Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl At Kruse Way, The during CMS and state inspections, most recent first.
The facility failed to notify the LTCO when two residents were transferred or discharged. One resident with hypo-osmolality and hyponatremia was discharged home, and another resident with a left femur fracture was hospitalized, but neither record showed LTCO notification. The Social Services Director stated she did not send transfer notices to the Ombudsman, and the former DNS said the facility had no system in place to carry out the requirement.
Expired OTC medications were found in the medication storage room, including Milk of Magnesia, TUMS, and Renovite. A CMA and the former DNS acknowledged the expired products, and the former DNS stated that nurses, CMAs, and Central Supply staff were expected to check expiration dates regularly.
A facility failed to follow physician orders for a resident with a femur fracture, who experienced extended periods without bowel movements. Despite orders for Milk of Magnesia, Dulcolax suppository, and Fleet enema, there was no evidence the resident received these medications. Staff interviews revealed a lack of recollection of the resident, and the DNS confirmed the absence of documentation for bowel care, placing the resident at risk for complications.
A resident admitted with a femur fracture developed pressure injuries that were not properly assessed or monitored by the facility. Despite treatments being administered, the care plan lacked necessary interventions, and no investigation into the cause of the ulcers was conducted until long after the resident's discharge. Staff interviews revealed a lack of recollection of the resident, and expected procedures were not followed.
The facility failed to provide baseline care plans to five residents upon admission, despite their cognitive ability to understand the plans. Diagnoses included joint replacement, depression, bone fractures, and more. The DNS confirmed the oversight, leaving residents uninformed about their care plans.
A facility failed to follow physician orders for medication administration, affecting four residents with conditions such as hypertension, prostate cancer, paralysis, depression, cognitive impairment, diabetes, and heart failure. Medications were administered late, with delays ranging from 30 minutes to over three hours, confirmed by the DNS. These delays risked reduced medication efficacy and adverse side effects.
The facility failed to secure medications, as a medication cart was left unlocked and unattended on [NAME] Hall, confirmed by an LPN. Additionally, a treatment cart containing insulin was found unlocked in the East Hall, confirmed by an RN and DNS.
The facility failed to comply with its Food Safety and Sanitation Policy, leading to improper labeling, storage, and handling of food items. Observations revealed unlabeled and expired food in the kitchen and unit refrigerators, improper glove use by a Prep Cook, and inadequate hair restraint by staff. The Executive Chef and Dietary Manager acknowledged these deficiencies.
A resident was not informed of a change in their Citalopram dosage, despite being cognitively intact and able to participate in treatment decisions. The dosage was reduced based on a pharmacy recommendation, but the resident was only informed four days later, leading to feelings of outrage and dissatisfaction.
A resident with high blood pressure was prescribed 50 mg of metoprolol every evening but received only 25 mg from mid-December to early January. This error was confirmed by a Regional RN, indicating a failure in administering the correct medication dosage.
A resident with a history of stroke and attention deficit was left alone in a wheelchair, contrary to their care plan, resulting in a fall. The care plan explicitly instructed staff not to leave the resident unattended, but this was not followed, leading to the resident attempting to self-transfer and falling.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman when two residents transferred or discharged from the facility. The facility’s 3/2021 Transfer or Discharge Notice Policy stated that the resident and representative are to receive a 30-day advance written notice of an impending transfer or discharge and that a copy of the notice is to be sent to the Ombudsman at the same time it is provided to the resident and representative. One resident was admitted with diagnoses including hypo-osmolality and hyponatremia and was discharged home from the facility, but the clinical record showed no indication that the LTCO was notified. Another resident was admitted with diagnoses including a fracture of the left femur and was hospitalized, but the clinical record also showed no indication that the LTCO was notified when the resident was transferred to the hospital. The Social Services Director stated she did not send transfer notices to the LTCO, and the former DNS acknowledged the requirement to notify the LTCO and stated the facility did not have a system in place to implement the requirement.
