Inspectors reviewed two medication carts and one medication room at the facility.
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The resident, identified in inspection records only as R54, had moderate cognitive impairment, used a walker, and depended on staff for most of his daily care.
The woman, identified in inspection records as Resident 34, has Alzheimer's disease.
A federal inspector watched the entire procedure on June 17, 2026.
Neither of those were the problem.
Federal inspectors documented the lapse in a June 2026 report.
Midway through the preparation, the cook walked to a speaker, touched it to turn off the music, then walked back and resumed handling the raw chicken.
She could not be expected to track her own blood sugar or flag a problem herself.
The order covered therapeutic exercise, therapeutic activity, gait training, and caregiver education.
Nobody had been assigned to close the doors.
The resident, identified in inspection records only as Resident 5, has hydronephrosis, a condition in which urine builds up and causes the kidneys to swell.
The resident, identified in inspection records as R12, should have been tested within 72 hours of admission.