MARTHA AND MARY HEALTH SERVICE

πŸ“ 19160 FRONT STREET NORTHEAST, poulsbo, WA 98370 πŸ“ž 3607797500 πŸ›οΈ 190 beds

Overall Rating

⭐⭐⭐⭐⭐
5/5

Health Inspection

⭐⭐⭐⭐
4/5

Staffing

⭐⭐⭐⭐
4/5

Quality Measures

⭐⭐⭐⭐⭐
5/5

Inspection History Overview

73
Total Violations
7 years of data
$13,635
Total Fines
1 penalties
4
Inspections
Since 2014
21
Quality Metrics
Tracked measures

Health Violations by Year

2025 2 violations

Tag 0684 D May 13, 2025

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

βœ“ Corrected: Jun 11, 2025
Tag 0677 D Apr 14, 2025

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

βœ“ Corrected: May 23, 2025

2024 1 violations

Tag 0880 E Jul 8, 2024

Provide and implement an infection prevention and control program.

βœ“ Corrected: Aug 16, 2024

2023 16 violations

Tag 0561 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0584 D Oct 27, 2023

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.

βœ“ Corrected: Dec 11, 2023
Tag 0636 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0638 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0657 D Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0658 D Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0677 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0684 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0690 D Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0695 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0725 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0810 D Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0812 E Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023
Tag 0849 D Oct 27, 2023

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.

βœ“ Corrected: Dec 11, 2023
Tag 0880 E Oct 27, 2023

Provide and implement an infection prevention and control program.

βœ“ Corrected: Dec 11, 2023
Tag 0883 D Oct 27, 2023

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

βœ“ Corrected: Dec 11, 2023

2022 12 violations

Tag 0561 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0580 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0604 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0677 E Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0692 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0725 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0758 D Oct 20, 2022

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.

βœ“ Corrected: Dec 2, 2022
Tag 0759 D Oct 20, 2022

Ensure medication error rates are not 5 percent or greater.

βœ“ Corrected: Dec 2, 2022
Tag 0778 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0812 F Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0868 D Oct 20, 2022

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

βœ“ Corrected: Dec 2, 2022
Tag 0881 D Oct 20, 2022

Implement a program that monitors antibiotic use.

βœ“ Corrected: Dec 2, 2022

2019 18 violations

Tag 0552 D Sep 12, 2019

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

βœ“ Corrected: Oct 25, 2019
Tag 0578 D Sep 12, 2019

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

βœ“ Corrected: Oct 25, 2019
Tag 0584 D Sep 12, 2019

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.

βœ“ Corrected: Oct 25, 2019
Tag 0600 D Sep 12, 2019

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

βœ“ Corrected: Oct 25, 2019
Tag 0609 D Sep 12, 2019

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

βœ“ Corrected: Oct 25, 2019
Tag 0610 D Sep 12, 2019

Respond appropriately to all alleged violations.

βœ“ Corrected: Oct 25, 2019
Tag 0623 F Sep 12, 2019

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

βœ“ Corrected: Oct 25, 2019
Tag 0625 D Sep 12, 2019

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

βœ“ Corrected: Oct 25, 2019
Tag 0658 D Sep 12, 2019

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

βœ“ Corrected: Oct 25, 2019
Tag 0676 D Sep 12, 2019

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

βœ“ Corrected: Oct 25, 2019
Tag 0677 E Sep 12, 2019

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

βœ“ Corrected: Oct 25, 2019
Tag 0689 E Sep 12, 2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

βœ“ Corrected: Oct 25, 2019
Tag 0690 D Sep 12, 2019

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

βœ“ Corrected: Oct 25, 2019
Tag 0692 D Sep 12, 2019

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

βœ“ Corrected: Oct 25, 2019
Tag 0732 C Sep 12, 2019

Post nurse staffing information every day.

βœ“ Corrected: Oct 25, 2019
Tag 0744 D Sep 12, 2019

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

βœ“ Corrected: Oct 25, 2019
Tag 0758 E Sep 12, 2019

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.

