Nursing homeActive
The PEARL AT KRUSE WAY
4550 Carman Drive, Lake Oswego, OR 97035503675605574 certified beds · 41 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
5
since 2023
Deficiencies
22
● 0● 22● 0
Penalties · 3 yrs
—
none on file
Last survey
2025-11-21
Standard
CMS overall
4 / 5
stars as published by CMS
CMS overall 4/5
Health 4
Staffing 4
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Oregon Department of Human Services · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-11-21 | Standard | 020 | CMS-2567 (Care Compare) | — |
| 2025-01-23 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-08-02 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2024-06-27 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-07-14 | Standard | 0110 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Oregon Department of Human Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-25Record 385271-20251121-F628
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-25Record 385271-20251121-F761
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-17Record 385271-20250123-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-17Record 385271-20250123-F686
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 385271-20240802-F552
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 385271-20240802-F655
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 385271-20240802-F684
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 385271-20240802-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 385271-20240802-F812
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 385271-20240627-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 385271-20240627-F689
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F584
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F657
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F689
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385271-20230714-F698
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385271-20230714-F725
F730Observe each nurse aide's job performance and give regular training.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F730
F732Post nurse staffing information every day.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-13Record 385271-20230714-F732
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-08-20Record 385271-20230714-F865
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F880
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-30Record 385271-20230714-F947
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day1.15
Facility
Oregon
National
Oregon 0.72 · National 0.69
Total nurse hours per resident day5.64
Facility
Oregon
National
Oregon 5.03 · National 3.86
Weekend total nurse hours4.81
Facility
Oregon
National
Oregon 4.51 · National 3.42
Total nursing staff turnover60%
Facility
Oregon
National
Oregon 47% · National 46%
Registered nurse turnover73%
Facility
Oregon
National
Oregon 52% · National 43%
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Carr, Kirsten Individual | CONTRACTED MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Kofstad, Mary Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Margolis, Erik Individual | W-2 MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Simpson, Andrew Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
Part of a chain
Avamere — 27 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Oregon.
No county cost figures on file for Clackamas.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| West Hills Health & Rehabilitation Portland | 3.5 mi | 2025-04-25 | 0231 |
| Avamere Crestview Of Portland Portland | 4.0 mi | 2026-02-13 | 0400 |
| Marquis Vermont Hills Portland | 4.4 mi | 2026-05-22 | 0130 |
| Marquis Tualatin Post Acute Rehab Tualatin | 3.9 mi | 2026-05-22 | 0110 |
| Robison Jewish Health Center Portland | 4.7 mi | 2025-11-04 | 0202 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |