Cycle 1
Health 2025-11-21 · Fire 2025-11-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Lake Oswego, OR
PEARL AT KRUSE WAY, The
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4550 Carman Drive, Lake Oswego, OR
(503) 675-6055
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
2006-01-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.15
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.63
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.84
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
2.20
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
5.10
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.40
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
5.76
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
771
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0186
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.60
Baseline 19.20% · Performance 18.84% · Measure score 5.60 · Achievement 5.60 · Improvement 1.15
Healthcare-associated infections
10
Baseline 5.67% · Performance 4.67% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
0
Baseline 64.52% · Performance 67.65% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
10
Performance 6.09 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.72% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 287 · Observed rate 5.92% · Lower 95% interval 6.04% |
| Discharge to community | 65.4% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 295 · Observed rate 63.39% · Lower 95% interval 60.31% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 156 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 77.37% |
53.69%
23.7 pts better
|
Numerator 106 · Denominator 137 |
| Discharge mobility score | 33.58% |
50.94%
17.4 pts worse
|
Numerator 46 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 3.77% |
2.29%
1.5 pts worse
|
Numerator 6 · Denominator 159 · Adjusted rate 4.53% |
| Healthcare-associated infections requiring hospitalization | 4.67% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 1.2% · Lower 95% interval 2.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | 43.06% |
42%
1.1 pts better
|
Numerator 31 · Denominator 72 |
| Discharge function score | 54.74% |
56.45%
1.7 pts worse
|
Numerator 75 · Denominator 137 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 99.25% |
96.28%
3 pts better
|
Numerator 133 · Denominator 134 |
| Resident COVID-19 vaccinations up to date | 45.71% |
25.2%
20.5 pts better
|
Numerator 32 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
85.4%
10.9 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 95.3% · Q3 96.8% · Q4 97.1% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
15.1%
1.8 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 16.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.7%
0.5 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.7% · Q3 0.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
81.2%
14.2 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
21.6%
3 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 21.4% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-02 · Fire 2024-08-02
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
11 health deficiencies
Top issue: Nursing and Physician Services (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-12-22
F · Potential for more than minimal harm
2024-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-08-02
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-08-02
F · Potential for more than minimal harm
2023-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-07-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-25
D · Potential for more than minimal harm
2025-11-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-25
D · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-17
E · Potential for more than minimal harm
2024-08-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-17
F · Potential for more than minimal harm
2023-07-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-07-14
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-07-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-07-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-07-14
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-08-30
Penalties and ownership
What sits behind the stars
Ownership
Ari Cbc LLC
5% Or Greater Direct Ownership Interest · Organization
Ari Operations, LLC
5% Or Greater Indirect Ownership Interest · Organization
Avamere Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Carr, Kirsten
Contracted Managing Employee · Individual
Kofstad, Mary
Corporate Officer · Individual
Margolis, Erik
W-2 Managing Employee · Individual
Miller, Karl
5% Or Greater Indirect Ownership Interest · Individual
Simpson, Andrew
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Tigard Rehabilitation And Care
Tigard, OR
1-star overall rating with 2-star inspections with abuse icon flag with $35,714 in total fines with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Fernwood Supportive Living At Madrona Grove
Portland, OR
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Willamette View Health Center
Milwaukie, OR
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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