She handed the liquid to one resident, then distributed the medication cups to two other residents identified as R15 and R21.
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She confirmed that nurses had received training on infection control and oxygen tubing care.
During interviews with facility staff, the Social Service Director admitted she didn't know when the mail actually arrived at the facility.
Federal inspectors found the facility's Direct Care Daily Staffing Numbers still showed November 11 when they arrived at 8:51 AM on November 12.
Resident #1 told federal inspectors in October that she experienced "some confusion with her medications at the facility" following her September admission.
The incident at Regency Village unfolded when the resident's catheter stopped working properly, soaking him in his own waste.
Assistant Director of Nursing A provided even more alarming details about the potential consequences.
The facility hired her on July 17, 2025, meaning she worked the entire duration of her employment without valid certification.
During interviews with federal inspectors in September, he initially said he had emailed a copy of the discharge notice to the ombudsman.
The Ellison John Transitional Care Center admitted the 28-year-old resident on October 28 with cellulitis in his lower leg, colon cancer, and heart failure.
"Last night and this morning it was better because facility staff responded within 10-15 minutes," the resident said during a November 25 interview.
State inspectors found the maintenance office propped open twice on October 14, with hazardous materials sitting within reach on a desk and shelf.