βœ“ Corrected: Oct 25, 2019
Tag 0759 D Sep 12, 2019

Ensure medication error rates are not 5 percent or greater.

βœ“ Corrected: Oct 25, 2019

2018 16 violations

Tag 0552 D Sep 18, 2018

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

βœ“ Corrected: Nov 15, 2018
Tag 0554 D Sep 18, 2018

Allow residents to self-administer drugs if determined clinically appropriate.

βœ“ Corrected: Nov 15, 2018
Tag 0578 E Sep 18, 2018

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

βœ“ Corrected: Nov 15, 2018
Tag 0584 D Sep 18, 2018

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.

βœ“ Corrected: Nov 15, 2018
Tag 0636 D Sep 18, 2018

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

βœ“ Corrected: Nov 15, 2018
Tag 0641 D Sep 18, 2018

Ensure each resident receives an accurate assessment.

βœ“ Corrected: Nov 15, 2018
Tag 0655 D Sep 18, 2018

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

βœ“ Corrected: Nov 15, 2018
Tag 0656 D Sep 18, 2018

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

βœ“ Corrected: Nov 15, 2018
Tag 0657 D Sep 18, 2018

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

βœ“ Corrected: Nov 15, 2018
Tag 0689 D Sep 18, 2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

βœ“ Corrected: Nov 15, 2018
Tag 0693 D Sep 18, 2018

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

βœ“ Corrected: Nov 15, 2018
Tag 0697 D Sep 18, 2018

Provide safe, appropriate pain management for a resident who requires such services.

βœ“ Corrected: Nov 15, 2018
Tag 0757 D Sep 18, 2018

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

βœ“ Corrected: Nov 15, 2018
Tag 0758 D Sep 18, 2018

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.

βœ“ Corrected: Nov 15, 2018
Tag 0759 D Sep 18, 2018

Ensure medication error rates are not 5 percent or greater.

βœ“ Corrected: Nov 15, 2018
Tag 0761 D Sep 18, 2018

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

βœ“ Corrected: Nov 15, 2018

2017 8 violations

Tag 0223 G Aug 31, 2017

Protect each resident from all abuse, physical punishment, and involuntary separation from others.

βœ“ Corrected: Oct 14, 2017
Tag 0225 E Aug 31, 2017

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

βœ“ Corrected: Oct 14, 2017
Tag 0226 E Aug 31, 2017

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

βœ“ Corrected: Oct 14, 2017
Tag 0280 D Aug 31, 2017

Allow residents the right to participate in the planning or revision of care and treatment.

βœ“ Corrected: Oct 14, 2017
Tag 0323 D Aug 31, 2017

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

βœ“ Corrected: Oct 14, 2017
Tag 0371 E Aug 31, 2017

Store, cook, and serve food in a safe and clean way.

βœ“ Corrected: Oct 14, 2017
Tag 0441 D Aug 31, 2017

Have a program that investigates, controls and keeps infection from spreading.

βœ“ Corrected: Oct 14, 2017
Tag 0464 E Aug 31, 2017

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

βœ“ Corrected: Oct 14, 2017

Detailed Inspection Reports

No detailed inspection reports available yet. Check back soon as we're processing new reports daily.

Fines and Penalties by Year

2017 1 penalties totaling $13,635

$13,635
Fine
August 31, 2017
Average: $13,635 | Range: $13,635 - $13,635

Fire Safety Deficiencies

Unknown Date

No description available

Inspection Survey Reports

Health

July 8, 2024
0.00

Health

October 27, 2023
0.00

Health

October 20, 2022
0.00

Health

September 12, 2019
0.00

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Ownership Information

Non profit - Corporation
Independent (Not part of a chain)
505474
505474
3607797500
Kitsap

Historical Ownership Records

August 25, 2025
Individual
August 25, 2025
Individual
August 25, 2025
Individual