B86

MARTHA AND MARY HEALTH SERVICE

Grade B 86/100 composite score

For profit - Individual

CMS Star Ratings

Overall
4/5
Health Insp.
3/5
Quality
5/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

135

Ownership

For profit - Individual

Total Fines

None

Last Survey

N/A

19160 FRONT STREET NORTHEAST, POULSBO, WA 98370
3607797500

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.87h
LPN
0.65h
CNA
2.39h
Total
3.91h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

KOERNER, EDWARD

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2024

LADENBURG, LYNETTE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2016

OCONER, ELLEN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Nov 2016

SHARMAN, DONALD

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2021

LADENBURG, LYNETTE

IndividualCORPORATE OFFICERSince Oct 2016

VERNON-COLE, CHRISTOPHER

IndividualCORPORATE OFFICERSince Apr 2017

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (45)

May 13, 2025Health1 deficiency
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jun 11, 2025
December 16, 2024Health16 deficiencies
0552DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Jan 24, 2025
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 24, 2025
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Jan 24, 2025
0656DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Jan 24, 2025
0657EMinimal harm, Pattern

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

Resident Assessment and Care Planning Deficiencies

Corrected Jan 24, 2025
0658DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Jan 24, 2025
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 24, 2025
0686DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 24, 2025
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 24, 2025
0700EMinimal harm, Pattern

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.

Quality of Life and Care Deficiencies

Corrected Jan 24, 2025
0757EMinimal harm, Pattern

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

Pharmacy Service Deficiencies

Corrected Jan 24, 2025
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Jan 24, 2025
0773DMinimal harm, Isolated

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

Administration Deficiencies

Corrected Jan 24, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 24, 2025
0604DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 24, 2025
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jan 24, 2025
October 27, 2023Health16 deficiencies
0658DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 11, 2023
0684EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Dec 11, 2023
0690DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Dec 11, 2023
0695EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Dec 11, 2023
0725EMinimal harm, Pattern

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

Nursing and Physician Services Deficiencies

Corrected Dec 11, 2023
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Dec 11, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 11, 2023
0638EMinimal harm, Pattern

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 11, 2023
0561EMinimal harm, Pattern

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

Resident Rights Deficiencies

Corrected Dec 11, 2023
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Dec 11, 2023
0636EMinimal harm, Pattern

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 11, 2023
0657DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 11, 2023
0677EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Dec 11, 2023
0810DMinimal harm, Isolated

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

Nutrition and Dietary Deficiencies

Corrected Dec 11, 2023
0812EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Dec 11, 2023
0883DMinimal harm, Isolated

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

Infection Control Deficiencies

Corrected Dec 11, 2023
October 20, 2022Health12 deficiencies
0580DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Dec 2, 2022
0604DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 2, 2022
0677EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Dec 2, 2022
0725DMinimal harm, Isolated

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

Nursing and Physician Services Deficiencies

Corrected Dec 2, 2022
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 2, 2022
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Dec 2, 2022
0778DMinimal harm, Isolated

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

Administration Deficiencies

Corrected Dec 2, 2022
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Dec 2, 2022
0881DMinimal harm, Isolated

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Dec 2, 2022
0561DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Dec 2, 2022
0692DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Dec 2, 2022
0868DMinimal harm, Isolated

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

Administration Deficiencies

Corrected Dec 2, 2022

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Frequently Asked Questions

What is the CareGrader rating for MARTHA AND MARY HEALTH SERVICE?

MARTHA AND MARY HEALTH SERVICE in POULSBO, Washington has a CareGrader grade of B (Good), with a composite score of 86.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for MARTHA AND MARY HEALTH SERVICE?

MARTHA AND MARY HEALTH SERVICE has an overall CMS star rating of 4 out of 5, a health inspection rating of 3/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does MARTHA AND MARY HEALTH SERVICE have?

MARTHA AND MARY HEALTH SERVICE has 45 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does MARTHA AND MARY HEALTH SERVICE have?

MARTHA AND MARY HEALTH SERVICE has 135 certified beds with approximately 107 current residents (79% occupancy). The facility is located at 19160 FRONT STREET NORTHEAST, POULSBO, Washington 98370. It is a for profit - individual facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.