Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lillian Carter Health Center By Harborview during CMS and state inspections, most recent first.
Bed rails were observed in use for five residents with physician orders for assist rails, including residents with diagnoses such as CVA, CHF, diabetes, CKD, and a vegetative state. The DON stated residents were expected to be checked for entrapment risk, but the Administrator reported the facility had no bed rail inspection or maintenance records in the maintenance system or elsewhere.
Inaccurate MDS coding was found for four residents. One resident with cerebral infarction, difficulty walking, legal blindness, and muscle weakness had a documented fall with injury, but the SCSA MDS was coded as no falls. Another resident with a mood disorder had a Level II PASARR on file, but the annual MDS was coded as no PASARR. Two residents were also miscoded for weight loss: one resident with diabetes and HF had weight gain, and another resident with dysphagia did not meet the coded weight-loss criteria at the ARD. The MDSC and DM acknowledged the coding errors during interview.
Bed rail use without documented alternatives: The facility failed to show that alternatives were tried before placing bed rails for five residents. Records and observations showed residents with diagnoses such as stroke, CHF, CKD, diabetes, and severe cognitive impairment using bilateral bed rails for mobility or bed positioning, while EMR assessments and staff interviews did not document attempted alternatives before the rails were installed or changed.
Failure to timely report resident-to-resident abuse: two residents with severe cognitive impairment were involved in verbal and physical altercations, including one resident attempting to hit the other and later grabbing the other resident by the neck. CNAs and an LPN separated the residents, but staff did not immediately report the abuse allegation to the Administrator or DON, and the SSA report was not made within the required 2 hours.
Hospice records were not maintained onsite for a resident on hospice care. The EMR contained no hospice care plan, hospice notes, or assessments, even though the facility’s hospice agreement said hospice would provide the IPoC, patient/family assessment, and plan-of-care updates within 72 hours. The DON stated the facility did not keep or access hospice notes, a CNA said she had never seen the resident’s hospice care plan, and the Administrator stated hospice had never left its notes with the facility.
Failure to follow an ordered fluid restriction occurred for a resident with HF and severe cognitive impairment. Nursing exceeded the resident’s allotted fluid amount on multiple days, and meal trays observed by surveyors included large glasses of fluids and ice cream. Staff interviews showed dietary and nursing were using inconsistent methods to track the restriction, the meal card did not document it, and the DON did not find meal-time fluid intake documentation.
Failure to Provide Updated Pneumococcal Vaccination and Education The facility failed to ensure that three residents reviewed for immunizations received education and updated pneumococcal conjugate vaccines per CDC guidance. One resident with CKD, HF, and DM2 had PPSV23 documented but no PCV, another resident with adult failure to thrive, cancer, and a history of COVID had no pneumococcal vaccine documented, and a third resident with malnutrition and epilepsy had PPSV23 only. No declinations with education were found in the EMR, and the IP stated that consents had been signed but the vaccines were not administered.
Bed Rails Not Inspected or Maintained per MIFU
Penalty
Summary
The facility failed to ensure bed frames and bed rails, when present, were inspected and maintained according to the Manufacturer's Instructions For Use (MIFU) for five residents identified as using bed rails. The deficiency was based on observation, interview, record review, and review of FDA guidance and MIFU, and the facility did not have bed rail inspection or maintenance records available when asked by the Administrator. R5 had diagnoses including mood disorder, chronic respiratory failure, polyneuropathy, and metabolic encephalopathy, and had an order for 1/4 assist rails to assist with bed mobility, transfers, and/or define bed parameters. R21 had diagnoses including CHF, history of heart attack, diabetes, peripheral vascular disease, chronic kidney disease, and panic/anxiety disorder, with an order for 1/4 assist rails x 2. R25 had diagnoses including brain hemorrhage, cerebral infarction, diabetes, anxiety, and a vegetative state, with an order for 1/4 assist rails x 2. R23 had a diagnosis including cerebral infarction and an order for 1/4 assist rails x 2. R7 had a diagnosis including cerebral infarction and an order for 3/4 assist rails. Observations showed these residents in bed with bed rails in use, including bilateral upper rails, 1/4 assist rails, and 1/2 side rails, with air mattresses noted for some residents. The DON stated residents were expected to be checked for risk of entrapment. When asked for bed rail inspection and maintenance records, the Administrator stated the facility did not have any, and corporate and maintenance staff confirmed there was nothing in the maintenance software program.
