Home / Washington / Poulsbo
19160 Front Street Northeast, Poulsbo, WA 98370 · Kitsap County · (360) 779-7500
135 certified beds, about 111 residents a day · Non profit - Corporation · Medicare and Medicaid since 1992
CMS Care Compare ratings, data as of September 1, 2026 · CCN 505474 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 13, 2026, inspectors cited 9 health deficiencies (the Washington average is 15.8, the national average 9.2).
None of its 46 health citations since October 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.77 hours per resident per day, against 4.36 across Washington and 3.86 nationally. Registered nurses accounted for 1.11 of those hours.
35.9% of nursing staff left within the year CMS measured (Washington average 45.1%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to assess, monitor and document a controlled fall timely for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk of delayed medical intervention and pain.
Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the state agency timely for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of abuse, fear and delayed investigation.
Inspectors wroteBased on interview and record review, the facility failed to initiate the bowel protocol and accurately document bowel protocol interventions for 4 of 6 sampled residents (Resident 12, 8, 58 & 63) reviewed for bowel care. The failure to initiate and document bowel care, placed residents at risk for pain/discomfort, unmet care needs and other potentially negative health outcomes.
Inspectors wroteBased on interview, and record review, the facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 2 of 2 residents (Residents 16 & 4) reviewed with a fluid restriction. The failure to accurately record fluid intake and to calculate the 24-hour fluid intake total, precluded staff from determining if residents was adherent with or were exceeding the fluid restriction. This placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unidentified education needs and other medical complications.
Inspectors wroteBased on interview and record review, the facility failed to provide documentation of records and evidence of real time analysis of their infection control program for 2 of 6 months (December 2025 and January 2026) reviewed for monthly line listings, monthly maps and/or monthly summaries for the facility's surveillance program. These failures could prevent the facility from identifying trends and implementing interventions that would prevent residents from acquiring facility related infections.
Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate resident choice related to frequency and type of bathing and access to fluids of choice for 3 of 3 residents (Residents 4, 38 & 6) reviewed for choices. The failure to promote and facilitate resident self-determination by offering and honoring residents' choices related to bathing type and frequency and access to beverages of choice, placed residents at risk for poor hygiene, dehydration, feelings of powerlessness, and diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable and homelike environment on 1 of 2 shower rooms ([NAME] Unit). The failure to ensure the floor was clean and in good repair and the vinyl wall panels were free of damage (cracks, missing pieces etc) placed resident at risk for a diminished quality of life and resulted in a less than homelike environment.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 3 of 24 residents (Residents 4, 16 & 38) whose care plans were reviewed. These failures placed residents at risk for unidentified and/or unmet care needs and diminished quality of life.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure bathing services were provided as scheduled, or reoffered if refused, for 1 of 1 resident (Resident 14) reviewed for Activities of Daily Living (ADL) care. This failure placed residents at risk for poor hygiene, skin breakdown, reduced dignity and a diminished quality of life.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered within ordered parameters for 1 of 5 residents (Resident 3) reviewed for unnecessary medications. This failure placed residents at risk of receiving medications outside of ordered parameters and a decreased quality of life.
Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a medication error rate of less than 5%, by having an error rate of 8%, with 2 of 25 medication administration errors for observed opportunities. This failure placed residents at risk of medication complications, misuse of medications, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for a surgical wound for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, infections and discomfort.
Inspectors wroteBased on interview and record review, the facility failed to provide assistance with toileting and bed mobility for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for skin breakdown, poor hygiene and pain.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 25 sampled residents (Residents 73, 99, 81, 8, 11 and 91) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess residents for the use of bed rails/mobility bars for 4 of 5 residents (Residents 11, 51, 40,and 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to use nonpharmacological interventions (NPI, nonmedicated methods of achieving an outcome) prior to the use of as needed (PRN) pain medications for 4 of 8 sampled residents (Residents 11, 24, 78 and 355) when reviewed for unnecessary medications and pain. This failure placed residents at risk of avoidable side effects, taking unneeded medications, and a diminished quality of life.
