Inspection Reports for The Pearl at Kruse Way
4550 SW Carman Drive Lake, Oswego, OR 97035, OR, 97035
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Inspection Report
Capacity: 74
Deficiencies: 27
Nov 21, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with deficiency history and licensing violations.
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failures in medication administration, staffing shortages, inadequate care planning, infection control lapses, and environmental cleanliness issues. Several deficiencies were not corrected at follow-up visits, indicating ongoing compliance challenges.
Deficiencies (27)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0628 - Discharge Process: Failure to notify the Office of the State Long-Term Care Ombudsman of resident transfers or discharges. |
| F0761 - Label/Store Drugs and Biologicals: Expired medications found in OTC medication storage room. |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0684 - Quality of Care: Failure to follow physician orders for bowel care and medication administration, placing residents at risk. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failure to assess and monitor pressure ulcers appropriately. |
| M0183 - Nursing Services: Minimum CNA Staffing: Failure to maintain minimum CNA staffing ratios on multiple days. |
| F0552 - Right to be Informed/Make Treatment Decisions: Failure to notify resident of medication changes timely. |
| F0655 - Baseline Care Plan: Failure to provide baseline care plan summaries to residents. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to ensure proper food labeling, storage, and staff hygiene. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to follow resident care plans to prevent accidents and falls. |
| F0698 - Dialysis: Failure to maintain coordinated dialysis care and provide necessary supplies and training. |
| F0725 - Sufficient Nursing Staff: Failure to provide sufficient nursing staff to meet residents' needs. |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Lack of system for conducting annual CNA performance reviews. |
| F0732 - Posted Nurse Staffing Information: Incomplete and inaccurate Direct Care Staff Daily Reports. |
| F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt: Failure to develop and implement an effective QAPI program. |
| F0880 - Infection Prevention & Control: Failure to ensure appropriate hand hygiene procedures by staff. |
| F0947 - Required In-Service Training for Nurse Aides: Failure to ensure CNA staff received required annual in-service training. |
| M0141 - Employees Reference Checks and Verifications: Failure to complete reference checks for multiple staff. |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failure to provide RN coverage for minimum required hours on multiple days. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failure to maintain clean environment and address missing personal items timely. |
| F0656 - Develop/Implement Comprehensive Care Plan: Failure to develop comprehensive care plan for resident activities. |
| F0657 - Care Plan Timing and Revision: Failure to update care plan for new diagnosis of UTI. |
| F0609 - Reporting of Alleged Violations: Failure to report allegation of neglect within required timeframe. |
| F0661 - Discharge Summary: Failure to complete discharge summaries for discharged residents. |
| F0842 - Resident Records - Identifiable Information: Failure to ensure accurate documentation in medical records. |
Report Facts
Inspections on page: 10
Total deficiencies: 33
Licensing violations: 10
Total surveys: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | DNS | Named in multiple findings related to quality of care, staffing, infection control, and oversight |
| Staff 10 | Staffing Coordinator | Named in staffing deficiency findings |
| Staff 4 | Regional RN / Former DNS / LPN | Named in medication and care plan related findings |
| Staff 21 | CNA | Named in fall and care plan supervision deficiencies |
| Staff 8 | CNA | Named in in-service training and dialysis care deficiencies |
| Staff 3 | DNS | Named in notification and monitoring deficiencies |
| Staff 5 | CMA | Named in infection prevention deficiency |
| Staff 33 | LPN | Named in dialysis care deficiency |
| Staff 30 | Staffing Coordinator | Named in CNA staffing deficiency |
| Staff 26 | RNCM | Named in dialysis care deficiency |
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