Place At Martinez, The

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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.

Based on observations, staff interviews, and policy review, the facility failed to maintain a safe, functional, and sanitary environment in the main dining room where 14 out of a total of 85 residents ate their meals.

This failure had the potential to lead to the spread of infection or feelings of discomfort and dissatisfaction among residents. Findings include:

Review of the undated policy titled, The Place Facilities Safe and Homelike Environment, revealed, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

During initial observations of the main dining room on 11/18/25 at 9:11 AM, four of five observed ceiling vents were covered with fuzzy dust and dirt. These vents were located above residents' dining tables. The wall below the pass-through window to the kitchen had spilled liquid or food debris running down the length of the wall and onto the floor below.

During observation of lunch in the main dining room on 11/18/25 beginning at 12:07 PM, 14 residents were seated at the tables eating lunch. The ceiling vents above the residents were observed with caked-on fuzzy dust and dirt. The wall and floor below the pass-through window continued to have the same liquid spills and food debris. During a concurrent observation and interview on 11/21/25 at 9:50 AM, the Director of Maintenance (DOM), who also served as the Director of Housekeeping, observed the ceiling vents caked with dust and dirt and stated they were dirty and needed to be cleaned. The DOM stated the dust was a concern because it was directly above where residents ate. The DOM stated the housekeeping department was responsible for cleaning the ceiling vents and stated they should be cleaned about every two weeks, but did not have documentation of the cleaning. He stated the vents needed to be cleaned immediately. The DOM also observed the wall and floor under the pass-through window to the kitchen and agreed it was soiled with food or liquid spills. The DOM stated the housekeeping staff cleaned the floor in that area, but

he felt the kitchen staff should be responsible for cleaning the wall under the pass-through window. The DOM stated the wall needed to be cleaned.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Place at Martinez, The

409 Pleasant Home Road Augusta, GA 30907

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observations, staff interviews, and document review, the facility failed to ensure that eight of the eight residents who received pureed diets out of a total of 85 residents received the foods as called for in

the menus. These failures placed the eight residents at risk for weight loss, malnutrition, or dissatisfaction with their meals.Findings include:

Review of a handwritten, undated document titled Texture Count, provided by the Dietary Manager (DM), revealed the facility had eight residents who received a pureed diet.

1. 1. During interview and concurrent observation of breakfast service in the kitchen on 11/20/25 at 7:34 AM,

Dietary Aide (DA) 2 stated she prepared pureed eggs, pureed waffles, and cream of wheat for the pureed meals. She was observed serving pureed meals consisting of pureed eggs, waffles, and cream of wheat.

Review of the Diet Extensions: Thursday, Week 1, Menu, provided on paper by the Dietary Manager (DM), revealed that the pureed breakfast meal should have consisted of pureed oatmeal, pureed banana, pureed sausage patty, and pureed waffle.

During an interview on 11/21/25 at 1:47 PM, the DM stated she had never prepared pureed oatmeal before and had never heard of it being done. She stated she did not know the menu called for pureed oatmeal. The DM 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. The DM stated she did not know why the pureed banana was not served. The DM stated DA2 probably overlooked it on the menu. The DM placed a call to DA2 for an interview; however, there was no response prior to survey exit. The DM stated she expected staff to serve food as called for on the menu.

2. 2. During interview and concurrent observation of breakfast service in the kitchen on 11/21/25 at 7:35 AM,

DA1 stated she had prepared pureed eggs, cream of wheat, and pureed oatmeal for the pureed meals. She was observed serving pureed meals consisting of pureed eggs, cream of wheat, and pureed oatmeal.

Review of the Diet Extensions: Friday, Week 1, Menu, provided on paper by the DM, revealed the pureed breakfast meal should have consisted of pureed banana, pureed eggs, pureed diced potatoes, and pureed wheat bread.

During an interview on 11/21/25 at 1:47 PM, the DM stated she was unaware that the menu was not followed at breakfast. She stated she did not know why pureed banana was not served, or why pureed oatmeal was served in place of pureed diced potatoes.

During an interview on 11/21/25 at 1:50 PM, DA1 stated she did not puree potatoes as the shipment had not come in. She confirmed she did not serve pureed banana.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Place at Martinez, The

409 Pleasant Home Road Augusta, GA 30907

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881

the EMR, revealed, Resident remains on abt [antibiotic] Macrobid. Resident remains afebrile.

Level of Harm - Minimal harm or potential for actual harm

Review of Resident R50's EMR and hard chart revealed no order for a UA/CS or lab results related to administration of Macrobid.