Inspectors wroteAMENDED 01/02/2024 Based on interview and record review, the facility failed to ensure 7 of 7 sampled residents (Residents 11, 73, 78, 27, 62, 22, and 82) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to fully complete the Abnormal Involuntary Movement Scale (AIMS, an assessment used to determine the severity of abnormal movements in a patient's body) for residents using antipsychotic (a class of drugs used to treat mental health conditions characterized by psychosis) medication. The facility also failed to identify, monitor, and document observed target behaviors and non-pharmacological interventions. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, unmet needs, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents on enhanced barrier precautions (EBP, infection control precaution of wearing gown and gloves during high contact activities during resident care) had precaution signage implemented correctly for 5 out of 14 residents (Residents 19, 576, 59, 24, and 155) reviewed for EBP, that infection control precautions were followed for 2 of 3 residents (Residents 54 and 91) sampled for observation of infection control practices, the antibiotic surveillance was accurate and complete, the Legionella Water Management Program identified and monitored internal areas of risk, and to store and clean continuous positive airway pressure machines (CPAP, device that uses mild air pressure to keep breathing airways open while you sleep) for 1 of 3 residents (Resident 51) reviewed for CPAP. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were provided accurate information regarding the risks and benefits associated with proposed drug therapies for 2 of 5 sampled residents (Residents 11 & 73) reviewed for unnecessary medications. The failure to accurately identify medication/drug class and associated adverse side effects (ASEs) detracted from residents' ability to make informed decisions about proposed drug therapies, and placed them at risk for making treatment decisions based on inaccurate information.
Inspectors wroteBased on observations, interview, and record review the facility failed to obtain an assessment, orders, consent, and develop a care plan for the use of potential restraints for 1 of 4 residents (Resident 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set Assessments (MDS), assessment tool, were accurate for 2 of 25 sampled residents (Residents 54 and 11). This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses and Level II PASRR evaluations were timely referred and completed for 1 of 5 residents (Resident 73) reviewed for PASRRs. The failure to ensure Level I PASRRs were accurately completed, and residents were timely referred for Level II PASRR evaluations, placed residents at risk for inappropriate placement, and not receiving timely and necessary mental health services to meet their mental health needs.
Inspectors wroteBased on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to included resident specific information for 5 of 25 sampled residents (Residents 59, 78, 91, 11 & 51) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 25 sampled residents (Residents 73, 51 and 40) reviewed for professional standards. Facility staff failed to timely transcribe and timely carry out physician orders, and/or clarify confusing or incomplete orders. Additionally, staff failed to ensure medications were secure, as nurses left the medication cart unlocked when unattended and/or left medication at a residents' bedside without an order to do so, or a self-medication assessment being completed. These failures placed residents at risk for medication errors, complications of treatments, and other potential negative health outcomes.
Inspectors wroteBased on interview and record review the facility failed to provide assistance with bathing for 1 of 5 residents (Resident 90) reviewed for activities of daily living (ADLs). The failed practice placed residents at risk for a decline in care and quality of life.
Inspectors wroteBased on interview and record review, the facility failed to implement care and services in accordance with accepted professional standards for 3 of 6 residents (Residents 82, 11, and 99) reviewed for quality of care related to bowel management and hospice services. This failure placed the residents at risk for discomfort and complications related to constipation and risk for substandard care related to lack of coordination with hospice (provides end of life orders/interventions).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pressure relieving device was working correctly for 1 of 3 sampled residents (Resident 81) reviewed for pressure ulcers. This failure placed residents at risk for delayed healing and further skin impairment.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen (O2), continuous positive airway pressure services (CPAP, an external device that provides a fixed pressure to keep breathing airways open while you sleep), and breathing treatments via nebulizer (a machine that turns liquid medicine into a mist that can be inhaled) were provided in accordance with accepted professional standards of practice for 3 of 5 residents (Residents 73, 51 and 81) reviewed for respiratory care. The failure of staff to document the amount of O2 administered, to ensure O2 orders included checking and replacing of humidifier bottles, and CPAP orders included the prescribed pressure settings, type of mask to be used (e.g. nasal pillows, nasal mask, full face mask), direction to check and refill the humidifier reservoir, and identification of the solution to be used (e.g. [...]
