Fair Oaks Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care were followed for one of three sampled residents (Resident 1), when the nursing staff did not administer ordered dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] failed to function) medication. This failure had the potential for Resident 1 to develop negative adverse reactions, elevated laboratory (lab) values, and other critical medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was assessed for the ability to self-administer medications prior to sending medications to dialysis treatment (a medical procedure when machine removes extra fluid and toxins from the blood when a person's kidneys cannot do it) with Resident 1. This failure placed Resident 1 at risk for unsafe medication administration and adverse outcomes. A review of the admission record indicated the facility admitted Resident 1 earlier this year with multiple diagnoses, which included chronic kidney disease and dependence on renal (kidney) dialysis. A review of MDS (Minimum Data Set, federally mandated assessment) dated 4/8/26 indicated that Resident 1 scored 11 out of 15 on cognitive assessment, which indicated mild cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to a dignified existence, self determination, and the exercise of rights for one of three sampled residents (Resident 1) when the facility improperly determined Resident 1 lacked capacity without adequate clinical assessment or legal authority and failed to support Resident 1 in updating her Durable Power of Attorney (DPOA Durable Power of Attorney- a legal document that appoints someone to make financial or medical decisions when someone becomes incapacitated). These failures resulted in mental anguish and interference with Resident 1's ability to exercise her rights.

Inspectors wroteBased on interview and record review, the facility failed to promptly act upon identified concern and request for a room change for one of 34 sampled residents (Resident 151), when the facility failed to honor and address Resident 151's power of attorney (POA, a person designated to make decisions) request to transfer Resident 151 to a different room. This failure had the potential to contribute to Resident 151's inability to rest and sleep and had the potential to affect Resident 151's emotional well-being and quality of life. A review of the admission record indicated the facility admitted Resident 151 in January of 2026 with multiple diagnoses which included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks) and traumatic brain bleed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage of medications when:Household and personal items were stored in medication carts and non-cleanable equipment used for multiple residents was kept with medications;Facility staff did not monitor refrigerator temperatures for staff vaccines twice daily; and,Medications were left in Resident 57's room. These deficient practices had potential for improperly stored and inadequately monitored medications, which could lead to unsafe and ineffective medication use for residents and staff. Thus, increasing the risk of contamination and infection for residents. 1. During a concurrent observation and interview on 2/13/26 at 9:16 a.m., with Licensed nurse 4 (LN 4) in the nursing station in [NAME] Wing (B Wing), a mouth guard used by residents was observed stored inside the medication cart 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow therapeutic diets (a nutritionally tailored meal plan prescribed by a physician and planned by a dietitian to treat, manage, or prevent specific medical conditions) for four of 147 sampled residents (Resident 75, Resident 166, Resident 111, & Resident 109). These failures had the potential to cause negative health outcomes for Resident 75, Resident 166, Resident 111, & Resident 109. During a review Resident 75's lunch meal ticket, (undated) ticket indicated, Diet Order: Fortified. During an observation on 2/11/26, at 11:54 a.m., [NAME] 1 did not add the fortified item (a prescribed diet, deliberately increasing the calorie and protein density of regular meals, snacks, and desserts to combat involuntary weight loss and malnutrition) to Resident 75's lunch meal tray. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store and distribute food according to professional practice standards for a census of 147 residents when:Sandwiches were stored in unsealed bags;Olives were stored in an unsealed container;Black and brown bananas were found in the kitchen; andTest tray vegetable holding temperature was below the acceptable range. This failure had the potential to result in food borne illness (any illness resulting from eating contaminated/spoiled/improperly stored foods) for residents who consume facility food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program for six of 34 sampled residents (Resident 123, Resident 172, Resident 56, Resident 181, Resident 59, and Resident 2) when:Staff did not change gloves after bowel care and staff did not perform hand hygiene in between glove use during wound care for Resident 123; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and secure environment to ensure that one of 34 sampled residents (Resident 125) received her mail, when two packages addressed to Resident 125 and delivered to facility were not safeguarded. This failure resulted in violation of Resident 125 rights to protection of personal property and caused Resident 125 to experience emotional distress. A review of the admission record indicated the facility admitted Resident 125 in 2017 with multiple diagnoses which included multiple sclerosis (MS, a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord) and heart disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable home-like environment for one of 34 sampled residents (Resident 70) when low sound levels were not maintained during the hours of sleep. This failure resulted in Resident 70 not being able to rest and sleep undisturbed through the night and had the potential to affect Resident 70's overall health. A review of the admission record indicated the facility admitted Resident 70 in 2022 with multiple diagnoses which included kidney disease and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), anxiety and depression. A review of Resident 70's Minimum Data Set (MDS, an assessment tool), dated 11/25/25, indicated the resident was cognitively intact and independent in decision making. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 34 sampled residents (Resident 103) was free from chemical restraints and unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 103's Lorazepam (medication used to treat anxiety) was given without appropriate target behavior and side effects monitoring, and no care plan was developed for Resident 103's use of antianxiety medication. These failures decreased the facility's potential to provide appropriate care and monitoring of Resident 103's target behaviors and increased Resident 103's risk and exposure to side effects associated with psychotropic medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing services were provided in accordance with professional standards of practice for two of two, sampled residents (Residents 185 and 172), when:1. Nursing staff did not follow safe handling standards for hazardous medications.2. A Nurse did not obtain or verify required vital signs prior to administering medications with physician hold parameters. These failures placed residents at risk for medication-related adverse effects and placed staff at risk for exposure to hazardous medications. During an observation and review of hazardous medication administration for Resident 185, on 2/4/26 at 8:38 a.m., LN 1 prepared and administered the following hazardous medications without wearing gloves:Mycophenolate Sodium 180 mg, and Tacrolimus 1 mg medications to treat a previous kidney transplant. