The Pearl at Kruse Way
4550 Carman Drive, Lake Oswego, OR 97035 · Clackamas County · (503) 675-6055
74 certified beds, about 41 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2006
Certified for Medicaid Certified for Medicare
Overall
4 of 5
Health inspections
4 of 5
Staffing
4 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385271 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on November 21, 2025, inspectors cited 2 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 22 health citations since July 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.64 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 1.15 of those hours.
60.3% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Avamere, an affiliated group of 27 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1107/23
206/24
508/24
201/25
211/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
7E
2F
Potential for minimal harm
0A
0B
0C
November 21, 2025Standard inspection · 2 citations
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, it was determined the facility failed to notify the Office of the State Long Term Care Ombudsman (LTCO) when residents transferred to the hospital or discharged from the facility for 2 of 4 sampled residents (#s 7 and 46) reviewed for hospitalization and discharge. This placed residents at risk for being unable to receive assistance from the LTCO.
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to discard expired medications for 1 of 1 medication storage room reviewed for medication storage. This placed residents at risk for lack of medication efficacy.
January 23, 2025Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and implement bowel care for 1 of 3 sampled residents (#4) reviewed for constipation. This placed residents at risk for medical complications from constipation including bowel impaction.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to assess and monitor pressure ulcers for 1 of 3 sampled residents (#4) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
August 2, 2024Standard inspection · 5 citations
- E Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a summary of the baseline care plan to 5 of 5 sampled residents (#s 19, 124, 125, 130, and 133) reviewed for pain, rehab services and unnecessary medication. This placed residents at risk for being uninformed of their plan of care.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 125, 135, 181, and 228) reviewed for medications. This placed residents at risk for reduced medication efficacy and adverse medication side effects.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure medications were secured and only accessible to authorized persons for 1 of 2 sampled medication carts and 1 of 1 treatment cart reviewed for medication storage. This placed residents at risk for drug diversion.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure food was labeled and stored in a manner to prevent food spoilage, expired food was discarded, staff used appropriate hand hygiene, and staff used hair restraints properly for 1 of 1 kitchen and 1 of 2 unit refrigerators reviewed for food storage and handling. This placed residents at risk for food contamination and food-borne illnesses.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident of a medication change for 1 of 5 sampled residents (#19) reviewed for unnecessary medications. This placed residents at risk for lack of participation in treatment decisions.
June 27, 2024Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to administer medications at the prescribed dose for 1 of 3 sampled residents (#3) reviewed for physician orders. This placed residents at risk to receive a sub-therapeutic dose of medication.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow the resident's plan of care for 1 of 3 sampled residents (#5) reviewed for accidents. This placed residents at risk for falls and injury.
July 14, 2023Standard inspection · 11 citations
- F Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 3 of 3 sampled residents (#s 2, 48 and 162) reviewed for staffing. This placed residents at risk for unmet ADL care needs.
- F Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a Quality Assessment and Assurance (QAA) program that identified quality deficiencies and developed and implemented action plans to correct identified quality deficiencies. The facility failed to conduct an analysis of quality data, design interventions, test those interventions, and determine if the desired outcome was achieved or sustained for 1 of 1 facility reviewed for QAPI. This failed practice placed all residents at risk for not receiving the care and services for optimal resident outcomes.
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wrote1. Based on interview and record review it was determined the facility failed to implement a system which addressed missing personal items in a timely manner for 1 of 1 sampled resident (#6) reviewed for personal property. This placed the resident at risk for loss of personal property.
- E Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were complete for 27 out of 39 sampled days reviewed for staffing. This placed residents at risk for incorrect staffing information.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure appropriate hand hygiene procedures was followed by staff during direct patient contact for 1 of 1 facility reviewed for infection control. This placed residents at risk for spread of infection.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (#6) reviewed for activities. This placed residents at risk for decreased participation in activities of interest.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review it was determined the facility failed to update the care plan for 1 of 1 sampled resident (#6) reviewed for UTI. This placed residents at risk for unmet needs and delayed healing.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow the plan of care for 1 of 2 sampled residents (#413) reviewed for falls. This placed residents at risk for falls.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a coordinated plan of care for 1 of 1 sampled resident (#6) reviewed for dialysis. This placed residents at risk for lack of coordinated transportation to and from dialysis and unmet nutritional needs.
