The Director of Nursing was at the cart with the inspector five minutes later.
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The resident, identified in inspection records as R28, had already fallen after his catheter collection bag and tubing caught him during a transfer.
The air conditioning failure at Sunset Ridge Post Acute began June 1, 2025, when a power surge damaged an indoor unit.
The facility's own portable lift policy, revised in August 2008, states the device must be operated by two staff members.
That deadline had already passed by the time inspectors finished their review.
The complaint inspection was completed August 28, 2025 at the 336 Edgewood Drive facility.
Three months later, on August 1, 2025, an incident occurred between that resident and another.
The resident, identified in inspection records only as R11, takes digoxin for atrial fibrillation.
The facility is disputing the citation.
The complaint inspection, which affected a small number of residents, identified failures in basic medication administration practices.
The August 2025 complaint inspection documented what happened to the resident, identified in the report as R3.
The incident happened on August 2, 2025.