St Michael Medical Center
An acute care hospital in Silverdale, Washington 98383
1800 NW Myhre Rd, Silverdale, Washington 98383. (360) 377-3911.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 4of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 3 deficiencies cited in the last three years (needs attention)
- 297 beds
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Apr 15, 2025: a complaint inspection.
3 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 2 months of the last 36. Last cited Apr 2025. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 15, 2025: complaint inspection1 deficiency
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Patient Rights: Restraint Or Seclusion
The inspectors’ words, 355 words
“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 27347 Based on interview and document review, the hospital failed to ensure staff removed restraints at the earliest possible time for 3 of 11 patient records reviewed (#1, #3, & #10). Failure to ensure that staff limit the use of restraints risks physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital policy and procedure titled, “Restraint and Seclusion Policy, 964,” revised 07/08/24, showed that staff must assess and monitor the patient’s condition on an ongoing basis so the patient is released from the restraints at the earliest possible time regardless of the scheduled expiration of the order. 2. On 04/10/25 between 9:00 AM and 12:00 PM, the investigator and the Health Educator (Staff #1) reviewed medical records of patients who had been placed in restraints for violent or self -destructive behavior. The review showed the following: a) On 03/01/25 at 12:00 AM, a provider ordered non-violent restraints to prevent Patient #1 from removing medical devices. During the every 2 hour required rounding for patients in non-violent restraints, at 2:00 AM and 4:00 AM, the patient was documented as sleeping and the restraints were left in place. At 6:00 AM the patient continued to sleep and the restraints were removed. b) On 03/01/25 at 5:30 PM, a provider ordered non-violent restraints to prevent Patient #3 from removing medical devices. During the 2-hour restraint assessments on 03/02/25 at 12:00 AM, 2:00 AM, and 4:00 AM, staff failed to remove the restraints despite documenting that the patient was sleeping. Staff documented removal of the restraints at 6:00 AM. c) On 08/29/24 at 10:15 PM, a provider ordered non-violent restraints to prevent Patient #10 from removing a medical device. On 08/30/24 at 2:00 AM, staff documented the patient was sleeping, but the restraints were not removed until 4:00 AM. 3. At the time of the review, Staff #1 confirmed the findings above.”
Mar 25, 2024: complaint inspection2 deficiencies
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Nursing Services
The inspectors’ words, 190 words
“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 38532 . Based on observation, interview, and document review, the hospital failed to ensure the Hospital operated under one unified nursing service under the direction of one Registered Nurse who was responsible for the quality of care provided to hospital patients by hospital and non-hospital nursing staff. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse accountable for the quality of nursing care provided to its patient’s places patients at risk for inconsistent or inadequate care, adverse outcomes, and death. Findings included: 1. The hospital failed to ensure that St. Michael Medical Center operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the services and the quality of the patient care provided by nursing services. Cross Reference: A0386 .”
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Organization Of Nursing Services
The inspectors’ words, 761 words
“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 38532 . Based on interview and document review, the hospital failed to ensure that St Michael Medical Center hospital operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the operation of the service and the quality of the patient care provided by nursing services. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse places patients at risk for suboptimal care, adverse outcomes, and death. Findings included: 1. Document review of the hospital’s organizational chart titled, “St. Michael Medical Center,” dated 02/24, showed the following: a. The Family Birth Center, Acute Care Services (Intensive Care Unit, Cardiovascular Progressive Care Unit, Progressive Care Unit Cardiopulmonary, the Hospital Registered Nurse Supervisors (RN) and Critical Care Educators), Emergency Services, Oncology Services, and Care Coordination reported directly to the Chief Nursing Officer. b. Perioperative Services including the Orthopedic Operating rooms, Orthopedic preadmission, and post anesthesia care unit, Cardiac Cath Lab and EP Lab, and the Main Operating Room also including Preoperative, Preadmissions, and Post Anesthesia Care Units reported directly to the St. Michaels Medical Center President. c. A notation on the document stated, “CNO has matrixed oversight for all nursing practice at St. Michael Medical Center.” d. The Organization chart stated that positions with a solid double line box indicated Direct Report director level and above. The position of Perioperative Services Director showed a double line box that linked directly to the Hospital President. Document review of the Job Description