The inspection, completed September 8, 2025, centered on Resident C, a man whose behavior had been escalating for weeks before inspectors arrived.
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Inspectors visiting Greene Health & Rehab Center that day documented the temperatures precisely.
That administrator, identified in federal inspection records only as V1, is also the facility's designated abuse coordinator.
Immediate Jeopardy is the most serious finding federal inspectors can assign.
The resident had been alone for hours.
The fall happened on July 7, 2025, at Lindengrove New Berlin.
Inspectors reviewed the August Treatment Administration Records for three residents during a complaint inspection completed September 5, 2025.
The confusion unfolded on August 31, 2025, and it ended with the family threatening to file a complaint.
He called the condition unsanitary and unacceptable.
Nobody on the morning shift had checked him before breakfast.
The next morning, inspectors asked two people about it.
Only then did they give him his money.