Resident 2 told inspectors on December 29 that he was "very upset" because he requested assistance transferring to a different facility but "did not receive any updates regarding the status of his request for approximately one month." The resident said he had stopped his physical therapy sessions to save his hours of treatment for when he transferred to his preferred facility.
The resident, who was admitted to Fountain View Subacute and Nursing Center with heart failure and obesity, requires maximum assistance for eating, dressing his upper body, and personal hygiene. Staff must do all the work for his toileting, lower body dressing, putting on shoes, showering, and turning in bed.
Despite needing extensive physical help, his cognitive abilities remained intact for making daily living decisions, according to his February assessment.
When inspectors interviewed the Social Services Worker at 1:30 PM that same day, she acknowledged the failure directly. The worker "admitted that she failed to follow up on the Resident 2's request by contacting the requested receiving facility." She also admitted she "did not provide Resident 2 with updates regarding the status of the transfer request during that period."
No documentation existed showing the requested facility had ever been contacted or that the resident had been informed of any progress or delays.
The resident told inspectors he experienced "frustration and concern due to the lack of communication and perceived lack of support with his care preferences." His decision to halt physical therapy represented a calculated response to institutional neglect — preserving his limited therapy hours for use at a facility that might actually help him transfer.
The Director of Nursing confirmed during her interview that helping residents with transfer requests fell squarely within the social worker's job responsibilities. She stated "it is the responsibility of the SSW to assist residents in obtaining resolution to grievances, requests, and accommodation of needs by communicating with residents any updates regarding their concerns."
The nursing director emphasized that "communicating with residents was important to maintain resident rights and quality of care."
Fountain View's own policies, dated September 2021, spell out exactly what the social worker should have been doing. The facility's Social Services policy states the director of social services must assist with "medically-related social service needs of residents" including helping with "transitions of care services" and "obtaining resolution to living conditions, grievances about treatment and accommodation of needs."
The policy specifically mentions helping residents with "situations that impede the resident's dignity and sense of control" — precisely what happened when the resident was left in limbo about his transfer request.
Federal inspectors found the facility failed to provide required social services to help the resident "achieve the highest possible quality of life." The violation resulted in the resident "experiencing frustration and dissatisfaction with communication and care and impeded Resident 2's request to transfer and maintain his highest practicable physical, mental and psychosocial well-being."
For a resident already dependent on staff for basic functions like toileting and dressing, the additional burden of institutional indifference created a double barrier to care. He couldn't physically advocate for himself, and the person paid to advocate for him chose not to make a phone call.
The inspection occurred after a complaint was filed about the facility's practices.
The resident's strategy of stopping therapy to preserve his benefits reveals the impossible calculations nursing home residents must make when institutions fail them. Rather than continue treatment at a facility he wanted to leave, he gambled his immediate rehabilitation needs against the possibility of eventually receiving care somewhere else.
That gamble depended entirely on a social worker doing her job. For at least a month, she didn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fountain View Subacute and Nursing Center from 2025-12-29 including all violations, facility responses, and corrective action plans.
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