Martha and Mary Health ServiceCMS ratings, inspections and fines
- Address
- 19160 Front Street Northeast, Poulsbo, WA 98370
- CCN
- 505474
- Ownership type
- Non-profit, corporation
- Certified beds
- 135
- Chain
- None in the CMS record
- Residents per day
- 111
- CMS flags
- None in the CMS record
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Martha and Mary Health Service an overall rating of 4 of 5 stars. The last standard survey was on 13 Feb 2026. The latest survey cycle has 11 health citations. The median for nursing homes in Washington is 14. CMS lists no fines for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Changes in the CMS recordFeed of changes in Washington (RSS)
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Kitsap County median | Washington median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 4 | 4.0 | 3.0 | 3.0 |
| Health inspection rating | 3 | 3.0 | 3.0 | 2.8 |
| Staffing rating | 4 | 4.0 | 4.0 | 2.9 |
| Quality measure rating | 5 | 4.0 | 4.0 | 3.6 |
A median is the middle value of the homes in the group: 9 homes in the county, 193 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Washington median |
|---|---|---|---|
| Cycle 1 (latest) | 13 Feb 2026 | 11 | 14 |
| Cycle 2 | 16 Dec 2024 | 18 | 17 |
| Cycle 3 | No date | 17 | 13 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J0 | K0 | L0 |
| Actual harm that is not immediate jeopardy | G0 | H0 | I0 |
| No actual harm, potential for more than minimal harm | F0 | ||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 11 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 13 May 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 10 Jun 2026 |
| 13 Apr 2026 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 15 May 2026 |
| 13 Feb 2026 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0584 | 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 | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0692 | Provide enough food/fluids to maintain a resident's health. | E | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Standard survey | 20 Mar 2026 |
| 13 Feb 2026 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 20 Mar 2026 |
Survey cycle 2: 18 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 13 May 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 11 Jun 2025 |
| 14 Apr 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint investigation | 23 May 2025 |
| 16 Dec 2024 | F0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0641 | Ensure each resident receives an accurate assessment. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0700 | 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. | E | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | E | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0758 | 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. | E | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | D | Standard survey | 24 Jan 2025 |
| 16 Dec 2024 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 24 Jan 2025 |
Survey cycle 3: 17 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 8 Jul 2024 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 16 Aug 2024 |
| 27 Oct 2023 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0584 | 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 | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | E | Complaint investigation | 11 Dec 2023 |
| 27 Oct 2023 | F0638 | Assure that each resident’s assessment is updated at least once every 3 months. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0849 | 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. | D | Standard survey | 11 Dec 2023 |
| 27 Oct 2023 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 11 Dec 2023 |
| 27 Oct 2023 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Complaint investigation | 11 Dec 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
CMS lists no fine and no payment denial for this home in its penalties file.
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Washington median | Washington average (CMS) |
|---|---|---|---|
| All nurse staff | 4.77 | 4.10 | 4.37 |
| Registered nurses (RN) | 1.11 | 0.90 | 0.94 |
| Licensed practical nurses (LPN) | 0.62 | 0.77 | |
| Nurse aides | 3.04 | 2.66 | |
| All nurse staff, weekends | 4.05 | 3.60 | 3.81 |
- Nurse staff turnover in a year
- 35.9%
- Nurse staff turnover, Washington median
- 43.2%
- RN turnover in a year
- 22.6%
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Washington median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 16.3% | 13.9% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.5% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | 1.1% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.1% | 2.1% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.0% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 13.0% | 16.6% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 0.5% | 3.7% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 20.8% | 14.1% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Non-profit, corporation
- Legal business name
- Martha and Mary Health Services
The CMS ownership record of this home lists no organisation.
The site shows organisations only. It does not show the names of persons.
Other homes in Kitsap County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Northwoods Lodge | Silverdale | 5 of 5 | 8 | $51,942 | 16 Mar 2026 | |
| Bainbridge Island Health & Rehab Center | Bainbridge Island | 5 of 5 | 6 | $0 | 17 Nov 2025 | |
| Bremerton Trails Post AcuteSpecial Focus candidate | Bremerton | 1 of 5 | 42 | $174,068 | 18 Nov 2025 | |
| Belmont Terrace | Bremerton | 3 of 5 | 17 | $0 | 2 Mar 2026 | |
| Port Washington Post Acute | Bremerton | 1 of 5 | 44 | $131,299 | 29 Jul 2025 | |
| Washington Veteran Home-Retsil | Pt Orchard | 4 of 5 | 16 | $23,920 | 11 May 2026 | |
| Life Care Center of Port Orchard | Port Orchard | 5 of 5 | 16 | $0 | 10 Apr 2026 | |
| Avamere Rehabilitation at Ridgemont | Port Orchard | 4 of 5 | 6 | $0 | 12 Sep 2025 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Martha and Mary Health Service (CCN 505474). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/martha-and-mary-health-service-poulsbo-wa-505474/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Martha and Mary Health Service last inspected?
- The latest inspection with a citation in the CMS record was on 13 May 2026. It was a complaint investigation. It gave 1 citation. The standard survey before the last one was on 16 Dec 2024.
- Who operates Martha and Mary Health Service?
- The CMS record gives the ownership type as non-profit, corporation. CMS lists no chain for the home. The CMS ownership file names no organisation for this home. This site does not show the names of persons.
- Is Martha and Mary Health Service a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 1 home in Washington as a Special Focus Facility and 5 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.