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)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
154% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
36
27
18
9
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
Deficiencies: 2
Date: Nov 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications and medication storage practices.
Findings
The facility failed to notify the Office of the State Long Term Care Ombudsman when residents were transferred to the hospital or discharged, and failed to discard expired medications in the medication storage room, placing residents at risk.
Deficiencies (2)
F 0628: The facility failed to notify the Office of the State Long Term Care Ombudsman when residents transferred to the hospital or were discharged for 2 of 4 sampled residents. This placed residents at risk of not receiving assistance from the Ombudsman.
F 0761: The facility failed to discard expired medications in the medication storage room, including laxatives and antacids expired several months prior. This placed residents at risk for lack of medication efficacy.
Report Facts
Expired medication bottles: 8
Residents sampled for hospitalization and discharge notification: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 10 | Social Services Director | Acknowledged failure to send notice of transfers to LTCO |
| Staff 4 | Former DNS | Acknowledged requirement to notify LTCO and lack of system to implement it; acknowledged expired medications issue |
| Staff 9 | CMA | Acknowledged expired medications in OTC storage room |
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
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to follow physician orders for bowel care and failure to assess and monitor pressure ulcers for a sampled resident.
Complaint Details
The visit was complaint-related, investigating allegations that the facility failed to provide appropriate bowel care and pressure ulcer monitoring for a resident. The deficiencies were substantiated as the facility did not follow orders or properly assess wounds.
Findings
The facility failed to implement ordered bowel care for one resident, resulting in prolonged constipation without administration or refusal documentation of bowel medications. The facility also failed to properly assess, stage, measure, and monitor pressure ulcers for the same resident, with no wound pictures taken and care plans not updated until after the resident was discharged.
Deficiencies (2)
F 0684: The facility failed to follow physician orders and implement bowel care for one resident, resulting in no bowel movements for multiple days without administration or refusal of ordered bowel medications.
F 0686: The facility failed to assess and monitor pressure ulcers for one resident, including lack of wound staging, measurements, photographs, and timely care plan updates.
Report Facts
Days without bowel movement: 6
Days without bowel movement: 5
Days delay in pressure ulcer investigation: 81
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 2, 2024
Visit Reason
The inspection was conducted to investigate complaints related to medication management, care planning, medication administration timeliness, medication security, and food safety practices at the facility.
Complaint Details
The investigation was complaint-driven, focusing on medication management, care planning, medication administration, medication security, and food safety. The complaints were substantiated with findings of minimal harm or potential for harm affecting some or few residents.
Findings
The facility failed to notify a resident of medication changes, did not provide baseline care plans to sampled residents, failed to ensure timely medication administration for multiple residents, left medication and treatment carts unsecured, and did not properly label or store food or enforce proper hygiene and hair restraint use among kitchen staff.
Deficiencies (5)
F 0552: The facility failed to notify Resident 19 of a medication change in Citalopram dosage, delaying communication until four days after the dose was reduced.
F 0655: The facility failed to provide baseline care plans to 5 of 5 sampled residents, placing them at risk of being uninformed of their plan of care.
F 0684: The facility failed to ensure physician medication orders were followed timely for 4 of 8 sampled residents, resulting in multiple late medication administrations.
F 0761: The facility failed to secure medications properly, leaving one medication cart and one treatment cart unlocked and unattended.
F 0812: The facility failed to ensure food was labeled and stored properly, discarded expired food, and enforce proper hand hygiene and hair restraints among kitchen staff.
Report Facts
Medication administration delays: 7
Medication administration delays: 4
Medication administration delays: 4
Medication administration delays: 5
Medication administration delays: 6
Medication administration delays: 4
Medication administration delays: 1
Medication administration delays: 3
Medication administration delays: 7
Medication administration delays: 3
Medication administration delays: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Director of Nursing (DNS) | Confirmed medication administration delays, lack of communication with Resident 19, and medication cart security issues. |
| Staff 3 | RN | Confirmed treatment cart contained insulin and was supposed to be locked. |
| Staff 4 | Executive Chef | Acknowledged food storage and labeling deficiencies. |
| Staff 8 | CNA | Verified improper food storage and labeling in unit refrigerator. |
| Staff 3 | Dietary Manager | Verified staff were not using gloves and hair restraints properly. |
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
Deficiencies: 2
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration and accident prevention in the nursing home.
Findings
The facility failed to administer the correct medication dose to one resident, resulting in sub-therapeutic dosing. Additionally, the facility did not follow the care plan for another resident, leading to a fall due to inadequate supervision.
Deficiencies (2)
F 0684: The facility failed to administer the prescribed dose of metoprolol to Resident 3, who received 25 mg instead of 50 mg from 12/15/23 through 1/8/24.
F 0689: The facility failed to follow Resident 5's care plan by leaving the resident alone in a wheelchair, resulting in a fall when the resident attempted to self-transfer.
Report Facts
Residents sampled: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional RN | Staff 4 verified medication dosing error and fall incident |
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
Deficiencies: 5
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident care, staffing, and performance reviews at the nursing home.