Inaccurate MDS Coding for Falls, PASARR, and Weight Loss
Penalty
Summary
The facility failed to ensure accurate MDS coding for four of 37 sampled residents. For one resident with diagnoses including cerebral infarction, difficulty walking, legal blindness, and muscle weakness, the significant change MDS dated with an ARD of 7/30/2025 was coded as having no falls since the previous assessment even though the resident had a documented fall on 7/21/2025 that resulted in a cracked tooth and fractured orbital bone and was also associated with a subarachnoid hemorrhage. During interview, the MDS Coordinator acknowledged the fall was missed and stated it had been in her notes. For another resident with a mood disorder and a completed Level II PASARR on file, the annual MDS dated with an ARD of 2/5/2025 was coded as no Level II PASARR having been completed. The resident’s EMR miscellaneous tab showed a Level II PASARR completed on 4/24/2024, and the care plan stated the resident had been evaluated for serious mental illness and/or intellectual disability and approved for nursing home level of care related to the mood disorder. The MDS Coordinator later verified the PASARR information was present in the record and stated the assessment should have been coded yes. Two additional residents were inaccurately coded for weight loss. One resident with diabetes and heart failure weighed 157 pounds on 8/12/2025, with prior weights showing gain rather than loss, yet the quarterly MDS dated with an ARD of 8/18/2025 was coded as having weight loss of 5% or more in the last month or 10% or more in the last six months. Another resident with dysphagia had weights showing a 5.66% loss over six months, but the annual MDS dated with an ARD of 8/2/2025 was coded as having weight loss of 5% or more in the last month or 10% or more in the last six months. The Dietary Manager, Registered Dietician, and MDS Coordinator reviewed the weights and stated the residents did not meet the coded weight-loss criteria at the ARD dates.
Bed Rail Use Without Documented Alternatives
Penalty
Summary
The facility failed to ensure alternatives were attempted before using bed rails for five of 48 residents identified with bed rails: R5, R7, R21, R23, and R25. The facility policy titled Side Rail Policy and Guidelines stated that appropriate alternatives would be attempted prior to installing a side rail. Surveyors reviewed records, observed residents in bed with bilateral rails in place, and interviewed staff and the administrator regarding how side rails were assessed, consented to, and ordered. R5 had diagnoses including mood disorder, chronic respiratory failure, polyneuropathy, and metabolic encephalopathy. R5 was observed multiple times in bed with bilateral upper bed rails and an air mattress. The EMR showed repeated bed rail assessments and an order for 1/4 assist rails to assist with bed mobility, transfers, and/or define bed parameters, but the assessments did not address what alternatives were attempted before the rails were installed and used. R5’s care plan included 1/4 assist rails x 2 for bed mobility and transfers. R21 had diagnoses including CHF, history of heart attack, diabetes, peripheral vascular disease, chronic kidney disease, and panic/anxiety disorder, and was observed asleep in bed with bilateral bed rails in place. The bed rail assessment indicated 1/4 assist/enabler bar and did not mention alternatives. R25 had diagnoses including brain hemorrhage, cerebral infarction, diabetes, anxiety, and a vegetative state, and was repeatedly observed in bed with bilateral upper rails in place during care and rest. R23 had cerebral infarction, severe cognitive impairment with a BIMS score of 5, and needed partial/moderate assistance to roll and sit up; the side rail evaluation noted that every resident should start with a bed without a side rail and that alternatives must be attempted, but the document did not show whether side rails were recommended or not recommended, and the resident was placed on bilateral 1/4 assist rails. R7 had cerebral infarction, severe cognitive impairment with a BIMS score of 5, and was dependent on staff for bed mobility and transfers; records showed a progression from 1/4 assist/enabler rails to 3/4 rails, and staff stated the rails were selected based on what bed was available and what was in the room rather than documented attempts at alternatives.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported timely for two residents, R20 and R23, and failed to report a resident-to-resident physical altercation to the Administrator. The facility policy titled, Abuse Prohibition Policy and Procedures, stated that once a complaint or situation involving alleged mistreatment, neglect, or abuse was identified, it would be immediately reported, and allegations of abuse were to be reported to the state within 2 hours. R20 and R23 both had severe cognitive impairment, with BIMS scores of 5 out of 15 on their most recent MDS assessments. A written statement from CNA4 described an incident in which R20 and R23 were near the dining room when R23 yelled out, R20 told R23 to shut up and attempted to hit him, and CNA4 separated them. Later in the shift, R20 approached R23 at the nurse's station and grabbed his neck in front of CNA4 and LPN3, who again separated them. Staff interviews showed the altercation was not reported immediately to the Administrator or DON; the Administrator learned of it the next morning from the DON, and the abuse allegation was reported to the SSA on 8/26/2025 at 11:06 am. The DON stated nursing staff did not report the incident to her, and CNA1 and LPN2 both described learning of the resident-to-resident abuse after the fact, with CNA1 stating it should have been reported right away to the nurse.