- D Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place for conducting annual performance reviews of CNA staff for 1 of 1 sampled Staff 8 (CNA) reviewed for annual performance reviews. This placed residents at risk for a lack of quality of care.
- D Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 1 of 1 sampled staff (#8) reviewed for in-service training. This placed residents at risk for lack of quality care.
Fire safety inspections
9 fire safety citations on file: 1 on November 21, 2025, 2 on August 2, 2024, 6 on July 14, 2023.
Every fire safety citation9 citations
- F Implement emergency and standby power systems.
- F Have simulated fire drills held at unexpected times.
- D Meet other general requirements.
- F Provide properly protected cooking facilities.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.64 | 5.03 | 3.86 |
| Registered nurses | 1.15 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.81 | 4.51 | 3.42 |
| Nurse aides | 3.31 | ||
| Licensed practical nurses | 1.18 | ||
| Nursing staff turnover (share who left in a year) | 60.3% | 47.4% | 45.8% |
| Registered nurse turnover | 72.7% | 51.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.66 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.98 on weekdays and 4.81 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.44 in April to June 2025 to 5.64 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.64 | 1.15 | 5.98 | 4.81 | 2.6% | 0 of 90 | 41 |
| Oct to Dec 2025 | 5.76 | 1.21 | 6.08 | 4.90 | 4.0% | 0 of 92 | 38 |
| Jul to Sep 2025 | 5.84 | 1.15 | 6.13 | 5.10 | 4.7% | 0 of 92 | 37 |
| Apr to Jun 2025 | 5.44 | 0.99 | 5.68 | 4.85 | 4.6% | 1 of 91 | 37 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.3 | 1.4 | 1.6 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.7 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 19.8 | 16.1 | 12.0 |
Owners and operators
Legal business name: AVAMERE LAKE OSWEGO OPERATIONS INVESTORS, LLC. CMS links this home to Avamere, a group of 27 nursing homes averaging 3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Carr, Kirsten | Contracted managing employee | Individual | 04/01/2022 | |
| Margolis, Erik | W-2 managing employee | Individual | 04/10/2024 | |
| Kofstad, Mary | Corporate officer | Individual | 02/13/2024 | |
| Simpson, Andrew | Corporate officer | Individual | 06/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 7 problems in this area, most recently on January 23, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 4 problems in this area, most recently on July 14, 2023: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 3 problems in this area, most recently on November 21, 2025: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on August 2, 2024: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Tigard Rehabilitation and Care Tigard, 3.4 mi · 1 of 5 stars · 44 citations
- Fernwood Supportive Living at Madrona Grove Portland, 3.4 mi · 4 of 5 stars · 19 citations
- Willamette View Health Center Milwaukie, 3.4 mi · 5 of 5 stars · 5 citations
- West Hills Health & Rehabilitation Portland, 3.5 mi · 4 of 5 stars · 26 citations
- Marquis Tualatin Post Acute Rehab Tualatin, 3.9 mi · 5 of 5 stars · 11 citations
- Avamere Crestview of Portland Portland, 4 mi · 4 of 5 stars · 57 citations
- Avamere Rehabilitation of King City Tigard, 4.1 mi · 4 of 5 stars · 33 citations
- Marquis Vermont Hills Portland, 4.4 mi · 5 of 5 stars · 13 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is The Pearl at Kruse Way's Medicare star rating?
- CMS rates The Pearl at Kruse Way 4 out of 5 stars overall, with 4 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did The Pearl at Kruse Way get at its last inspection?
- 2 health deficiencies at the standard inspection on November 21, 2025. The Oregon average is 9.2.
- Has The Pearl at Kruse Way been fined?
- CMS lists no fines in the last three years.
- Does The Pearl at Kruse Way accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns The Pearl at Kruse Way?
- CMS lists 4 owners and managers, and links the home to Avamere. Legal business name: AVAMERE LAKE OSWEGO OPERATIONS INVESTORS, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.