Overall sentiment across the reviews is highly mixed and polarized. A recurring theme is that the facility has pockets of excellent individual caregivers and leaders who deliver compassionate, competent care, but these positives exist alongside systemic problems with cleanliness, staffing, and administration that seriously undermine resident safety and quality of life. Many reviewers explicitly praise named staff and teams (Cheryl, Nurse Mike/Michael, Jennifer in Social Services, Debbie the activities director, Alex) for professionalism, communication, and going above and beyond. Several families reported that communication was strong, management was accessible, and therapy staff helped patients recover, producing positive outcomes and satisfied residents in these cases.
At the same time, numerous reviews describe severe and recurring cleanliness and infection-control problems. Complaints include filthy bathrooms, urine and feces left on toilets, walkers, and portable commodes, trash and used gauze with blood left in rooms, and a persistent old-building odor or poor ventilation. Multiple reviewers linked hygiene problems to actual health risks: delayed cleanups, denied showers during COVID isolation, and at least one reported COVID infection acquired at the facility. These reports suggest inconsistent or inadequate housekeeping and infection-prevention practices in parts of the facility.
Care quality and responsiveness are similarly inconsistent. Many reviewers praised attentive caregivers and helpful nursing staff, but an equal or larger number reported unresponsive staff, especially on night shifts, slow call-light responses, and situations where patients were left in bed for days with minimal care. There are multiple accounts of delayed or withheld pain medications, medication errors, and in one or more reports, alleged medication theft. Several families described instances where bedside needs were deprioritized in favor of room cleanup or other tasks, contributing to perceptions of neglect.
Staffing and management emerge as central drivers of the mixed experience. Reports indicate high staff burnout, overwork, and frequent shift problems that translate into inconsistent care. Some reviews explicitly blame administrative decisions (removal of medication aides, poor scheduling) for reduced care quality and dangerous conditions. Conversely, other reviews single out administrators and managers for praise, describing accessible leadership that communicates well and supports families. This contrast suggests variability over time or between different units/shifts, with strong frontline employees mitigating but not fully compensating for systemic staffing and organizational issues.
Safety and ethics concerns are among the most serious patterns. Beyond cleanliness and medication problems, reviewers allege food theft, residents' meals being taken, verbal abuse by supervisory staff (DNS), and even calls for license revocation. Such allegations, if substantiated, are severe and point to lapses in oversight, employee vetting, inventory controls, and workplace culture. Several reviewers urged caution, referencing inspection concerns and warning prospective families to monitor closely.
Dining and activities receive mixed feedback. Multiple reviewers describe meals as dry, cold, or of low quality, with instances of residents’ food taken or missing. In contrast, activities — led in at least one account by a well-regarded director — are a bright spot, providing engagement like daily puzzles that families appreciated. Rehab and therapy services are also noted as effective in many cases, supporting recovery for some residents.
In summary, Sapphire at Tigard Rehab appears to deliver excellent, compassionate care from many individual staff members and teams, with particular strengths in communication, certain administrative leaders, therapy/rehab services, and activities. However, serious and recurring concerns about facility cleanliness, infection control, inconsistent staffing and responsiveness, medication handling, possible theft or abuse, and uneven management practices create significant risk and dissatisfaction for other families. The reviews suggest a facility that can be very good when staffed and managed well, but that also has systemic vulnerabilities that can lead to neglectful or unsafe conditions. Prospective residents and families should conduct careful, repeated on-site evaluations, ask about staffing levels (including night coverage), infection-control and housekeeping protocols, medication and food-control procedures, and speak with current families and named staff. If possible, verify recent inspection reports and monitor care closely after admission; consider alternatives if cleanliness, staffing, or safety systems are not clearly and demonstrably reliable.
