Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Place At Martinez, The during CMS and state inspections, most recent first.
A facility failed to ensure its arbitration agreement was not required as a condition of admission or continued care. The admissions packet stated the arbitration provision was executed with the admission agreement and was part of that agreement, and the Administrator confirmed that all residents signed it and that it was not designated separately from the admission contract.
A facility arbitration agreement signed by all residents did not include a clause for selecting a venue convenient to both parties. Review of the admissions packet showed no process or statement for determining a neutral location, and the Administrator confirmed the agreement was part of the admission contract and was unaware the required venue language was missing.
Dirty Dining Room Vents and Soiled Wall Surfaces: The facility failed to maintain a sanitary main dining room when ceiling vents above residents’ tables were covered with fuzzy dust and dirt and the wall and floor below the kitchen pass-through window had spilled liquid or food debris. During observation, the DOM, who also served as the D of Housekeeping, acknowledged the vents were dirty, said they needed cleaning, and noted there was no documentation showing the vents had been cleaned every two weeks as expected.
Pureed Diet Menus Not Followed: Staff did not serve pureed meals as listed on the menu for residents on pureed diets. During breakfast observations, DAs served items such as pureed eggs, cream of wheat, and pureed oatmeal instead of the menu items called for, and the DM stated she was unaware the menus were not being followed.
Antibiotic stewardship failed when multiple residents received antibiotics without documented signs, symptoms, or lab findings meeting McGeer’s criteria. A resident with renal insufficiency and diabetes had a UA/C&S ordered and Omnicef started without symptom documentation, another resident with CAD and renal insufficiency received doxycycline for cough despite no fever and a negative chest x-ray, and a resident with Alzheimer’s disease and TBI received azithromycin for cough/congestion without completed infection documentation. Additional residents were treated with Macrobid for confusion or dysuria without supporting UTI criteria, and the record did not show physician notification or documented rationale when criteria were not met.
Missing pneumococcal vaccine offer/refusal documentation was cited for two residents. One resident had a prior Pneumovax 23 dose documented, but there was no record of the later pneumococcal vaccine being offered, received, or refused; another resident had no documentation showing the Pneumovax vaccine was offered or refused. The IP/WCN said vaccinations were being handled by an LPN, and the DON stated the facility reviews immunizations on admission, checks GRITS, and revisits Pneumovax and flu vaccine consents.
A resident with CIDP and intact cognition was assessed as needing setup or clean-up help for eating, but the adaptive equipment section of the diet communication form was left blank. The resident requested built-up utensils, staff did not initially ask about or observe her mealtime needs, and she was seen eating with regular utensils while having difficulty holding the spoon. The DOT stated she did not assess for adaptive mealtime equipment during the screening, and the LPN/unit manager later noted the facility obtained built-up utensils for the resident to use.
A resident reviewed for unnecessary medications received buspirone 15 mg BID for "nerves," even though the MDS showed full cognition and no active anxiety disorder diagnosis. The DON verified the order was documented for nerves, said the VA discharge orders used that wording, and stated the nurse who reconciled medications was expected to enter the order as received; the facility's physicians did not have involvement with respite residents' medications because they brought medications from home with the indication of use.
Arbitration Agreement Included as Part of Admission Contract
Penalty
Summary
The facility failed to ensure that the arbitration agreement provided to all residents was not required as a condition of admission to, or continued receipt of, care at the facility. Review of the admissions packet showed that under the dispute resolution procedure, the arbitration provision was executed in conjunction with the admission agreement and was described as part of that agreement, binding on the Center and the patient and their successors, heirs, executors, administrators, or assigns. During interviews, the Administrator stated that the facility's arbitration agreement was within the admission contract and that all residents had signed the arbitration agreement form. In a later interview, the Administrator stated that she had discussed the admission packet with new residents and families when admission staff were unavailable, answered questions for them, and was not aware that the arbitration contract stated acceptance was contingent on admission. She stated that she did not believe that was the intent and confirmed that the arbitration agreement was signed by all residents in the facility and was not designated separately from the admission agreement.