Complaint Details
The visit was complaint-related, investigating issues including fall risk care plan noncompliance, dialysis care coordination, staffing shortages, lack of CNA performance reviews, and incomplete staffing reports. Substantiation status is not explicitly stated.
Findings
The facility failed to follow the care plan for a resident at risk for falls, did not maintain a coordinated plan of care for a resident requiring dialysis, lacked sufficient nursing staff to meet resident needs, failed to conduct annual performance reviews for CNA staff, and did not ensure complete nurse staffing daily reports.
Deficiencies (5)
F 0689: The facility failed to follow the plan of care for Resident 413, resulting in a minor injury fall when staff left the resident unsupervised in the bathroom.
F 0698: The facility failed to maintain a coordinated plan of care for Resident 6 requiring dialysis, leading to risks of unmet nutritional needs and lack of coordinated transportation.
F 0725: The facility failed to provide sufficient nursing staff for 3 sampled residents, resulting in long call light response times and unmet ADL care needs.
F 0730: The facility failed to have a system for conducting annual performance reviews for CNA staff, placing residents at risk for lack of quality care.
F 0732: The facility failed to ensure Direct Care Staff Daily Reports were complete for 27 out of 39 sampled days, risking incorrect staffing information.
Report Facts
Residents requiring mechanical lift: 4
Residents requiring two staff for transfers: 2
Call light delay instances for Resident 48: 67
Call light delay instances for Resident 2: 13
Call light delay instances for Resident 19: 27
Days with incomplete staffing reports: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 21 | CNA | Named in fall care plan noncompliance resulting in minor injury fall |
| Staff 2 | DNS (Director of Nursing Services) | Verified fall injury and acknowledged staffing concerns and lack of CNA performance reviews |
| Staff 25 | Culinary Director | Interviewed regarding dialysis transportation and lunch coordination |
| Staff 26 | RNCM | Interviewed regarding dialysis lunch provision and communication |
| Staff 4 | LPN | Reported short staffing and workload concerns |
| Staff 5 | CMA | Reported times with no nurses working in the facility |
| Staff 11 | CNA | Reported call light delays and staffing challenges |
| Staff 12 | CNA | Reported staffing shortages and call light delays |
| Staff 10 | Staffing Coordinator | Acknowledged staffing based on census and incomplete staffing reports |
| Staff 8 | CNA | Had no annual performance review documentation |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jul 14, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to implement timely systems for missing personal items, inadequate environmental cleanliness, incomplete and outdated care plans, failure to follow fall prevention plans, insufficient dialysis care coordination, inadequate staffing levels, lack of annual CNA performance reviews and in-service training, incomplete nurse staffing documentation, failure to conduct ongoing quality assurance activities, and lapses in infection control hand hygiene practices.
Deficiencies (12)
F 0584: The facility failed to implement a timely system to address missing personal items for a resident, placing them at risk for loss of property.
F 0584: The facility failed to maintain a clean and homelike environment for multiple residents, including unclean bathrooms and damaged flooring.
F 0656: The facility failed to develop a comprehensive care plan addressing a resident's activities of interest, risking decreased participation.
F 0657: The facility failed to update the care plan within 7 days for a resident diagnosed with a urinary tract infection, risking unmet needs.
F 0689: The facility failed to follow the fall care plan for a resident, resulting in a minor injury fall due to staff leaving the resident unsupervised.
F 0698: The facility failed to maintain coordinated dialysis care, risking lack of transportation and unmet nutritional needs for a resident.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in long call light response times and unmet ADL care.
F 0730: The facility failed to conduct annual performance reviews for CNA staff, risking lack of quality care.
F 0732: The facility failed to post complete nurse staffing information daily, with many days missing CNA or RN hours.
F 0865: The facility failed to develop and implement a Quality Assessment and Assurance program with ongoing meetings and action plans.
F 0880: The facility failed to ensure staff followed proper hand hygiene procedures during direct patient care, risking infection spread.
F 0947: The facility failed to ensure CNA staff received required annual in-service training, risking lack of quality care.
Report Facts
Call light response delays: 67
Call light response delays: 13
Call light response delays: 27
Days with incomplete staffing reports: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 21 | CNA | Named in findings related to failure to follow fall care plan and missing personal items system. |
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged staffing concerns, lack of annual CNA performance reviews, incomplete staffing reports, and QAPI meeting gaps. |
| Staff 8 | CNA | Reviewed for lack of annual performance review and in-service training documentation. |
| Staff 14 | Housekeeping Manager | Acknowledged unclean resident bathrooms and lack of cleaning documentation. |
| Staff 15 | Maintenance Director | Reported reliance on staff for maintenance requests and waiting on bids for repairs. |
| Staff 26 | RN Care Manager (RNCM) | Acknowledged lack of care plan for UTI and dialysis lunch notification system. |
| Staff 10 | Staffing Coordinator | Acknowledged incomplete staffing documentation and CNA staff sent home without ensuring coverage. |
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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