The Pearl at Kruse Way

Name: The Pearl at Kruse Way
Address: 4550 CARMAN DRIVE, Lake Oswego, OR, 97035, US
Telephone: 5036756055

4550 Carman Drive, Lake Oswego, OR 97035 · Clackamas County · 74 certified beds · avg 41 residents/day · certified since Jan 25, 2006

Part of chain: AVAMERE (27 facilities, chain avg rating 3.0★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

5.91

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (22)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Nov 21, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Nov 21, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 23, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 23, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 2, 2024	E · Potential for harm, repeated	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Aug 2, 2024	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 2, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 2, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 2, 2024	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jun 27, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jun 27, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 14, 2023	F · Potential for harm, facility-wide	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Jul 14, 2023	F · Potential for harm, facility-wide	The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them.
Jul 14, 2023	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jul 14, 2023	E · Potential for harm, repeated	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Jul 14, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 14, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 14, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jul 14, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 14, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jul 14, 2023	D · Potential for harm, one-off	The facility did not observe each nurse aide's job performance or provide regular training as required.
Jul 14, 2023	D · Potential for harm, one-off	The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (5 → 2).

Year	Citations	Worst severity that year
2023	11	F
2024	7	E
2025	4	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Oregon avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.91	5.42	3.95	top 18% in Oregon; top 4% in the U.S.
Registered Nurse hours	1.21	0.78	0.69	top 10% in Oregon; top 9% in the U.S.
Weekend total nurse staffing	5.04	4.85	3.50	top 31% in Oregon; top 6% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.48	0.48	0.48	top 32% in Oregon; top 35% in the U.S.
Total nursing staff turnover (%)	60.3	47.4	45.8	bottom 21% in Oregon; bottom 16% in the U.S.
RN turnover (%)	72.7	51.6	42.9	bottom 14% in Oregon; bottom 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.64, RN 1.15, weekend 4.81. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: —/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Carr, Kirsten	Individual	Contracted Managing Employee	NOT APPLICABLE	04/01/2022
Kofstad, Mary	Individual	Corporate Officer	NOT APPLICABLE	02/13/2024
Margolis, Erik	Individual	W-2 Managing Employee	NOT APPLICABLE	04/10/2024
Simpson, Andrew	Individual	Corporate Officer	NOT APPLICABLE	06/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you explain health changes and treatment options to residents and their families?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Tigard Rehabilitation and Care	3.4 mi	Tigard, OR	★☆☆☆☆	1/5	SFF
Fernwood Supportive Living at Madrona Grove	3.4 mi	Portland, OR	★★★★☆	3/5
Willamette View Health Center	3.5 mi	Milwaukie, OR	★★★★★	5/5
West Hills Health & Rehabilitation	3.5 mi	Portland, OR	★★★★☆	3/5
Marquis Tualatin Post Acute Rehab	3.9 mi	Tualatin, OR	★★★★★	4/5
Avamere Crestview of Portland	4.0 mi	Portland, OR	★★★★☆	3/5
Avamere Rehabilitation of King City	4.1 mi	Tigard, OR	★★★★☆	3/5
Marquis Vermont Hills	4.4 mi	Portland, OR	★★★★★	5/5
Robison Jewish Health Center	4.7 mi	Portland, OR	★★☆☆☆	2/5
Marquis Autumn Hills Memory Care	4.8 mi	Portland, OR	★★★★★	4/5
Rose Linn Care Center	5.4 mi	West Linn, OR	★★★☆☆	4/5
Beaverton Post Acute Care of Cascadia	5.5 mi	Beaverton, OR	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Lake Oswego →

Facility data as of CMS processing date 2026-08-01. CCN 385271.

The Care File

Visit checklist — The Pearl at Kruse Way

4550 Carman Drive, Lake Oswego, OR 97035 · 5036756055

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 385271 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)