Plains, GA

Lillian Carter Health Center by Harborview

3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

225 Hospital Street, Plains, GA

(229) 824-7796

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

100

Certified beds

Average residents

51

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Harborview Health Systems

Operator or chain grouping

Approved since

1993-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

21 facilities

Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.30

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

1.38

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

1.93

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.61

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.69

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.90

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.29

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.29

CMS adjusted RN staffing hours

Adjusted total hours

3.40

CMS adjusted total nurse staffing hours

Case-mix index

1.46

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,046

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

24.90

Composite VBP score used to determine payment impact.

Payment multiplier

0.9836

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.91

Baseline 56.92% · Performance 51.79% · Measure score 2.91 · Achievement 2.91 · Improvement 1.10

Adjusted total nurse staffing

2.07

Baseline 3.05 hours · Performance 3.67 hours · Measure score 2.07 · Achievement 2.07 · Improvement 1.77

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.32%	10.72% 1.6 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 21.88% · Lower 95% interval 7.7%
Discharge to community	49.28%	50.57% 1.3 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 40.63% · Lower 95% interval 35.68%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	86.36%	95.27% 8.9 pts worse	Numerator 19 · Denominator 22
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 22
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 22 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	1.35%	8.2% 6.8 pts worse	Numerator 1 · Denominator 74
Staff flu vaccination coverage	21.69%	42% 20.3 pts worse	Numerator 18 · Denominator 83
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.9%	91.2% 7.7 pts better	93.4% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 100.0% · Q4 97.9% · 4Q avg 98.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.1%	95.0% 0.9 pts worse	95.5% 1.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of long-stay residents experiencing one or more falls with major injury	2.1%	3.2% 1.1 pts better	3.3% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.1% · Q3 0.0% · Q4 2.1% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.6%	9.6% 7 pts better	11.4% 8.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 5.6% · Q4 2.6% · 4Q avg 2.6%
Percentage of long-stay residents who lose too much weight	12.2%	5.9% 6.3 pts worse	5.4% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 19.0% · Q3 17.5% · Q4 6.8% · 4Q avg 12.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.5%	20.7% 0.8 pts worse	19.6% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 20.5% · Q3 24.4% · Q4 22.2% · 4Q avg 21.5%
Percentage of long-stay residents who received an antipsychotic medication	14.7%	21.4% 6.7 pts better	16.7% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 13.8% · Q3 11.5% · Q4 14.8% · 4Q avg 14.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	15.6%	17.9% 2.3 pts better	16.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 37.8% · 4Q avg 15.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.3%	16.2% 3.1 pts worse	14.9% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 29.7% · Q3 16.7% · Q4 22.9% · 4Q avg 19.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	1.1% 0.5 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.2%	2.5% 0.3 pts better	1.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.3% · Q4 4.3% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	12.0%	16.1% 4.1 pts better	19.8% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 24.3% · Q3 8.0% · Q4 9.5% · 4Q avg 12.0%
Percentage of long-stay residents with pressure ulcers	7.3%	6.2% 1.1 pts worse	5.1% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.3% · Q3 5.8% · Q4 7.2% · 4Q avg 7.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.8%	80.4% 9.4 pts better	81.7% 8.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 89.7% · Q3 88.2% · Q4 91.3% · 4Q avg 89.8%
Percentage of short-stay residents who had an outpatient emergency department visit	10.5%	12.2% 1.7 pts better	12.0% 1.5 pts better	Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 11.5% · Expected 12.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.8%	2.2% 1.6 pts worse	1.6% 2.2 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.7%	78.2% 8.5 pts better	79.7% 7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.2%	24.2% 3 pts better	23.9% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 23.1% · Expected 26.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-12 · Fire 2025-09-12

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-03-10 · Fire 2024-03-10

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-05-19 · Fire 2022-05-19

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-09-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-12

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-10-24

F · Potential for more than minimal harm 2024-03-10

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-24

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-12

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2025-10-24

E · Potential for more than minimal harm 2025-09-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-10-24

E · Potential for more than minimal harm 2025-09-12

F700 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-12

F883 · Infection Control Deficiencies

Health

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

Corrected 2025-10-24

E · Potential for more than minimal harm 2024-03-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-10

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-04-24

D · Potential for more than minimal harm 2022-05-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-07-03

Penalties and ownership

What sits behind the stars

Ownership

Westbury, James R

5% Or Greater Indirect Ownership Interest · Individual

25% 2 facilities 2023-05-01

Davis Iii, William C

5% Or Greater Indirect Ownership Interest · Individual

13% 8 facilities 2023-05-01

Davis, William

5% Or Greater Indirect Ownership Interest · Individual

13% 9 facilities 2023-05-01

Orne, David

5% Or Greater Indirect Ownership Interest · Individual

13% 4 facilities 2023-05-01

Parker, David

5% Or Greater Indirect Ownership Interest · Individual

13% 5 facilities 2023-05-01

Windham, Ashton

5% Or Greater Indirect Ownership Interest · Individual

13% 4 facilities 2023-05-01

Windham, Spencer

5% Or Greater Indirect Ownership Interest · Individual

13% 4 facilities 2023-05-01

Bledsoe, Rena