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
Date: 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)
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
Date: 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)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 6
Date: 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)
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
Date: 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)
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
Date: 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)
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
Date: 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)
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
Date: 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)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 74
Deficiencies: 10
Date: 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)
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
Date: 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)
M0000 - Initial Comments
Inspection Report
Capacity: 74
Deficiencies: 1
Date: 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)
M0000 - Initial Comments
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