for the job title, “Director Perioperative Service,” states that the position reports to, “Depends on facility assigned.” Under the section titled, “Job Summary,” the document stated, “working with the Medical Director and other hospital department managers to integrate/coordinate/evaluate all phases of patient care,” and “providing input to the hospital President of development, implementation, monitoring, and other operational issues.” Investigator #5 was unable to determine any reporting structure to the CNO for Perioperative Services or the Perioperative Services Director. Document review of the Director of Perioperative Service’s (Staff #514) job evaluation titled, “Annual Performance Review FY23-Leader. Review Period 07/01/22-06/30/23 showed that the review was completed and signed by this staff person’s manager identified in the document as the President of St Michael Medical Center (Staff #513). Investigator #5 found no evidence the CNO was responsible for the operation of the service “Perioperative Services or evaluated the performance of Staff #514 as part of his/her responsibility for a single nursing service under the direction of one Registered Nurse. 2. On 03/07/23 at 3:28 PM, Investigator #5 and the President of St Michael Medical Center (Staff #513) discussed the hospital’s organizational chart and nursing services. Staff #513 verified that all Perioperative Services reported to him and that he was not a nurse. He stated that the organization’s philosophy was to work in a Dyad and that he and the CNO (Staff #516) give continuous feedback about services and practice. He stated that this is also completed during Performance Calibration Meetings. Staff #513 provided Investigator #5 with meeting minutes titled, “SMMC Performance Calibration Meeting, 06/19/23 4 PM-5PM.” The document showed a list of names titled “guests” with check marks next to their names that included Staff #513, #514, and #515. The CNO (Staff #516) and the Chief Medical Officer (Staff #517) were on the printed list, but the names were not checked. Staff #513 verified that the names were not checked but stated that the CNO was in attendance. Review of the meeting minutes showed that the document listed out and defined the purpose and process of the meeting. Investigator #5 found no evidence the CNO (Staff #516) provided input, or oversight for the Director of Perioperative Services (Staff #514) or any other documentation that would demonstrate that the hospital had only one nursing service hospital-wide and the single nursing service was under the direction of one RN (Staff #516). The document did not reflect any specific information for either Director level staff in attendance, Staff #514 or #515. .”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 15, 2025 | Complaint inspection | 1 deficiency cited |
| Sep 30, 2024 | Complaint inspection | No deficiencies cited |
| Mar 25, 2024 | Complaint inspection | 2 deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 4 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 2 better and 0 worse of 8; safety of care, 1 better and 0 worse of 7; readmission, 2 better and 0 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (728 surveys completed, Oct 1, 2024 to Sep 30, 2025): 68% rated it 9 or 10 out of 10, and 66% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), better than the national benchmark; catheter urinary tract infections (CAUTI), better than the national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.2%, heart failure 10.2%, pneumonia 13.9%, COPD 10.6%, stroke 8.1%, heart bypass surgery 1.4%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 13.4%, heart failure 17.3%, pneumonia 13.9%, COPD 23.1%, heart bypass surgery 11.4%, hip or knee replacement 5.5%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 205 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 4% left before being seen.
- 67% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.95 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 3 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 82% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Commonspirit Washington owns 100% directly since Aug 7, 2013.
- 21 owners or officers are people: David Hohimer (corporate director, 0%); Robert Carlile (corporate director); Diann E Puls (corporate director); Uli Han-Hsiang Chi (corporate director); Gregg S Meyer (corporate director); Robert Lemon (corporate director); Charles R Arnold (corporate director, 0%); David Nosacka (corporate officer, 0%); David Nosacka (managing employee (on the payroll), 0%); Karen T Lee (corporate director); John F Oppenheimer (corporate director); Anne Lupita Mcnamara (corporate director, 0%); David Butcherite (managing employee (on the payroll)); Carolyn Corvi (corporate director); Ketul J Patel (corporate officer, 0%); Ketul J Patel (corporate director, 0%); Ketul J Patel (managing employee (on the payroll), 0%); Miriam Chambliss (corporate officer, 0%); Ruth Elizabeth Goodwin (corporate director); Dennis Joseph Hunthausen (corporate director); Tod Hamachek (corporate director).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Commonspirit Health | Owns 5% or more through other companies | 100% | Aug 7, 2013 |
| Commonspirit Washington | Owns 5% or more directly | 100% | Aug 7, 2013 |
How does it compare nearby?
- No other hospital CMS lists is in Kitsap County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.