 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. May 112026

   Standard health inspection

   13 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level KImmediate jeopardyCorrected May 9, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 9, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 18, 2026
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected May 18, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 18, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected May 18, 2026
   • 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.Level DNo actual harm, potential for moreCorrected May 18, 2026

   Enforcement Action

   Civil money penalty, $9,214 imposed May 11, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 11, 2026, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $12,753 imposed May 11, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 11, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Nov 172025

   Complaint investigation

   3 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 17, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 17, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 1, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jul 182025

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 20, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jan 172025

   Standard health inspection

   7 findings

   The same visit included a complaint investigation.

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 3, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Mar 3, 2025
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Mar 3, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 3, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 3, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 3, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Mar 3, 2025

   Enforcement Action

   Civil money penalty, $35,714 imposed April 18, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 17, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Oct 102024

   Complaint investigation

   1 finding

   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Nov 5, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. May 32024

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jun 4, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Apr 112024

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 14, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Dec 112023

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jan 16, 2024
   • F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Jan 16, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Aug 112023

   Standard health inspection

   15 findings

   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Sep 19, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 19, 2023
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Sep 19, 2023
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Sep 19, 2023
   • 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.Level ENo actual harm, potential for moreCorrected Sep 19, 2023
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Sep 19, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 19, 2023
   • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Sep 19, 2023
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Sep 19, 2023
   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Sep 19, 2023
   • 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.Level DNo actual harm, potential for moreCorrected Sep 19, 2023
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Sep 19, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 19, 2023
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 19, 2023
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 19, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Five Inspections

   Inspectors cited F684 in August 2023, April 2024, January 2025, November 2025 and May 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F684 across all 9 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in August 2023, December 2023 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F689 across all 9 inspections, oldest to newest
3. 3

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in August 2023, January 2025 and May 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F812 across all 9 inspections, oldest to newest
4. 4

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in May 2024 and July 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F600 across all 9 inspections, oldest to newest
5. 5

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in January 2025 and May 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F656 across all 9 inspections, oldest to newest
6. 6

   Citation F730, Cited in Two Inspections

   Inspectors cited F730 in August 2023 and January 2025. The agency describes it this way: Observe each nurse aide's job performance and give regular training. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F730 across all 9 inspections, oldest to newest
7. 7

   Medical Records, Cited in Two Inspections

   Inspectors cited F842 in August 2023 and May 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F842 across all 9 inspections, oldest to newest
8. 8

   Infection Control, Cited in Two Inspections

   Inspectors cited F880 in August 2023 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232324242425252526F880 across all 9 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in five inspections, most seriously at level D.

2. 02

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in three inspections, most seriously at level J.

3. 03

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

4. 04

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.

5. 05

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level D.

6. 06

   What changed after F730 was cited, and how do you check it now?

   Citation F730: cited in two inspections, most seriously at level F.

7. 07

   How can a family request a resident’s records, and how are they kept accurate?

   Medical Records: cited in two inspections, most seriously at level D.

8. 08

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level K.

9. 09

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

10. 10

    What led to the 2026 fine, and has it been paid?

    A $9,214 civil money penalty was imposed May 11, 2026. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Aug 11, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Dec 11, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Apr 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection May 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Oct 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Jan 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Jul 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Nov 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection May 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 385272

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.