Arbitration Agreement Lacked Neutral Venue Provision
Penalty
Summary
The facility failed to ensure that the arbitration agreement signed by all residents in a census of 79 included a venue selection that was convenient to both parties. Review of the facility’s admissions packet showed that under I. Dispute Resolution Procedure, the arbitration agreement did not contain a clause allowing arbitration to be conducted at a site convenient to both parties, and no statement or process was documented for determining a neutral location for a dispute. During interviews, the Administrator stated that the arbitration agreement was part of the facility’s admission contract, that all residents had signed it, and that it was not designated separately from the admission agreement. The Administrator also stated she had discussed the admission packet with new residents and families when admission staff were unavailable and was not aware that the arbitration contract did not include the required venue location agreed on by both parties.
Dirty Dining Room Vents and Soiled Wall Surfaces
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the main dining room where 14 of 85 residents ate their meals. During initial observation, four of five ceiling vents above residents’ dining tables were covered with fuzzy dust and dirt, and the wall below the pass-through window to the kitchen had spilled liquid or food debris running down the wall and onto the floor below. During lunch observation, the same vents remained caked with fuzzy dust and dirt, and the wall and floor below the pass-through window continued to have the same liquid spills and food debris while residents were eating. During a concurrent observation and interview, the DOM, who also served as the Director of Housekeeping, acknowledged that the ceiling vents were dirty and needed to be cleaned. He stated the dust was a concern because it was directly above where residents ate. He also stated housekeeping was responsible for cleaning the vents about every two weeks, but there was no documentation of the cleaning. The DOM further observed the wall and floor under the pass-through window and agreed they were soiled with food or liquid spills, stating the wall needed to be cleaned.
Pureed Diet Menus Not Followed
Penalty
Summary
The facility failed to ensure that the eight residents who received pureed diets were served foods as called for in the menus. Review of a handwritten, undated Texture Count document provided by the Dietary Manager showed that eight residents received pureed diets. During breakfast service observation in the kitchen, a Dietary Aide prepared and served pureed eggs, pureed waffles, and cream of wheat for the pureed meals, even though the Diet Extensions menu for Thursday, Week 1 called for pureed oatmeal, pureed banana, pureed sausage patty, and pureed waffle. The Dietary Manager stated she had never prepared pureed oatmeal before, had never heard of it being done, and did not know the menu called for it. She also stated she did not know why pureed eggs were served instead of pureed sausage or why cream of wheat was served instead of pureed oatmeal, and believed the Dietary Aide probably overlooked the menu. On the following day, another breakfast observation showed a Dietary Aide serving pureed eggs, cream of wheat, and pureed oatmeal. The Diet Extensions menu for Friday, Week 1 called for pureed banana, pureed eggs, pureed diced potatoes, and pureed wheat bread. The Dietary Manager stated she was unaware the menu was not followed and did not know why pureed banana was not served or why pureed oatmeal was served in place of pureed diced potatoes. The Dietary Aide stated she did not puree potatoes because the shipment had not come in and confirmed she did not serve pureed banana.
Antibiotic Stewardship Program Did Not Follow McGeer’s Criteria
Penalty
Summary
The facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing antibiotics for five residents reviewed for antibiotic stewardship. The report states the facility’s policy required an antibiotic stewardship program with protocols and a system to monitor antibiotic use, and that McGeer’s criteria or another surveillance tool would be used to define infections. Review of McGeer’s criteria showed the facility was expected to use specific symptom and microbiologic criteria before identifying a urinary tract infection. For one resident with renal insufficiency and diabetes mellitus, a UA/C&S was ordered without documentation of signs or symptoms to support the order, and Omnicef was later prescribed. The IP/WCN confirmed there was no documentation of symptoms and that the urine culture result of 10,000–49,000 CFU/ml Proteus mirabilis did not meet McGeer’s criteria for a UTI, even though the infection control report documented that it did meet criteria. No additional documentation was provided before the exit conference. For another resident with coronary artery disease and renal insufficiency, doxycycline was ordered for infection after a complaint of cough, but the resident denied fever, sore throat, runny nose, body aches, chills, chest pain, and shortness of breath, oxygen saturation was 95% on room air, and the chest x-ray showed no acute cardiopulmonary process. The IP/WCN confirmed this did not meet McGeer’s criteria. For a third resident with Alzheimer’s disease and traumatic brain injury, azithromycin was ordered for cough/congestion, but the IP/WCN stated the resident did not meet McGeer’s criteria and the infection control report was not completed to reflect the resident’s signs and symptoms at the time the antibiotic was ordered. For a resident noted with increased confusion, a UA/C&S was ordered and Macrobid was later prescribed for UTI, but the infection report form did not check any criteria for UTI and the lab result of 40,000–50,000 CFU/ml Enterococcus faecalis did not support the documented criteria. The record did not show that the physician was notified that the infection did not meet criteria or that there was a documented rationale for continuing the antibiotic. For a hospice resident, Macrobid was ordered for dysuria without documentation of a UA/C&S or other supporting symptoms in the record, and the infection report form did not show criteria for UTI. The IP/WCN stated the hospice physician initiated the antibiotic as a prophylactic, and the Medical Director stated he expected a UA/C&S to typically be performed before treatment and that the hospice physician’s practice was not the way it should be done.