Residents Affected - Some

Review of Resident R50's Infection Report Form, provided on paper by the IP/WCN, revealed that none of the criteria listed to determine if a UTI was present were checked. The form instructed that acute dysuria must be accompanied by at least 1,000,000 cfu/mL of microorganisms detected. The form documenting Resident R50's symptoms did not meet the criteria of a UTI. The form also documented that Macrobid was prescribed.

Review of Resident R50's EMR and hard chart did not reveal any documentation that the physician was notified that there was no criteria documented for antibiotic use. There was no documented rationale for the continuation of the antibiotic without meeting criteria for a UTI. During an interview on 11/20/25 at 6:19 PM, the IP/WCN stated that to determine whether a UTI met criteria for treatment, there must be a UA/CS performed. She stated Resident R50 did not have a UA/CS ordered or performed because she was on hospice, and the hospice physician initiated the Macrobid order as a prophylactic. The IP/WCN stated, Hospice does that a lot. The IP/WCN was unsure if she provided any education to the hospice physician regarding antibiotic stewardship and the criteria to meet before initiation of antibiotic treatment. The IP/WCN stated the Medical Director was aware of this issue, but the Hospice had its own Medical Director who took care of all the residents in hospice. She stated she did not know if the facility's Medical Director provided any education to the hospice staff.

During an interview on 11/20/25 at 6:31 PM, the Medical Director stated the hospice physician managed care for residents on hospice. He stated the hospice takes the patients as their own, they do what they want to do. The Medical Director stated the hospice did not allow a facility physician to oversee medical care for

the residents on hospice. The Medical Director stated his expectation was to typically perform a UA/CS, even for his patients on hospice, prior to treatment with antibiotics. He stated there could be instances where it was impossible to get a urine sample, and treatment would be initiated without a UA/CS; however,

this was rare. The Medical Director stated the hospice physician typically treated residents on hospice with antibiotics without first ordering a UA/CS. The Medical Director stated this was the way the hospice physician practiced, but he did not practice that way, and it was not the way it should be done.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Place at Martinez, The

409 Pleasant Home Road Augusta, GA 30907

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, staff interviews, policy review, and the review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for pneumonia vaccines for two of five residents (Residents (R)25 and Resident R63) and/or their resident representatives (RR) out of 27 sampled residents. This failure had the potential to put these residents at increased risk of developing pneumonia.Findings include:

Residents Affected - Few

Review of the CDC website page titled Pneumococcal Vaccine Timing for Adults, dated March 2025 and located at https://www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf, revealed the CDC recommended pneumococcal vaccination for all adults [AGE] years of age or older. A PCV20 or PCV21 (types of pneumonia vaccines) should be administered greater to or equal to one year after PPSV23 given at any age.

1. 1. Review of Resident R25's Face Sheet, located under the Profile tab in the electronic medical record (EMR)

indicated Resident R25 was admitted to the facility on [DATE REDACTED] with the diagnosis of diabetes mellitus and was [AGE] years old upon admission.

Review of Resident R25's Immunizations, located under the Immunization tab in the EMR, indicated Resident R25 received Pneumovax 23 on 05/21/22. There was no documentation of Resident R25 receiving or refusing any pneumococcal vaccinations that were recommended a year after the initial Pneumovax vaccine was given to Resident R25.

2. 2. Review of Resident R63's Face Sheet, located under the Profile tab in the EMR, indicated Resident R63 was originally

admitted to the facility on [DATE REDACTED] and was currently [AGE] years old.

Review of Resident R63's Immunizations, located under the Immunization tab in the EMR, indicated no documentation to reflect that Resident R63 was offered or refused the Pneumovax vaccination.

During an interview on 11/21/25 at 2:15 PM, the IP/WCN stated she did not keep up with vaccinations and that they were being completed by Licensed Practical Nurse (LPN4).

During an interview on 11/21/25 at 4:15 PM, LPN4 was notified of the missing documentation for Resident R25 regarding being offered or refusing the Pneumovax vaccination. Resident R63 had missing documentation to reflect being offered or refusing the Pneumovax vaccinations. LPN4 stated she would gather this information and bring it to the surveyor.

During an interview on 11/21/25 at 4:45 PM, the Director of Nursing (DON) stated, Upon admission, we

review with the resident their immunizations. Our expectation is to check and see if the resident is in the GRITS system [Georgia Registry of Immunization Transactions Services]. We started consents for flu vaccines in September, and we also revisited the residents' Pneumovax vaccines.

No further information was provided to the survey team prior to the exit conference.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet