Mountain View Care Center: Undercooked Beef Served - WV
The October 12 incident began simply enough. The facility had run out of chicken at lunch, so a kitchen worker pulled frozen hamburger patties from the freezer and started frying them in a skillet. When the patties came off the stovetop, neither cook took a temperature reading. They put the burgers on buns, placed them on trays, and moved toward the service cart.
The state surveyor stepped in and asked a cook to take the temperature of two patties, straight from the stove. They read 149 degrees and 151 degrees. Ground beef should reach 160 degrees. Ground meat, including hamburger patties, should reach 165 degrees. These burgers were more than 14 degrees short of that mark.
That gap matters. Undercooked ground beef can harbor E. coli and other pathogens that cause serious illness, particularly dangerous in a population of elderly residents whose immune systems are already compromised.
After the surveyor flagged the temperatures, Cook #119 told kitchen staff to put the two trays with the undercooked hamburgers back on the service cart anyway and send them down the D hallway. The surveyor intervened a second time. The hamburgers were pulled from the cart and never served.
Two interventions. The same meal. The same cart.
The inspection report, completed October 16, 2025, cited the failure as having the potential to affect more than a limited number of residents. The deficiency was rated at the minimal harm level, in part because the surveyor caught the problem before residents ate the meat. Had the surveyor not been present for lunch service that day, the trays would have gone out.
What the report describes is not a complicated lapse. Taking the temperature of cooked ground beef before serving it is a basic step, the kind of task that takes seconds and requires nothing more than a food thermometer. Neither cook did it. Not once during the preparation, and not before the food left the kitchen. When a surveyor had to ask them to check the temperature, the readings came back unsafe. When told the food was unsafe, a cook still directed staff to serve it.
Mountain View Care Center sits at 107 Miller Drive in Ripley, a small city in Jackson County. The facility serves residents who depend entirely on staff for their meals, their medication, and their safety. They cannot inspect their own food. They cannot send a tray back because the meat looks underdone. They eat what is placed in front of them.
On October 12, what was about to be placed in front of them was a hamburger cooked to 149 degrees, pulled from a skillet by a worker who had not checked the temperature, approved by a cook who, even after learning the patties were unsafe, told staff to serve them anyway.
The surveyor's second intervention is the detail that lingers. The first stop, asking for a temperature check, could be read as routine oversight catching an honest mistake. The second stop, pulling trays off a cart after staff had already been told the meat was undercooked, is something else. It is a cook looking at that information and deciding to send the food out regardless.
The residents on the D hallway did not get those hamburgers. What they got instead, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Care Center from 2025-10-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Mountain View Care Center in RIPLEY, WV was cited for violations during a health inspection on October 16, 2025.
The October 12 incident began simply enough.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.