Missing Pneumococcal Vaccine Offer/Refusal Documentation
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after record review, staff interviews, policy review, and review of CDC guidance showed the facility failed to offer or document consent or refusal for pneumococcal vaccination for two residents. The CDC guidance reviewed stated pneumococcal vaccination is recommended for adults [AGE] years of age or older, and that PCV20 or PCV21 should be given at least one year after PPSV23 when PPSV23 was administered at any age. R25’s EMR showed admission with diabetes mellitus and that the resident was [AGE] years old on admission. The immunization record showed Pneumovax 23 was given on 05/21/22, but there was no documentation that R25 received or refused any pneumococcal vaccination recommended one year later. R63’s EMR showed the resident was originally admitted on [DATE] and was currently [AGE] years old, but the immunization record contained no documentation that R63 was offered or refused the Pneumovax vaccination. The IP/WCN stated she did not keep up with vaccinations and that they were being completed by LPN4. LPN4 was notified of the missing documentation for both residents and stated she would gather the information. The DON stated that upon admission the facility reviews immunizations, checks GRITS, and started flu vaccine consents in September while revisiting residents’ Pneumovax vaccines.
Failure to Provide Needed Adaptive Mealtime Equipment
Penalty
Summary
The facility failed to ensure that one resident had the adaptive equipment needed for meals. The resident was admitted and readmitted with a diagnosis of chronic inflammatory demyelinating polyneuritis (CIDP). The MDS showed a BIMS score of 15 out of 15, indicating the resident was fully cognitively intact, and that the resident needed setup or clean-up assistance for eating. The MDS also showed no upper extremity ROM impairment. The facility assessment listed nutrition services as including individualized dietary requirements and assistive devices. The resident’s diet order was for a regular textured, no added salt diet, but the adaptive equipment section on the Diet Order & Communication form was not completed. A nutrition note documented that the resident requested built-up utensils, stating she used them at home, and nursing would be notified. A later health status note documented that the resident again requested special utensils from home and that her daughter would bring them to the facility. During observation, the resident was seen eating cereal with regular dining utensils and appeared to have difficulty holding the spoon. The resident stated staff had not asked her about adaptive equipment or observed her eating. The DOT stated she did not ask the resident about mealtime adaptive equipment and did not observe her eating during the screening. The LPN/unit manager later observed the resident with a built-up spoon and fork and stated the facility obtained them for use until the family brought the resident’s own equipment from home.
Unnecessary Psychotropic Medication Lacked Adequate Indication
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for unnecessary medications, Resident 107, had an adequate indication for buspirone use. The resident was admitted and later readmitted with diagnoses including PTSD and bipolar disorder, and the admission MDS showed a BIMS score of 15 out of 15, indicating full cognitive intactness. The Active Diagnoses section of the MDS did not identify an active anxiety disorder diagnosis. Review of the physician order summary showed an order for buspirone 15 mg by mouth twice daily for "nerves," with the facility Medical Director listed as the ordering physician. Review of the DSM-5-TR noted that "nerves" is a cultural idiom of distress and a symptom associated with many different mental health diagnoses, not a diagnosis. During interview, the DON verified the buspirone order was documented for nerves and stated the VA hospital discharge orders reflected nerves as the diagnosis. The DON also stated it was her expectation that the nurse who reconciled medications would enter the order as shown on the discharge orders received, and that the facility's physicians did not have involvement with respite residents' medications because they brought medications from home with the indication of use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Augusta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrington Park Health And Rehabilitation | 0.3 mi | ★★★★★ | 8 | 0 |
| Harborview Health Center Of Augusta | 1.5 mi | ★★★★★ | 0 | 0 |
| Stevens Park Health And Rehabilitation | 2 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Richmond, Llc | 2.1 mi | ★★★★★ | 1 | 0 |
| Pavilion At Brandon Wilde | 3.1 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.