Expired OTC Medications Found in Storage Room
Penalty
Summary
Drugs and biologicals in the OTC medication storage room were not kept free of expired medications. During a review of the medication storage room, four bottles of Milk of Magnesia were found expired in 6/2025, two bottles of TUMS were found expired in 3/2025, and two bottles of Renovite were found expired in 7/2025. Staff 9, a CMA, acknowledged that the medications were expired, and Staff 4, the former DNS, also acknowledged the expired medications and stated it was her expectation that nurses and CMAs check for expired medications at least weekly. Staff 4 further stated that Central Supply staff were to check expiration dates before placing medications in the OTC room and medication carts.
Failure to Implement Bowel Care Protocol
Penalty
Summary
The facility failed to adhere to physician orders and implement bowel care for a resident diagnosed with a femur fracture, who was admitted to the facility. The physician's orders dated 1/6/24 specified that the resident should receive Milk of Magnesia (MOM) every 24 hours as needed for bowel care and constipation, a Dulcolax suppository if there was no bowel movement for four days and MOM was ineffective, and a Fleet enema as needed for constipation. However, the resident's bowel records indicated no bowel movements from 1/14/24 to 1/19/24 and from 1/21/24 to 1/25/24, totaling six and five consecutive days without a bowel movement, respectively. There was no documentation to show that the resident received or refused the prescribed bowel medications during these periods. Interviews conducted with various staff members, including LPNs, RNs, and the Therapy Director, revealed that they did not recall the resident in question. Attempts to contact a CNA who frequently worked with the resident were unsuccessful. On 1/23/25, the Director of Nursing Services (DNS) acknowledged the lack of bowel movements on the specified dates and confirmed the absence of evidence indicating that the resident was offered the prescribed bowel medications. This oversight placed the resident at risk for medical complications associated with constipation, such as bowel impaction.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers for a resident who was admitted with a femur fracture and later developed pressure injuries. Upon admission, the resident was noted to have no skin issues, and subsequent weekly skin audits did not identify any new skin issues. However, a physician's progress note later documented bilateral pressure injuries on the heels and a Stage 2 pressure ulcer on the left buttock. Despite this, there was no evidence in the resident's clinical record of proper assessment, including staging and measuring the wounds. The care plan for the resident did not include information or interventions for the identified pressure ulcers. Although treatments were administered as ordered, there was no investigation into the cause of the pressure ulcers or interventions to prevent further skin decline until 81 days after the resident was discharged. Interviews with various staff members revealed a lack of recollection of the resident, and the Director of Nursing Services acknowledged that the expected procedures, such as taking pictures, staging the wounds, and updating the care plan, were not followed.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to five sampled residents upon their admission, which is a requirement to ensure residents are informed of their care plan. The residents involved were admitted with various diagnoses, including joint replacement surgery, depression, bone fractures, hearing loss, cognitive impairment, hypertension, diabetes, and seizures. Despite being cognitively intact or having moderate cognitive impairment, none of these residents received a copy of their baseline care plan, as confirmed by the Director of Nursing Services (DNS). The deficiency was identified through interviews and record reviews, which revealed that the clinical records of the residents did not contain any indication that a baseline care plan or summary was provided. This oversight was confirmed by the DNS, who acknowledged that the baseline care plans were not given to the residents. The lack of documentation and communication regarding the baseline care plans placed the residents at risk of being uninformed about their care plans, which is crucial for their understanding and participation in their own care.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure physician orders were followed for four of eight sampled residents, leading to untimely administration of medications. Resident 228, admitted with hypertension and prostate cancer, experienced delays in medication administration ranging from one hour and 38 minutes to two hours and 49 minutes on multiple occasions. Similarly, Resident 135, with paralysis and depression, had medications administered up to two hours and 47 minutes late. These delays were confirmed by Staff 2 (DNS) during a facility audit. Resident 125, diagnosed with cognitive impairment and hypertension, also faced significant delays in receiving medications, with some administered up to three hours late. Resident 181, with diabetes and heart failure, experienced multiple instances of late medication administration, with delays ranging from 30 minutes to over three hours. These repeated failures to administer medications timely placed residents at risk for reduced medication efficacy and adverse side effects, as confirmed by the facility's audit and Staff 2.
