Federal inspection record · CMS data as of October 1, 2026
Martha And Mary Health Service
19160 Front Street Northeast, Poulsbo, WA · (360) 779-7500
- Certified beds
- 135
- Residents per day
- 114
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 1, 1992
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Washington.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Washington homes
Martha And Mary Health Service carries 72 inspection points. That is fewer than 62% of Washington's 192 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Washington: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–31 pts
- 4★ 31–69 pts
- 3★ 69–100 pts
- 2★ 100–167 pts
- 1★ over 167 pts
Bars show every rated home in Washington by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
46 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care15E
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide enough food/fluids to maintain a resident's health.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
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.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Resident Assessment and Care Planning10E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Infection Control5E
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Resident Rights5E
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
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.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
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.
Pharmacy Service4E
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure medication error rates are not 5 percent or greater.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
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.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Administration2D
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- D
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.
Nutrition and Dietary2E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Nursing and Physician Services1E
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspection history
2026-02-13
11 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-12-16
18 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2023-10-27
17 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 54 min of nursing staff time a day, 1 h 5 min of it from a registered nurse.
This home
4 h 54 min
Washington average
4 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 36% of nursing staff and 17% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.3 pts better | 1.0 | 1.3 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.3 pts better | 0.2 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.8 pts better | 98.0% | 96.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.7 pts better | 100.0% | 94.3% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2 pts worse | 4.6% | 2.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms18.7 pts worse | 36.6% | 17.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts better | 3.9% | 5.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication8.2 pts worse | 20.7% | 12.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.1 pts worse | 20.1% | 15.0% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened3.5 pts better | 12.1% | 15.6% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2.4 pts worse | 16.2% | 13.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.8 pts better | 0.0% | 0.8% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.4 pts better | 0.3% | 1.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4 pts worse | 25.6% | 21.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.4 pts better | 1.0% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine5.8 pts better | 94.5% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4.8 pts better | 8.2% | 13.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.4 pts worse | 1.7% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine7.7 pts better | 92.1% | 84.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.3 pts worse | 23.0% | 19.7% | 23.4% |
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Who owns and runs it
12 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Koerner, Edward | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Koerner, Edward | Adp Of The SNF · Individual | 0% | 1 facilities |
| Ladenburg, Lynette | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Ladenburg, Lynette | Corporate Officer · Individual | 0% | 1 facilities |
| Ladenburg, Lynette | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Ladenburg, Lynette | Adp Of The SNF · Individual | 0% | 1 facilities |
| Oconer, Ellen | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Oconer, Ellen | Adp Of The SNF · Individual | 0% | 1 facilities |
| Sharman, Donald | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Sharman, Donald | Adp Of The SNF · Individual | 0% | 1 facilities |
| Vernon-Cole, Christopher | Corporate Officer · Individual | 0% | 1 facilities |
| Vernon-Cole, Christopher | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
14 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke7F
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Install corridor and hallway doors that block smoke.
- D
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems4F
- D
Ensure proper usage of power strips and extension cords.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Have generator or other power source capable of supplying service within 10 seconds.
Egress2F
- F
Install emergency lighting that can last at least 1 1/2 hours.
- F
Have properly located and lighted "Exit" signs.
Services1F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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