Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MARTHA AND MARY HEALTH SERVICE

POULSBO, WA · 135 certified beds · Last Life Safety survey February 13, 2026

CMS Certification Number 505474 · first certified July 1992

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WA

14 citations — more than 6% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was February 2026. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index

F-0584 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.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	14
Median facility in WA	31
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
October 27, 2023	2
December 16, 2024	7
February 13, 2026	5

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2026-02-13
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-12-16
K-0363	Install corridor and hallway doors that block smoke.	2	2026-02-13
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	2	2026-02-13
K-0293	Have properly located and lighted "Exit" signs.	1	2024-12-16
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	1	2024-12-16
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	1	2026-02-13
K-0920	Ensure proper usage of power strips and extension cords.	1	2026-02-13

What the citations cover

Citations by CMS category

Smoke Deficiencies 7
Gas, Vacuum, and Electrical Systems Deficiencies 4
Egress Deficiencies 2
Services Deficiencies 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	7
Gas, Vacuum, and Electrical Systems Deficiencies	4
Egress Deficiencies	2
Services Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 13, 2026 — 5 citations

Citations issued on February 13, 2026
Tag	What the surveyor checks	Status
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (March 16, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 16, 2026)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (March 16, 2026)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (March 16, 2026)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (March 16, 2026)

December 16, 2024 — 7 citations

Citations issued on December 16, 2024
Tag	What the surveyor checks	Status
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (December 23, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 14, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (January 13, 2025)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (December 19, 2024)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (December 13, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (December 23, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 5, 2025)

October 27, 2023 — 2 citations

Citations issued on October 27, 2023
Tag	What the surveyor checks	Status
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 28, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 28, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.