On August 28, 2025, following a significant change in his condition, he was formally reassessed and designated high risk.
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That was not supposed to happen that way.
A separate case labeled August 20 contained celery and cabbage, the celery visibly spoiled.
The fall happened on September 12, four days before inspectors arrived.
Inspectors found those standards were not being met.
Inspectors reviewed pest sighting reports dating from May 29 to August 30, 2025, and counted 35 documented rodent sightings.
The man, identified in federal inspection records as Resident 23, left the facility on a date redacted from the report.
Immediate Jeopardy is the most serious classification available to federal inspectors.
The resident, identified in inspection records as R5, was cognitively intact, scoring a perfect 15 on a standardized mental assessment.
The resident's wife noticed the swelling first.
Three weeks later, on August 20, the same resident's blood pressure was 83/60.
The resident did not respond when spoken to and did not appear to be breathing.