MARTHA AND MARY HEALTH SERVICE
19160 FRONT STREET NORTHEAST, POULSBO, WA, 98370 · 3607797500
Legal business name: MARTHA AND MARY HEALTH SERVICES
On the CMS record
- Overall rating (CMS)
- 4 / 5
- Health inspection rating
- 3 / 5
- Staffing rating
- 4 / 5
- Certified beds
- 135
- Ownership type
- Non profit - Corporation
Inspection findings on record (46)
Quoted exactly as CMS published them. We do not rewrite findings.
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
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.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Recorded as corrected on .
— Administration Deficiencies
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.
Recorded as corrected on .
— Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 505474