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Public Record

Martha and Mary Health Service

Nursing HomePoulsbo, WACMS 505474
56 citations on record

From CMS

Facility profile

CMS overall rating
5 / 5

*CMS Five-Star

Certified beds
135

*CMS

Avg. residents per day
108.1

*CMS

Inspection record

On record from CMS

Health citations
56

*CMS

Fire safety findings
30

*CMS

Inspections on file
11

*CMS

Last inspection
2026-02-13

*CMS

Citations

56 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0584Generalpotential for harm

    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.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0641Generalpotential for harm

    Ensure each resident receives an accurate assessment.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0758Generalpotential for harm

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0773Generalpotential for harm

    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0700Generalpotential for harm

    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0552Generalpotential for harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0604Generalpotential for harm

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0636Generalpotential for harm

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0584Generalpotential for harm

    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.

  • 0638Generalpotential for harm

    Assure that each resident’s assessment is updated at least once every 3 months.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0690Generalpotential for harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0810Generalpotential for harm

    Provide special eating equipment and utensils for residents who need them and appropriate assistance.

  • 0849Generalpotential for harm

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0868Generalpotential for harm

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0778Generalpotential for harm

    Help the resident make transportation arrangements to and from radiology services.

  • 0758Generalpotential for harm

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0604Generalpotential for harm

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

Showing the 10 most recent inspections. 1 earlier inspection is also on record.

FAQ

Questions and answers

What is Martha and Mary Health Service?
Martha and Mary Health Service is a Medicare- and Medicaid-certified nursing home in Poulsbo, WA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 505474.
What is the CMS rating for Martha and Mary Health Service?
Martha and Mary Health Service has a CMS overall rating of 5 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Martha and Mary Health Service have?
Martha and Mary Health Service is certified for 135 beds. It serves an average of 108.1 residents per day.
How many citations does Martha and Mary Health Service have?
Martha and Mary Health Service has 56 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Martha and Mary Health Service last inspected?
Martha and Mary Health Service was last inspected on February 13, 2026. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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