Mary's Woods At Marylhurst

  • MEDICARE CERTIFIED
Mary's Woods At Marylhurst was recognized and ceritified in 2002 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Mary's Woods At Marylhurst which is located in 17360 Holy Names Drive Lake Oswego, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Mary's Woods At Marylhurst is being offered ceritified services and products in Oregon.
Address:   17360 Holy Names Drive
       Lake Oswego, OR 97034

Phone:   (503) 675-2004

County: Clackamas
Federal Provider Number: 385265
Map and Directions
Participates in: Medicare And Medicaid
Certified Date: Friday, June 21, 2002 (22 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Marys Woods At Marylhurst Inc
Ownership Type: Non Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
PersonMarvin KaiserW-2 Managing Employee
PersonMarvin KaiserDirector/officer
PersonDiane HoodW-2 Managing Employee
PersonDiane HoodDirector/officer
PersonMary Ellen HolohanDirector/officer
PersonDavid GaltDirector/officer
PersonJacqueline GalloDirector/officer
PersonRoswitha FrawleyW-2 Managing Employee
PersonDennis FinniganDirector/officer
PersonMichael DiamondDirector/officer
PersonMichael DeshaneDirector/officer
PersonWinnifred DannerDirector/officer
PersonMargaret CarleyDirector/officer
PersonKandis Brewer NunnDirector/officer
PersonMary BreilingDirector/officer
PersonJames ArpDirector/officer
PersonTherese AbramsDirector/officer
PersonJudith MayerDirector/officer
PersonDonald RushmerDirector/officer
PersonKimberly ScottDirector/officer
PersonKimberly ScottW-2 Managing Employee
PersonLynda ThompsonDirector/officer

Provider Resides in Hospital: No
Number of Federally Certified Beds: 5
Number of Residents in Federally Certified Beds: 24 (480% occupied)
Continuing Care Retirement Community: Yes
Special Focus Facility: No
With a Resident and Family Council: None
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Friday, May 31, 2013
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, May 31, 2013
Survey Type: Health
Deficiency: F0516 (Keep clinical record information safe.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, May 31, 2013
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, May 31, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0070 (Restrictions on the use of portable space heaters.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, June 3, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, June 3, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0146 (A separate and independent backup electrical power source.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, June 11, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, July 20, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 30, 2013
Survey Type: Fire Safety
Deficiency: K0043 (Rooms that can be unlocked from inside without a key.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 15, 2013
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, February 28, 2012
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, February 28, 2012
Survey Type: Health
Deficiency: F0174 (Provide residents with private access to a telephone.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, February 22, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, April 15, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Friday, October 28, 2011
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 16, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0073 (Restrictions on the use of highly flammable decorations.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0130 (Other fire safety features required by fire safety codes.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, November 8, 2010
Survey Type: Fire Safety
Deficiency: K0072 (Exits that are free from obstructions and can be used at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, November 4, 2010
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, November 4, 2010
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, November 4, 2010
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, November 4, 2010
Survey Type: Health
Deficiency: F0387 (Make sure that doctors visit residents regularly, as required.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 24, 2010
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 1
Number of Substantiated Complaints: 0
Number of Fines: 0
Number of Payment Denials: 0
Total Number of Penalties: 0
Total Amount of Fines in Dollars: USD 0
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (4 out of 5 stars)
Quality Rating (5 out of 5 stars)
Staffing Rating Data not available
RN Staffing Rating Data not available
Overall Rating (5 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
6%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
12%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
13%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
5%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
6%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
24%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
93%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
92%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
5%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
8%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
18%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
49%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
82%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
2%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
84%
84%

N/A
Data not available.

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Mary's Woods At Marylhurst [Federal No:385265] near 17360 Holy Names Drive, Lake Oswego OR

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