Martha and Mary Health Service

Name: Martha and Mary Health Service
Address: 19160 FRONT STREET NORTHEAST, Poulsbo, WA, 98370, US
Telephone: 3607797500

19160 Front Street Northeast, Poulsbo, WA 98370 · Kitsap County · 135 certified beds · avg 111 residents/day · certified since Jul 1, 1992

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.94

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (46)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 13, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Apr 13, 2026	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 13, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 13, 2026	E · Potential for harm, repeated	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 13, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 13, 2026	D · Potential for harm, one-off	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Feb 13, 2026	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 13, 2026	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Feb 13, 2026	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Feb 13, 2026	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Feb 13, 2026	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 13, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Apr 14, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Dec 16, 2024	E · Potential for harm, repeated	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Dec 16, 2024	E · Potential for harm, repeated	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Dec 16, 2024	E · Potential for harm, repeated	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Dec 16, 2024	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Dec 16, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Dec 16, 2024	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 16, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 16, 2024	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Jul 8, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Oct 27, 2023	E · Potential for harm, repeated	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · from a complaint
Oct 27, 2023	E · Potential for harm, repeated	The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Oct 27, 2023	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 27, 2023	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (16 → 9).

Year	Citations	Worst severity that year
2023	16	E
2024	17	E
2025	2	D
2026	11	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Washington avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.94	4.24	3.95	bottom 46% in Washington; top 42% in the U.S.
Registered Nurse hours	0.92	0.91	0.69	top 41% in Washington; top 20% in the U.S.
Weekend total nurse staffing	3.35	3.69	3.50	bottom 41% in Washington; bottom 50% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.74	0.67	0.48	top 33% in Washington; top 14% in the U.S.
Total nursing staff turnover (%)	35.9	45.1	45.8	top 26% in Washington; top 26% in the U.S.
RN turnover (%)	22.6	45.4	42.9	top 10% in Washington; top 18% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.77, RN 1.11, weekend 4.05. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Koerner, Edward	Individual	Operational/Managerial Control	NOT APPLICABLE	09/23/2024
Koerner, Edward	Individual	ADP of the SNF	NOT APPLICABLE	09/23/2024
Ladenburg, Lynette	Individual	Managing Control - Governing Body	NOT APPLICABLE	10/31/2016
Ladenburg, Lynette	Individual	Corporate Officer	NOT APPLICABLE	10/31/2016
Ladenburg, Lynette	Individual	Operational/Managerial Control	NOT APPLICABLE	10/31/2016
Ladenburg, Lynette	Individual	ADP of the SNF	NOT APPLICABLE	10/31/2016
Oconer, Ellen	Individual	Operational/Managerial Control	NOT APPLICABLE	11/01/2016
Oconer, Ellen	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2016
Sharman, Donald	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2021
Sharman, Donald	Individual	ADP of the SNF	NOT APPLICABLE	04/24/2025
Vernon-Cole, Christopher	Individual	Corporate Officer	NOT APPLICABLE	04/25/2017
Vernon-Cole, Christopher	Individual	ADP of the SNF	NOT APPLICABLE	04/25/2017

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Northwoods Lodge	4.5 mi	Silverdale, WA	★★★★★	4/5
Bainbridge Island Health & Rehab Center	9.5 mi	Bainbridge Island, WA	★★★★★	5/5
Bremerton Trails Post Acute	10.6 mi	Bremerton, WA	★☆☆☆☆	1/5	SFF
Belmont Terrace	10.7 mi	Bremerton, WA	★★★☆☆	2/5
Port Washington Post Acute	12.0 mi	Bremerton, WA	★☆☆☆☆	1/5
Richmond Beach Rehab	12.7 mi	Shoreline, WA	★★★★☆	3/5
Washington Veteran Home-Retsil	13.3 mi	Pt Orchard, WA	★★★★☆	3/5
Ballard Center	13.3 mi	Seattle, WA	★★☆☆☆	2/5
The Broadview Center	13.5 mi	Seattle, WA	★★☆☆☆	1/5
Bridges to Home	14.6 mi	Shoreline, WA	★★☆☆☆	2/5
Columbia Lutheran Home	14.9 mi	Seattle, WA	★★★★☆	3/5
Life Care Center of Port Orchard	15.2 mi	Port Orchard, WA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Poulsbo →

Facility data as of CMS processing date 2026-08-01. CCN 505474.

The Care File

Visit checklist — Martha and Mary Health Service

19160 Front Street Northeast, Poulsbo, WA 98370 · 3607797500

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 505474 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)