Inspectors wroteBased on interview and record review, the facility failed to promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for 1 of 5 sample residents (Resident 73) reviewed for unnecessary medications. This failure placed residents at risk for delayed treatment and potential negative outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 3 staff members (Staff A, B and C) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident choices regarding bathing frequency were honored for 4 of 4 residents (Residents 33, 100, 73 and 19) reviewed for choices related to bathing. The facility's failure to accommodate resident preferences related to frequency of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident admission and annual Minimum Data Sets (MDS, an assessment tool) were completed within the required timeframes for 8 of 11 sampled residents (Residents 1, 37, 26, 49, 43, 75, 33 & 94) reviewed for resident assessments. Failure to complete admission and annual assessments within the required timeframes, placed residents at risk for a delay in identification of care needs and/or unmet care needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident quarterly Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of the assessment reference date (ARD) as required for 9 of 11 residents (Residents 1, 37, 26, 49, 43, 75, 33, 90 & 94) reviewed for resident assessments. Failure to timely complete resident quarterly assessments, placed residents at risk for a delay in identification of care needs and/or unmet care needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include trimming residents' fingernails and toenails and providing assistance with eating for 3 of 4 dependent residents (Residents 100, 19 & 97) reviewed for ADL's. The failure to provide assistance with eating and nail care to dependent residents, placed them at risk for decreased intake, weight loss, poor hygiene, embarrassment, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services as ordered for 4 of 7 residents (Residents 93, 31, 97 and 51) reviewed for bowel management. The failure to provide bowel care in accordance with the facility's bowel protocol and/or physician's orders placed residents at risk for constipation, pain/discomfort and other potential negative health outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice and physicians' orders for 2 of 2 residents (Residents 97 & 100) reviewed for respiratory care. The facility's failure to ensure nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs) tubing and masks were cleaned and periodically changed, and a residents' peripheral oxygen saturation were monitored, as ordered to determine if administration of supplemental oxygen was indicated, placed residents at risk for unidentified and/or unmet respiratory needs and potential negative outcomes.
Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff to assess resident care needs, and to provide and supervise that care as evidenced by the failure to complete resident assessments within required time frames for 8 of 11 residents (Residents 1, 37, 26, 49, 43, 75, 33 & 94) reviewed, to honor resident preferences related to bathing frequency for 4 of 4 residents (Residents 33, 100, 73 and 19) reviewed for choices, and to provide assistance with activities of daily living (ADLs) for 3 of 4 dependent residents (Residents 100, 19 & 97) reviewed for ADLs. These failures placed residents at risk for poor hygiene, unidentified and unmet care needs, feelings of powerlessness, and decreased quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 3 of 3 nourishment refrigerators (Bay Unit, Hydration Station, and [NAME] Unit). This failure placed residents at risk for cross-contamination and food borne illness.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control principles were followed related to management of urinary drainage bags, proper use of Personal Protective Equipment (PPE), appropriate infection control measures during COVID-19 (a disease which can be very contagious and spreads quickly and capable of progressing to severe symptoms including death) testing, and following transmission-based precautions (TBP) for COVID-19 virus for 4 of 8 sampled residents (97, 102, 10 & 311) reviewed for infection control measures related to urinary drainage bags, PPE, COVID-19 testing and TBP. These failures placed residents at risk for contracting COVID-19 and a diminished quality of life.
Inspectors wroteBased on observation and interview, the facility failed to ensure visibly dirty/soiled bed linen was removed and clean linen provided for 1 of 2 residents (Resident 97) reviewed for environment. This failure placed the resident at risk of feeling unclean, undignified, for potential infections and diminished self-worth.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised and accurately reflected resident care needs for 3 of 25 sampled residents (Resident 97, 73, and 100) reviewed for care plans. This placed residents at risk for unmet care needs and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 25 sampled residents (Residents 97 & 100) reviewed. The failure to follow and/or clarify physicians' orders when indicated and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) were assessed for catheter removal as soon as possible, had a documented justification for ongoing catheter use if removal was contraindicated, or were referred to urology for evaluation in the absence of a documented justification. Additionally, the facility failed to ensure catheter care and management was provided in a manner that minimized the risk for complications and catheter related urinary tract infections for 1 of 2 residents (Resident 97) reviewed for urinary catheters. These failures placed residents at risk for catheter associated urinary tract infections and other potential negative health complications/outcomes.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide adaptive equipment with meals, for 1 of 1 resident (Resident 100) reviewed and who required assistance. Failure to provide adaptive equipment placed residents at risk for decreased independence with self-feeding, poor meal intake, and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to designate a member of their inter-disciplinary team (IDT) who would be responsible for working with hospice representatives to ensure effective coordination of care between the facility and hospice staff, for 1 of 1 resident (Resident 97) reviewed for hospice services. Additionally, the facility failed to obtain a copy of the resident's hospice plan of care, which identified what services were to be provided, and which delineated hospice/facility responsibilities. These failures detracted from establishing a system by which consistent communication between the facility and hospice staff occurred and placed the residents at risk for not for receiving necessary care and services.
Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents (Resident 93) reviewed for pneumonia vaccinations. This failure placed residents at risk for developing pneumonia with potential negative outcomes.
14 fire safety citations on file: 5 on February 13, 2026, 7 on December 16, 2024, 2 on October 27, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Washington | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.77 | 4.36 | 3.86 |
| Registered nurses | 1.11 | 0.94 | 0.69 |
| All nursing staff on weekends | 4.05 | 3.80 | 3.42 |
| Nurse aides | 3.04 | ||
| Licensed practical nurses | 0.62 | ||
| Nursing staff turnover (share who left in a year) | 35.9% | 45.1% | 45.8% |
| Registered nurse turnover | 22.6% | 45.4% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.64 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.06 on weekdays and 4.05 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 10.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.84 in April to June 2025 to 4.77 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.77 | 1.11 | 5.06 | 4.05 | 10.1% | 0 of 90 | 111 |
| Oct to Dec 2025 | 4.69 | 1.07 | 4.99 | 3.95 | 7.3% | 0 of 92 | 108 |
| Jul to Sep 2025 | 4.72 | 1.05 | 5.03 | 3.93 | 5.5% | 0 of 92 | 108 |
| Apr to Jun 2025 | 4.84 | 1.09 | 5.20 | 3.94 | 7.2% | 0 of 91 | 110 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Washington, Jan to Mar 2026 | 4.21 | 0.90 | 4.44 | 3.66 | 3.7% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Washington, all employers | |||
| CNAs (nursing assistants) | $23.65 | $22.59 to $27.85 | 30,270 |
| LPNs and LVNs | $39.98 | $36.98 to $45.18 | 6,780 |
| Registered nurses | $59.71 | $49.57 to $64.54 | 69,260 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Washington | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.3 | 14.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.0 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.1 | 2.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.0 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.9 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 0.5 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.9 | 15.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.4 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 10.8 | 13.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.3 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Martha and Mary Health Service's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
55.4% this home
No different from the national rate
US median of homes 51.5% · Washington: 71 better, 16 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 121 eligible stays.
9.1% this home
No different from the national rate
US median of homes 10.7% · Washington: 7 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 117 eligible stays.
6.0% this home
No different from the national rate
US median of homes 7.1% · Washington: 4 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 87 eligible stays.
76.8% this home
Median of homes: Washington61.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 69 residents counted.
0.8% this home
Median of homes: Washington0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 123 residents counted.
0.7% this home
Median of homes: Washington1.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 123 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Washington98.3% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 10 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: MARTHA AND MARY HEALTH SERVICES.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ladenburg, Lynette | Managing control - governing body | Individual | 10/31/2016 | |
| Ladenburg, Lynette | Corporate officer | Individual | 10/31/2016 | |
| Vernon-Cole, Christopher | Corporate officer | Individual | 04/25/2017 | |
| Koerner, Edward | Operational/managerial control | Individual | 09/23/2024 | |
| Ladenburg, Lynette | Operational/managerial control | Individual | 10/31/2016 | |
| Oconer, Ellen | Operational/managerial control | Individual | 11/01/2016 | |
| Sharman, Donald | Operational/managerial control | Individual | 04/01/2021 | |
| Koerner, Edward | Adp of the SNF | Individual | 09/23/2024 | |
| Ladenburg, Lynette | Adp of the SNF | Individual | 10/31/2016 | |
| Oconer, Ellen | Adp of the SNF | Individual | 11/01/2016 | |
| Sharman, Donald | Adp of the SNF | Individual | 04/24/2025 | |
| Vernon-Cole, Christopher | Adp of the SNF | Individual | 04/25/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Washington. NursingHomeClear cannot take or act on complaints.