Federal Nursing-Home Survey Record
MARTHA AND MARY HEALTH SERVICE
Does MARTHA AND MARY HEALTH SERVICE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), MARTHA AND MARY HEALTH SERVICE (CCN 505474), in POULSBO, WA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 10 deficiencies; the most serious carries scope/severity E on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2026-02-13. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 5 · CMS state average: 3.3
Deficiency timeline — full federal history
Provide and implement an infection prevention and control program.
Provide enough food/fluids to maintain a resident's health.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure medication error rates are not 5 percent or greater.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
34 citations from earlier inspection cycles — historical, not current (expand)
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide and implement an infection prevention and control program.
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.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Ensure each resident receives an accurate assessment.
PASARR screening for Mental disorders or Intellectual Disabilities
Ensure that residents are fully informed and understand their health status, care and treatments.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide safe and appropriate respiratory care for a resident when needed.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Provide and implement an infection prevention and control program.
Provide safe and appropriate respiratory care for a resident when needed.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide and implement an infection prevention and control program.
Assure that each resident’s assessment is updated at least once every 3 months.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Ensure services provided by the nursing facility meet professional standards of quality.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Document what happened
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