Medication Security Lapses
Penalty
Summary
The facility failed to ensure that medications were secured and only accessible to authorized personnel, as observed in two separate incidents. On August 1, 2024, a medication cart on [NAME] Hall was found unlocked and unattended outside of a resident's room. This was confirmed by an LPN who acknowledged the oversight. Additionally, on July 31, 2024, a treatment cart in the East Hall was observed to be unattended and unlocked, with staff and visitors passing by. An RN confirmed that the cart contained insulin and other treatment supplies and should have been locked when not in use. The DNS later confirmed that treatment carts are required to be locked when unattended.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its Food Safety and Sanitation Policy, resulting in improper labeling, storage, and handling of food items in the kitchen and unit refrigerators. During an inspection, surveyors observed several food items in the walk-in refrigerator and freezer that were not labeled or dated, including a dark liquid in a dispenser, bagged grapes in brown liquid, mushy strawberries with white fuzz, and various containers with expired or missing use-by dates. Additionally, the freezer contained open bags of frozen hamburger patties and chicken tenders with ice crystals, and a casserole with a foil lid that had holes and visible ice crystals. The Executive Chef acknowledged these deficiencies, confirming that the food storage process was not followed correctly. Further observations revealed that the unit refrigerators contained improperly labeled and stored items, such as a wrapped sandwich with an expired use-by date and a partially consumed jug of milk with no date. Additionally, during a kitchen observation, a Prep Cook was seen wearing the same pair of gloves while handling various surfaces and food items, and multiple staff members, including the Chef and Dietary Aide, were noted to have hair not fully covered by hair restraints. The Dietary Manager verified these lapses in proper glove use and hair restraint adherence.
Failure to Inform Resident of Medication Change
Penalty
Summary
The facility failed to notify a resident of a medication change, which was identified during a review of unnecessary medications for a sample of residents. Resident 19, who was admitted with a diagnosis of depression and was cognitively intact, was administered 40 mg of Citalopram at bedtime. A pharmacy recommendation to decrease the dosage to 20 mg was agreed upon by the provider, and a gradual reduction was initiated. However, the resident was not informed of this change until four days after the dosage was reduced, despite the resident's cognitive ability to understand and participate in treatment decisions. The lack of communication regarding the medication change led to the resident feeling outraged and disgusted, as expressed during an interview. The resident experienced no adverse reactions from the dosage change, but the failure to inform them in a timely manner resulted in dissatisfaction and a sense of being disregarded. The Director of Nursing Services confirmed that the first communication with the resident about the dosage change occurred only after the resident requested to speak with the provider.
Medication Administration Error
Penalty
Summary
The facility failed to administer medications at the prescribed dose for a resident reviewed for physician orders, which placed the resident at risk of receiving a sub-therapeutic dose of medication. The resident was admitted with a diagnosis of high blood pressure and had a physician's order for 50 mg of metoprolol to be administered every evening. However, a review of the Medication Administration Records (MARs) for December 2023 and January 2024 revealed that the resident received only 25 mg of metoprolol from December 15, 2023, through January 8, 2024. This discrepancy was verified by a Regional Registered Nurse (RN) on June 27, 2024.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident who was admitted with diagnoses including stroke and attention and concentration deficit. The resident's Activities of Daily Living (ADL) Care Plan, dated December 21, 2023, specifically instructed staff not to leave the resident alone when up in a wheelchair. However, on January 31, 2023, a progress note indicated that the resident was left alone in their room while in a wheelchair. As a result, the resident attempted to self-transfer and fell to the floor. This incident was confirmed by a Regional RN on June 25, 2024, who acknowledged that the care plan was not followed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lake Oswego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tigard Rehabilitation And Care | 3.4 mi | ★★★★★ | 19 | 2 |
| Fernwood Supportive Living At Madrona Grove | 3.4 mi | ★★★★★ | 0 | 0 |
| Willamette View Health Center | 3.4 mi | ★★★★★ | 0 | 0 |
| West Hills Health & Rehabilitation | 3.5 mi | ★★★★★ | 0 | 0 |
| Marquis Tualatin Post Acute Rehab | 3.9 mi | ★★★★★ | 9 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.