Hospice Records Not Maintained Onsite
Penalty
Summary
The facility failed to maintain onsite the hospice medical records for one resident, R9, who was on hospice care. Review of the facility’s Hospice Nursing Home Agreement stated that hospice would provide the facility with a copy of the Interdisciplinary Plan of Care, the Patient/Family Assessment, and any modifications to the plan of care within 72 hours. However, review of R9’s EMR showed no hospice care plan, no hospice notes, and no hospice assessments available on site. R9’s record showed admission to the facility with diagnoses including cerebral infarction, dysphasia, Alzheimer disease, kidney failure, vascular dementia, and depression, and a significant change MDS documented that R9 had a condition resulting in a life expectancy of six months or less and was placed on hospice care. The facility’s policy stated that its goal was to collaborate with the hospice provider. During interview, the DON stated the facility did not keep hospice care plans or hospice care notes on site and had no access to them, relying instead on the facility care plan and phone calls to hospice when questions arose. A CNA stated she did not have access to nursing notes or hospice notes and had never seen R9’s hospice care plan. The Administrator stated hospice had never left its notes with the facility and acknowledged that access to hospice notes could affect continuity of care because verbal communication can be lost without written records to refer to.
Failure to Follow Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure a physician-ordered fluid restriction was followed for one resident with heart failure and severe cognitive impairment. The resident was admitted with a diagnosis of heart failure, had a care plan intervention to provide fluids per fluid restriction parameters, and had a quarterly MDS showing a BIMS score of 5 out of 15. Her orders dated 8/21/2025 specified a 1200 ml daily fluid restriction, with 480 ml allotted by nursing and 720 ml by the kitchen. Review of the resident’s MARs for August and September 2025 showed that nursing exceeded the ordered 480 ml allotment on nine days between 8/22/2025 and 9/9/2025, with documented amounts ranging from 500 ml to 540 ml. During observations, the resident’s meal trays included large glasses of fluids, including Kool-Aid, water, and tea, along with ice cream. On one observation, the tray contained two large glasses filled with Kool-Aid and water; on another, the tray contained a large glass of water, a large glass of tea, and a 120 ml container of ice cream. Staff interviews showed inconsistent understanding and implementation of the restriction. The resident stated she drank what was given to her and did not keep track of her fluids. CNA3 said she served what dietary provided and could not provide additional fluids without consulting a nurse. Dietary staff reported they were unaware of the resident’s fluid restriction and said it was indicated on meal cards, but the resident’s meal card did not document the restriction. The Dietary Manager stated the kitchen used a fluid restriction instruction sheet that did not include the resident’s name and had the wrong amounts highlighted. Nursing staff and the DON acknowledged that fluid restriction amounts were broken down between nursing and dietary, but the DON did not see documentation of the resident’s fluid intakes at meals.
Failure to Provide Updated Pneumococcal Vaccination and Education
Penalty
Summary
The facility failed to ensure that three residents reviewed for immunizations were provided education and received updated pneumococcal conjugate vaccine(s). Review of the facility’s policy titled Pneumococcal Vaccine stated that all residents would be offered pneumococcal vaccines and that administration or revaccination would follow current CDC recommendations. Record review showed that one resident with chronic kidney disease, heart failure, and type II diabetes had received PPSV23 but no other pneumococcal vaccine was documented, and no declination with education was found in the EMR. CDC guidance reviewed by surveyors indicated that this resident should have received PCV15, PCV20, or PCV21. A second resident with adult failure to thrive, history of COVID, and cancer had no pneumococcal vaccines documented in the EMR, and no declination with education was found; CDC guidance indicated the resident should have received PCV20 or PCV21. A third resident with malnutrition and epilepsy had PPSV23 documented, but no other pneumococcal vaccine was shown and no declination with education was found; CDC guidance indicated the resident should have received PCV15, PCV20, or PCV21. During interview, the Infection Preventionist stated that one resident’s RP had signed for vaccines without selecting which vaccines, and that the other two residents had signed consents for pneumococcal vaccines but the vaccines had never been administered. The DON stated the expectation that residents who want pneumococcal vaccines should receive them.
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What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Manor Methodist Nsg C | 9.9 mi | ★★★★★ | 7 | 0 |
| Four County Health And Rehabilitation | 16.5 mi | ★★★★★ | 0 | 0 |
| Dawson Health And Rehabilitation | 18.8 mi | ★★★★★ | 5 | 0 |
| Magnolia Manor Of Marion County | 21.6 mi | ★★★★★ | 7 | 0 |
| Lee County Health And Rehabilitation | 25 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.