Lillian Carter Health Center by Harborview
225 Hospital Street, Plains, GA 31780 · Sumter County · (229) 824-7796
100 certified beds, about 71 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1993
Ownership changed in the last 12 months Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
3 of 5
Staffing
1 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 115550 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 12, 2025, inspectors cited 7 health deficiencies (the Georgia average is 5, the national average 9.2).
None of its 13 health citations since May 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 2.98 hours per resident per day, against 3.56 across Georgia and 3.86 nationally. Registered nurses accounted for 0.39 of those hours.
CMS links it to Harborview Health Systems, an affiliated group of 22 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
105/22
503/24
709/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
3E
1F
Potential for minimal harm
0A
0B
0C
September 12, 2025Standard inspection · 7 citations
- F 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.
Inspectors wroteBased on observation, interview, record review, review of the Food and Drug Administration (FDA) guidelines and review of Manufacturer's Instructions for Use (MIFU), the facility failed to ensure bed frames and bed rails, if present, were inspected and maintained per the Manufacturer's Instructions For Use (MIFU) to minimize the risks of bed malfunction or resident injury for five Residents (R) (R5, R7, R21, R23, and R25) identified as having bed rails in the sample of 37 residents.
- E Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure four out of 37 sampled Residents (R) (R3, R5, R6, and R27) Minimum Data Set (MDS) assessments were accurately coded. Specifically, the facility failed to accurately code the MDS assessment for (R3) related to falls, (R5) related to (Level II Preadmission admission Screening and Resident Review (PASARR), and (R6 and R27) related to weight loss. This failure had the potential to affect the care planning and provision of needed services.
- E 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.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled Side Rail Policy and Guidelines, the facility failed to ensure alternatives were attempted prior to the use of bed rails for five out of 48 Residents (R) (R5, R7, R21, R23, and R25) identified with bed rails. This failure had the potential to increase accidental entrapment or injury from bed rail usage when an alternate assistive device may have been effective.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Abuse Prohibition Policy and Procedures, the facility failed to ensure allegations of abuse were reported timely for two of two Residents (R) (R20 and R23) reviewed for abuse out of a total sample of 37 residents. The facility failed to report resident-to-resident abuse within two hours to the state survey agency (SSA). Facility staff failed to report an allegation of physical abuse between R20 and R23 to the Administrator. Failure to report resident-to-resident altercations could potentially lead to continued abuse and neglect.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review, record review, and review of the facility document titled Hospice Nursing Home Agreement, the facility failed to maintain onsite, the hospice medical records for one Resident (R) (R9) out of 37 sampled residents. This had the potential to interfere with the continuity of care between the facility and hospice.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled, Encouraging and Restricting Fluids, the facility failed to ensure a physician-ordered fluid restriction was followed for one of one Residents (R) (R6) reviewed for fluid restriction out of a total sample of 37 residents. Failure to limit fluids in the presence of an order for a fluid restriction has the potential to cause symptoms of fluid overload.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interviews, record review, review of Centers for Disease Control (CDC) guidelines, and review of the facility's policy titled Pneumococcal Vaccine, the facility failed to ensure three of five Residents (R) (R3, R28, and R44) reviewed for immunizations had been provided with education and received an updated pneumococcal conjugate vaccine. This failure had the potential to affect the resident's ability to decrease the possibility of a serious pneumococcal infection and potential hospitalization.
March 10, 2024Standard inspection · 5 citations
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment on one of four halls in six bathrooms. The facility census was 53 residents.
- D PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interviews, and record review the facility failed to ensure a Preadmission Screening/Resident Review Level II referral was made to ensure that individualized care and services were offered to meet resident needs for one resident (R 45) of 25 sampled residents.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Care Plan-Comprehensive the facility failed to develop and implement a comprehensive, person-centered care plan for three resident's, resident (R) R30 for pain, R36 for diabetes and insulin usage, and R37 for implementing monitoring of behaviors while on psychotropic medications. The sample size was 25 residents.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, and record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of one resident (R) (R9) reviewed for tracheostomy (trach) care. Specifically, the facility failed to provide tracheostomy care supplies to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R9's risk for compromise airway and respiratory distress.
- D 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.
Inspectors wroteBased on staff interviews, clinical record review, and review of facility policy titled, Depression - Clinical Protocol, the facility failed to monitor behaviors and side effects of psychotropic medications for one resident (R37) of five residents reviewed for unnecessary medications.
May 19, 2022Standard inspection · 1 citation
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Infection Control Recommendations the facility failed to properly store suctioning equipment for two of three residents (R) (R#12 and R#63) with tracheostomies.
Fire safety inspections
6 fire safety citations on file: 2 on September 12, 2025, 4 on March 10, 2024.
Every fire safety citation6 citations
- D Inspect, test, and maintain automatic sprinkler systems.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F Establish an Emergency Preparedness Program (EP).
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Install an approved automatic sprinkler system.
