Tigard Rehabilitation and Care

In the surveyor’s words

From the most serious findings on record at Tigard Rehabilitation and Care, in the surveyor’s own words.

• Immediate jeopardy, patternF880May 11, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure the community use glucometer was properly sanitized between resident use for 2 of 2 sampled residents (#s 9 and 53) reviewed for infection control during CBG checks. This failure, determined to be an Immediate Jeopardy (IJ) situation, placed all residents who required CBG checks at significant risk for bloodborne illness. On 5/6/26 the facility was informed of the IJ situation and provided a copy of the IJ template. Findings include:The True Metrix Blood Glucose System manufacturer instructions indicated to disinfect the meter with EPA-registered wipes between each resident. […]

• Immediate jeopardy, patternF880Jun 16, 2022

  Based on observation, interview and record review it was determined the facility failed to properly disinfect a glucometer between resident uses for 1 of 2 sampled residents (#107) reviewed for CBG monitoring. This failure, which was determined to be immediate jeopardy, placed Residents 156, 2, 104 and 155 at risk for [CONDITION(S)] C infection. Findings include: On 6/10/22 at 12:38 PM Staff 3 (RN) used a glucometer (a device used to check CBG levels from a blood sample) from the treatment cart to check Resident 107's CBG. […]

• Immediate jeopardy, isolatedF689May 11, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure foods and fluids were served in a manner to prevent accidental choking for 2 of 3 sampled residents (#s 28 and 30) reviewed for accidents. This failure, determined to be an Immediate Jeopardy situation (IJ), resulted in Resident 30 choking after the resident received food of the wrong texture. This failure also placed other residents at risk for choking and lack of oxygen. It was determined the IJ began on 3/26/26. On 5/6/26 the facility was notified of the IJ situation and was provided a copy of the IJ template. Findings include: a. […]

• Immediate jeopardy, isolatedF686Mar 7, 2022

  Based on interview and record review it was determined the facility failed to ensure a resident received the necessary treatment and services to prevent infection and the worsening of a Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) for 1 of 3 sampled residents (#22) reviewed for pressure ulcers. This failure, which was determined to be immediate jeopardy, resulted in worsening of Resident 22's pressure ulcer and subsequent transfer to the hospital where the resident died from complications related to the worsening of the pressure ulcer. Findings include: Resident 22 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, patternF692Mar 7, 2022

  Based on interview and record review it was determined the facility failed to promptly verify weights, identify and assess when residents' nutritional and hydration intake was less than the residents required needs and/or had an unintended severe weight loss for 6 of 12 sampled residents (#s 1, 2, 9, 10, 22 and 35) reviewed for change in condition, dehydration, weight loss, eating assistance and change in condition. This failure resulted in an unintended severe weight loss for Resident #s 1 and 35, worsening wounds contributing to her/his death for Resident 22 and dehydration for Resident 10. Findings include: 1. […]