MARY'S WOODS AT MARYLHURST

The information listed below provides an in-depth look into the type and quality of care offered at Mary's Woods at Marylhurst. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

MARY'S WOODS AT MARYLHURST
17360 HOLY NAMES DRIVE
LAKE OSWEGO, OR 97034
(503) 534-3937

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

87%

Number of Residents and Certified Beds

  • Residents: 20
  • Certified Beds: 23

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Non Profit - Corporation
  • This Facility Does Not Offer Any Resident or Family Counseling
  • Part of a Continuing Care Retirement Community (CCRC)
  • This Facility is Not Part of a Chain or Franchise

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This FacilityFor-ProfitNon-ProfitGovt

Nearby Cities:

Milwaukie | Gladstone | West Linn

Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Medium Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Mary's Woods at Marylhurst. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 0-518.9%
Total Percent:18.9%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 6-1012.6%
ADL Index Range: 0-55.4%
Total Percent:18.0%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 6-104.5%
ADL Index Range: 0-523.4%
Total Percent:27.9%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 11-1612.6%
ADL Index Range: 6-1022.5%
Total Percent:35.1%
 

Rating Details For Mary's Woods at Marylhurst

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours1 Hour and 30 Minutes56 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours40 Minutes34 Minutes
Certified Nursing Assistant (CNA) Hours3 Hours and 55 Minutes2 Hours and 36 Minutes
Total Licensed Nurse Hours2 Hours and 11 Minutes1 Hour and 30 Minutes
Total Nurse Hours6 Hours and 6 Minutes4 Hours and 6 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Oregon are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityOregon Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season67%83%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination80%83%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Have Moderate to Severe Pain6%5%
Percent of Long-Stay Residents Who Were Physically Restrained2%5%
Percent of Long-Stay Residents Who Are More Depressed or Anxious19%13%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder38%60%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse6%9%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair-7%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder-8%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection15%11%
Percent of Long-Stay Residents Who Lose Too Much Weight2%9%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased2%10%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores2%10%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season90%75%
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%76%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Delirium-3%
Percent of Short-Stay Residents Who Have Pressure Sores-11%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain38%30%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 11/04/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Administration

Post Nurse Staffing Information.
  • Inspection Date: 12/18/2009
  • Correction Date: 01/23/2010
Keep Accurate and Appropriate Medical Records.
  • Inspection Date: 11/04/2010
  • Correction Date: 12/24/2010

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 11/04/2010
  • Correction Date: 12/24/2010
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
  • Inspection Date: 11/04/2010
  • Correction Date: 12/24/2010

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 12/18/2009
  • Correction Date: 01/23/2010

Quality Care

Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 12/18/2009
  • Correction Date: 01/23/2010

Resident Assessment

Make Sure That Doctors Visit Residents Regularly, As Required.
  • Inspection Date: 11/04/2010
  • Correction Date: 12/24/2010

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for Mary's Woods at Marylhurst, as well as complaints by residents or their family in the previous three years.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Formal ComplaintsDegree of HarmResidents Affected

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Complaint Filed: 12/04/2009
  • Correction Date: 12/23/2009

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Mary's Woods at Marylhurst had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 11/08/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010
Portable Fire Extinguishers.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Building Construction

Approved Construction Type or Materials.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Electrical

Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Emergency Plans and Fire Drills

Did Not Have a Written Emergency Evacuation Plan.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010
Restrictions on the Use of Highly Flammable Materials.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas.
  • Inspection Date: 12/15/2009
  • Correction Date: 01/23/2010
Proper Medical Gas Storage and Administration Areas.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010

Miscellaneous

Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 11/08/2010
  • Correction Date: 12/24/2010
Source: Medicare Nursing Home Compare; Seniors and People with Disability - Retrieved 2011