Powell Valley Care Center

In the surveyor’s words

From the most serious findings on record at Powell Valley Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 2, 2025

  Based on medical record review, staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 11 sample residents (# 2, #4) reviewed for allegations of abuse. This failure resulted in actual harm to resident #2 and resident #4. The findings were: 1. Review of the 10/21/25 annual MDS assessment showed resident #1 had a BIMS score of 0, indicating severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression. Review of the care plan, initiated 5/23/23, showed the resident had impaired thought processes and impaired decision making. […]

• Actual harm, isolatedF689Dec 7, 2023

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to implement interventions to ensure resident safety for 1 of 3 sample residents (#100) reviewed for falls. This failure resulted in actual harm to resident #100 who sustained fractures and was hospitalized . The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #100 had a brief interview for mental status (BIMS) score of 3 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and anxiety disorder. Further review showed the resident required extensive physical assistance of 2 or more people for transfers and extensive physical assistance of 1 person for toileting and personal hygiene. […]

• Actual harm, isolatedF692Aug 12, 2021

  Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to provide services to ensure residents maintained acceptable parameters of nutritional status for 1 of 4 sample residents (#40) with weight loss. This failure resulted in harm to resident #40, who experienced an avoidable 7.6% loss of body weight in a 53 day period. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #40 had a BIMS score of 8 out of 15, indicating the resident had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS assessment showed the resident had no identified weight loss, no swallowing issues, and required supervision of 1 person for eating. […]

• No harm, potential for more than minimal, isolatedF676Jan 31, 2025

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents received services to maintain or improve their ability to carry out activities of daily living for 1 of 3 residents (#21) reviewed for activities of daily living. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #21 had short-term and long-term memory problems and diagnoses which included Alzheimer's disease. The review showed the resident required substantial/maximal assistance with oral hygiene, toileting hygiene, upper and lower body dressing, rolling left and right, sitting to standing, sitting to lying, lying to sitting, and transfers. […]

• No harm, potential for more than minimal, isolatedF656Dec 7, 2023

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure care plans were implemented for 1 of 3 sample residents (#100) with falls. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #100 had a brief interview for mental status (BIMS) score of 3 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and anxiety disorder. Further review showed the resident required extensive physical assistance of 2 or more people for transfers and extensive physical assistance of 1 person for toileting and personal hygiene. […]