- D Inspect, test, and maintain automatic sprinkler systems.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Georgia | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 2.98 | 3.56 | 3.86 |
| Registered nurses | 0.39 | 0.50 | 0.69 |
| All nursing staff on weekends | 2.40 | 3.10 | 3.42 |
| Nurse aides | 1.55 | ||
| Licensed practical nurses | 1.04 | ||
| Nursing staff turnover (share who left in a year) | not reported | 46.0% | 45.8% |
| Registered nurse turnover | not reported | 44.5% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.68 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.21 on weekdays and 2.40 on weekends, 25% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.54 in April to June 2025 to 2.98 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 2.98 | 0.39 | 3.21 | 2.40 | 0.0% | 0 of 90 | 71 |
| Oct to Dec 2025 | 3.31 | 0.44 | 3.62 | 2.52 | 0.0% | 0 of 92 | 57 |
| Jul to Sep 2025 | 3.61 | 0.30 | 3.89 | 2.90 | 0.2% | 0 of 92 | 51 |
| Apr to Jun 2025 | 3.54 | 0.26 | 3.81 | 2.86 | 0.4% | 0 of 91 | 52 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Georgia, Jan to Mar 2026 | 3.50 | 0.46 | 3.68 | 3.03 | 3.3% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for Georgia
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Georgia, all employers | |||
| CNAs (nursing assistants) | $18.12 | $17.06 to $20.66 | 43,440 |
| LPNs and LVNs | $29.82 | $25.43 to $33.99 | 21,060 |
| Registered nurses | $44.98 | $38.02 to $51.12 | 100,950 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Georgia | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.4 | 15.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.2 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.7 | 2.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.1 | 3.2 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.5 | 2.6 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 10.7 | 15.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.3 | 5.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 15.2 | 19.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.9 | 25.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 12.0 | 11.6 | 12.0 |
Owners and operators
Legal business name: LILLIAN CARTER HEALTH CENTER LLC. CMS links this home to Harborview Health Systems, a group of 22 nursing homes averaging 2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Plains Wanesboro Holdings LLC | Direct ownership interest | Organization | 10/01/2025 | |
| Cl 2022 Irrv Tr | Indirect ownership interest | Organization | 10/01/2025 | |
| De 2021 Irrv Tr | Indirect ownership interest | Organization | 10/01/2025 | |
| Englander, David | Managing control - governing body | Individual | 10/01/2025 | |
| Leibowitz, Chaim | Managing control - governing body | Individual | 10/01/2025 | |
| Cedarwood Management LLC | Operational/managerial control | Organization | 10/01/2025 | |
| Blaxton, Brandi | Operational/managerial control | Individual | 10/01/2025 | |
| Bledsoe, Rena | Operational/managerial control | Individual | 10/01/2025 | |
| Bridges, Teresa | Operational/managerial control | Individual | 10/01/2025 | |
| Englander, David | Operational/managerial control | Individual | 10/01/2025 | |
| Fendrich, Warren | Operational/managerial control | Individual | 10/01/2025 | |
| High, Renee | Operational/managerial control | Individual | 10/01/2025 | |
| Hunt, Heather | Operational/managerial control | Individual | 10/01/2025 | |
| Leibowitz, Chaim | Operational/managerial control | Individual | 10/01/2025 | |
| Rogers, Art | Operational/managerial control | Individual | 10/01/2025 | |
| Semones, Charles | Operational/managerial control | Individual | 10/01/2025 | |
| Taylor, Robert | Operational/managerial control | Individual | 10/06/2025 | |
| Cedarwood Management LLC | Adp of the SNF | Organization | 10/01/2025 | |
| Lawrence Bay Partnership | Adp of the SNF | Organization | 01/27/2026 | |
| Blaxton, Brandi | Adp of the SNF | Individual | 10/01/2025 | |
| Bledsoe, Rena | Adp of the SNF | Individual | 10/01/2025 | |
| Bridges, Teresa | Adp of the SNF | Individual | 10/01/2025 | |
| Englander, David | Adp of the SNF | Individual | 10/01/2025 | |
| Fendrich, Warren | Adp of the SNF | Individual | 10/01/2025 | |
| High, Renee | Adp of the SNF | Individual | 10/01/2025 | |
| Hunt, Heather | Adp of the SNF | Individual | 10/01/2025 | |
| Leibowitz, Chaim | Adp of the SNF | Individual | 10/01/2025 | |
| Rogers, Art | Adp of the SNF | Individual | 10/01/2025 | |
| Semones, Charles | Adp of the SNF | Individual | 10/01/2025 | |
| Taylor, Robert | Adp of the SNF | Individual | 10/06/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 5 problems in this area, most recently on September 12, 2025: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on September 12, 2025: "Ensure each resident receives an accurate assessment."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on September 12, 2025: "Develop and implement policies and procedures for flu and pneumonia vaccinations."
- Can we see a resident room, a shower room and the dining room on this visit?Inspectors cited 1 problem in this area, most recently on September 12, 2025: "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."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.40 hours per resident per day, below the Georgia average of 3.10.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Magnolia Manor Methodist Nsg C Americus, 9.9 mi · 3 of 5 stars · 13 citations
- Four County Health and Rehabilitation Richland, 16.5 mi · 5 of 5 stars · 3 citations
- Dawson Health and Rehabilitation Dawson, 18.8 mi · 1 of 5 stars · 17 citations
- Magnolia Manor of Marion County Buena Vista, 21.6 mi · 5 of 5 stars · 14 citations
Georgia contacts for a concern about a nursing home
These are the official offices in Georgia. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Georgia Department of Community Health, Healthcare Facility Regulation Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Georgia Long-Term Care Ombudsman Program, 1-866-552-4464. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: GaMap2Care, Find a Facility, where Georgia publishes its own records on licensed homes.
Common questions
- What is Lillian Carter Health Center by Harborview's Medicare star rating?
- CMS rates Lillian Carter Health Center by Harborview 2 out of 5 stars overall, with 3 for health inspections, 1 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Lillian Carter Health Center by Harborview get at its last inspection?
- 7 health deficiencies at the standard inspection on September 12, 2025. The Georgia average is 5.
- Has Lillian Carter Health Center by Harborview been fined?
- CMS lists no fines in the last three years.
- Does Lillian Carter Health Center by Harborview accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Lillian Carter Health Center by Harborview?
- CMS lists 30 owners and managers, and links the home to Harborview Health Systems. Legal business name: LILLIAN CARTER HEALTH CENTER LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.