Inspection Reports for The Pearl at Kruse Way
4550 SW Carman Drive Lake, Oswego, OR 97035, OR, 97035
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 5
Nov 21, 2025
Visit Reason
Multiple deficiencies including failure to notify Office of the State Long-Term Care Ombudsman on resident discharges and expired medications found in storage.
Findings
Multiple deficiencies including failure to notify Office of the State Long-Term Care Ombudsman on resident discharges and expired medications found in storage.
Deficiencies (5)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0628 - Discharge Process |
| F0761 - Label/Store Drugs and Biologicals |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 2
Jul 29, 2025
Visit Reason
No deficiencies found but citations noted for initial comments.
Findings
No deficiencies found but citations noted for initial comments.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 6
Jan 23, 2025
Visit Reason
Deficiencies related to quality of care, pressure ulcer treatment, CNA staffing, and nursing services with some corrected and some not corrected upon revisit.
Findings
Deficiencies related to quality of care, pressure ulcer treatment, CNA staffing, and nursing services with some corrected and some not corrected upon revisit.
Deficiencies (6)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0684 - Quality of Care |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| M0000 - Initial Comments |
| M0183 - Nursing Services: Minimum CNA Staffing |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 8
Aug 2, 2024
Visit Reason
Multiple deficiencies including failure to inform residents of medication changes, baseline care plan provision, medication storage, food safety, and staffing issues with some corrected and some not corrected upon revisit.
Findings
Multiple deficiencies including failure to inform residents of medication changes, baseline care plan provision, medication storage, food safety, and staffing issues with some corrected and some not corrected upon revisit.
Deficiencies (8)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0552 - Right to be Informed/Make Treatment Decisions |
| F0655 - Baseline Care Plan |
| F0684 - Quality of Care |
| F0761 - Label/Store Drugs and Biologicals |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 5
Jun 27, 2024
Visit Reason
Deficiencies related to medication administration errors, resident safety, and care plan adherence with some corrected and some not corrected upon revisit.
Findings
Deficiencies related to medication administration errors, resident safety, and care plan adherence with some corrected and some not corrected upon revisit.
Deficiencies (5)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0684 - Quality of Care |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 17
Jul 14, 2023
Visit Reason
Numerous deficiencies including safe environment, care planning, staffing, infection control, employee checks, and dialysis care with multiple visits showing some corrections but many deficiencies not corrected.
Findings
Numerous deficiencies including safe environment, care planning, staffing, infection control, employee checks, and dialysis care with multiple visits showing some corrections but many deficiencies not corrected.
Deficiencies (17)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0584 - Safe/Clean/Comfortable/Homelike Environment |
| F0656 - Develop/Implement Comprehensive Care Plan |
| F0657 - Care Plan Timing and Revision |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0698 - Dialysis |
| F0725 - Sufficient Nursing Staff |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service |
| F0732 - Posted Nurse Staffing Information |
| F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt |
| F0880 - Infection Prevention & Control |
| F0947 - Required In-Service Training for Nurse Aides |
| M0000 - Initial Comments |
| M0141 - Employees Reference Checks and Verifications |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff |
| M0183 - Nursing Services: Minimum CNA Staffing |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 2
Jun 29, 2022
Visit Reason
No deficiencies found but citations noted for initial comments.
Findings
No deficiencies found but citations noted for initial comments.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 10
Nov 24, 2021
Visit Reason
Deficiencies related to notification of changes, reporting alleged violations, discharge summaries, quality of care, pressure ulcer treatment, accident hazards, resident records, and nursing services with some corrected and some not corrected upon revisit.
Findings
Deficiencies related to notification of changes, reporting alleged violations, discharge summaries, quality of care, pressure ulcer treatment, accident hazards, resident records, and nursing services with some corrected and some not corrected upon revisit.
Deficiencies (10)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.) |
| F0609 - Reporting of Alleged Violations |
| F0661 - Discharge Summary |
| F0684 - Quality of Care |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0842 - Resident Records - Identifiable Information |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Capacity: 74
Deficiencies: 1
Sep 16, 2021
Visit Reason
No deficiencies found but citation noted for initial comments.
Findings
No deficiencies found but citation noted for initial comments.
Deficiencies (1)
| Description |
|---|
| M0000 - Initial Comments |
Inspection Report
Capacity: 74
Deficiencies: 1
Feb 11, 2021
Visit Reason
No deficiencies found but citation noted for initial comments.
Findings
No deficiencies found but citation noted for initial comments.
Deficiencies (1)
| Description |
|---|
| M0000 - Initial Comments |
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