Lillian Carter Health Center by Harborview
225 Hospital Street, Plains, GA 31780 · For profit - Limited Liability company · 100 certified beds · (229) 824-7796 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.4% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 9.9% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.7% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 43.7% | 11.3% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.1% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.7% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.1% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.5% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.2% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 86.7% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.9% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.0% | 11.6% | 12.0% | typical |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.3%CMS range 35.7–64.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 7.7–17.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 88.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 70.6 residents a day — about 71% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.98 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.55 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.40 hrs/resident/day on weekends vs 3.21 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.41 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
13 citations, most serious first — scroll within the box to see all.
- Potential for harm · F2025-09-12 · tag F0909 — failed to maintain a comfortable temperature — widespreadRegularly 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: Review of the facility's policy titled Side Rail Policy and Guidelines dated 1/16/2023 revealed, Policy Statement, Side rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. The facility will attempt to use appropriate alternatives prior to installing a side rail. If a side rail is used, the facility must ensure correct installation, use, and maintenance of the side rail,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: 1. Review of R3's admission Record in the electronic medical record (EMR) Profile tab revealed a facility admission date of 4/23/2025 with diagnoses that included cerebral infarction, difficulty walking, legal blindness, and muscle weakness. During an interview on 9/10/2025 at 8:28 am, R3 related she had a fall that caused a cracked tooth and fractured orbital bone. Review of R3's EMR Care Plan tab revealed R3 had a fall on 7/21/2025 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-12 · tag F0700 — patternTry 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: Review of the facility's policy titled Side Rail Policy and Guidelines dated 1/16/2023 revealed, Policy Statement, Side rails are adjustable metal or rigid plastic bars that attach to the bed.The facility will attempt to use appropriate alternatives prior to installing a side rail. 1. Review of R5's admission Record in the electronic medical record (EMR) Profile tab revealed the resident admitted to the facility with diagnoses that included but not limited to, mood disorder, chronic respiratory failure, polyneuropathy, and metabolic encephalopathy.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:Review of the facility's policy titled, Abuse Prohibition Policy and Procedures dated January 2017 revealed, Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported. If it is an allegation of abuse, it should be reported to the state…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:Review of the facility document titled Hospice Nursing Home Agreement dated 10/22/2024 indicated that services provided by hospice will providing the facility with a copy of the Interdisciplinary Plan of Care, shall furnish the facility with a copy of the Patient/Family Assessment and a copy any modifications to the patient plan of care and shall be provided to the facility within 72 hours.Review of the facility's policy titled Hospice Services dated 3/2016 indicated that the facility goal is to collaborate with the Hospice provider. Review of R9'sadmission Record located under the Profile tab of the Electronic Medical Record (EMR) revealed R9 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:Review of the facility's policy titled, Encouraging and Restricting Fluids dated 3/24/2017 revealed, Verify that there is a physician's order for this procedure. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Record fluid intake if ordered by the physician. Review of R6's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R6 was admitted to the facility on [DATE] with diagnosis of heart failure.Review of R6's Care Plan tab of the EMR revealed that she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: Review of the facility's policy titled Pneumococcal Vaccine dated 9/5/22 revealed: Policy Statement All residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections. Policy Interpretation and Implementation.7) Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Review of R3's admission Record in the electronic medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Observation on 3/8/2024 at 8:47 am revealed in the shared bathroom between rooms [ROOM NUMBERS] had four unlabeled, un-bagged wash basins stored stacked on the floor. Observation on 3/8/2024 at 8:58 am revealed in the shared bathroom between rooms [ROOM NUMBERS] urinal sitting inside of specimen hat, inside of bed pan on floor. None were labeled or bagged. An additional two wash basins were stacked unlabeled, un-bagged on the floor. Observation on 3/8/2024 at 9:05 am revealed in the shared bathroom between rooms [ROOM NUMBERS] a bedpan unlabeled and un-bagged. Interview on 3/8/2024 at 9:10 am with Assistant Director of Nursing confirmed the above findings and revealed resident care equipment should be labeled with the resident room number and bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-10 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings: Review of the electronic medical record revealed diagnoses (dx) that included (but not limited to) Major Depressive Disorder, Anxiety, and Post Traumatic Stress Disorder (PTSD). Review of Level 1 does not indicate dx of a serious mental illness. Review of the care plan for R45 revealed a potential for psychosocial well-being problem related to anxiety, depression, and PTSD. Further review of the medical record revealed the following behaviors: 1. A Behavior Note dated 10/10/2023 indicated behaviors of yelling and cussing by R45 due to Certified Nursing Assistants (CNAs) coming into room to assist because the call light was on. 2. A second Behavior Note dated 10/10/2023 R45 sat dinner tray outside of room door and when told not to sit the tray outside R45 then kicked the tray further into the hallway.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of facility policy titled, Care Plan-Comprehensive with revised date 4/18/2017 revealed, under Policy Interpretation and Implementation number 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. numbers 6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident care interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. 8. Assessments of residents are ongoing and care plans are revised as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility policy titled, Tracheostomy Care dated 3/24/2017, under general Guidelines number 6. A replacement tracheostomy tube must be available at the bedside at all times. Review of admission Record for R9 located in the Electronic Medical Record (EMR), revealed R9 was admitted to the facility with multiple diagnoses including but not limited to encounter for attention to tracheostomy, chronic obstructive pulmonary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: Review of the facility policy titled, Depression - Clinical Protocol dated 3/23/2017 Monitoring and Follow-up 2. The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. Review of the medical record for R37 revealed diagnoses that included but was not limited to unspecified psychosis not due to a substance or known physiological condition, depression, and anxiety. Review of the Annual Minimum Data Set (MDS) dated [DATE] in Section N revealed medication usage that included antianxiety and antidepressants. There was an order for Effexor XR Oral Capsule Extended Release 24 Hour 37.5 MG…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of facility policy titled, Infection Control Recommendations (not dated) revealed under section 'Suction Machines: suction tubing should be changed when soiled; Suction catheters are to be changed after use; discarded when soiled; Suction Yankauer are to be discarder when soiled; Equipment should be bagged when not in use. Observation on 5/17/22 at 9:39 a.m. of R#12 revealed in room [ROOM NUMBER] next to bed 'A' and 'B' revealed suction machines sitting on bedside table with tubing extending from the suction machines into a drawer. The cannisters on the suction machines had a large amount of cloudy watery substance. Observation on 5/18/22 at 8:33 a.m., 11:07 a.m., and 2:19 p.m. of R#63 revealed the residents suction tubing was lying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HARBORVIEW HEALTH SYSTEMS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 1 of 5 | 2.4 | -1.4 vs chain |
| Quality measures | 3 of 5 | 2.3 | +0.7 vs chain |
The other 21 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PLAINS WANESBORO HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 10/01/2025 |
| CL 2022 IRRV TR | Organization | INDIRECT OWNERSHIP INTEREST | since 10/01/2025 |
| DE 2021 IRRV TR | Organization | INDIRECT OWNERSHIP INTEREST | since 10/01/2025 |
| ENGLANDER, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| LEIBOWITZ, CHAIM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| CEDARWOOD MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| BLAXTON, BRANDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| BLEDSOE, RENA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| BRIDGES, TERESA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| FENDRICH, WARREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| HIGH, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| HUNT, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| ROGERS, ART | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| SEMONES, CHARLES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2025 |
| TAYLOR, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/06/2025 |
| LAWRENCE BAY PARTNERSHIP | Organization | ADP OF THE SNF | since 01/27/2026 |
CMS files one row per role, so the 30 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $480K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115550. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.