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADLs: fundamental self-care tasks that individuals perform daily to maintain independence and hygiene) to residents dependent with ADL care for one of 34 sampled residents (Resident 30), when the facility failed to trim Resident 30's toenails after multiple requests from nursing staff. This failure had the potential for Resident 30 to experience dignity concerns related to not being groomed properly, and with the potential for fungal infection due to long toenail length. During an observation on 2/10/25, at 10:02 a.,m., in Resident 30's room. Resident 30 was observed to have long, thickened, discolored toe nails. During an interview on 2/10/26, at 10:45 a.m., with Licensed Nurse (LN) 6, LN 6 stated, Resident 30 does have long nails. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary treatment and services were implemented to promote healing and prevent worsening of the pressure injury (PI, area of damaged skin caused by prolonged pressure on a specific area of the body or friction) for one of 34 sampled residents (Resident 26), by failing to utilize a low air loss mattress (LAL, a special mattress designed to circulate a constant airflow used for residents who have pressure injuries) as indicated in the policy and recommended by wound care physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with bowel incontinence received appropriate treatment to restore normal bowel function for one of 34 sampled residents (Resident 66) when Resident 66 received a laxative [substance that relieve constipation by softening stool or stimulating bowel movements] while having diarrhea (loose, watery stools occurring three or more times daily) and loose stools caused by C. Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection. This failure had the potential to result in prolonged fecal incontinence, decreased skin integrity, dehydration, and frustration for Resident 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards for three of 34 sampled residents (Resident 124, Resident 144, and Resident 188) when: Resident 124's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was on the floor;Resident 144's continuous positive airway pressure (CPAP, a medical device that is used to deliver pressurized air directly into the airways) was not placed in an infection control bag after use;Resident 188's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was left on top of the nightstand and was not placed in an infection control bag after use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of significant medication errors for one of 34 sampled residents (Resident 56) when Resident 56's antibiotic (medication used to treat infections) doses were not administered as ordered by the physician. This failure had the potential to result in Resident 56's prolonged use of antibiotics and not having the desired effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when:The glass windows were cracked and shattered in the laundry room; and,The clean linen cart cover had a rip/tear. These failures had the potential for moisture build up leading to growth of molds in the laundry area and clean linens to be exposed to contaminants such as dust. During a concurrent observation and interview with the Laundry Staff 1 (LS 1) in the clean side of the laundry area on 2/11/26 at 10:07 a.m., a cardboard was taped over a broken glass window, another window was cracked with blue tape on the cracks, and the clean linen cover had a rip (linear tear) on the top portion. The LS 1 stated she placed the cardboard to prevent cold air from coming in the room and the windows had been like this for 2-3 months. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate a complaint of mistreatment for one of five sampled residents (Resident 1), when Resident 1's Family Member (FM) notified facility staff of Resident 1's complaint and facility did not conduct an investigation including resident and staff interviews and, staff education. This failure had the potential to place Resident 1 and other residents at risk for mistreatment leading to psychosocial distress. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and protective environment to be free from physical abuse was provided for one of three sampled residents (Resident 1), when Resident 1 was hit in the back of the head by Resident 2. This failure resulted in Resident 1's feeling scared of Resident 2 and had the potential to expose Resident 1 and other residents from further possible physical abuse from Resident 2. During a review of Resident 1's admission Record (AR) dated 5/2018, the AR indicated Resident 1 had diagnoses which included major depression. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/29/25, the MDS indicated Resident 1's memory was intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from injury when Resident 1 slid off the edge of the bed to the floor when a Certified Nursing Assistant (CNA) was assisting with dressing. This failure resulted in Resident 1 sustaining a right hip fracture causing pain, decreased mobility and functional level.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services in accordance with professional standards of practice to meet the needs of one of four sampled residents (Resident 1), when the facility did not follow a physician order to perform laboratory blood tests. This failure had the potential to result in worsening of Resident 1 ' s bladder infection and subsequent need to transfer to a hospital.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of four sampled residents (Resident 1), when there was documentation that the blood tests ordered by physician were performed and there was no documentation the physician was notified of resident's refusal of the lab tests. In addition, the order to reschedule blood tests for later date was not entered into Resident 1 ' s records. These failures resulted in the confusion among the facility ' s staff whether the tests were performed as ordered and had the potential to result in Resident 1's continued deterioration of health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmacy services were maintained to ensure a system that will account for and maintain accurate reconciliation (count of pills matches documentation for administration of medication) of all pharmaceutical products for a census of 134 residents when: 1. Loose medication found in the bottom of the medication drawer. 2. Packaged medication with a resident label found in the back of medication drawer. 3. The controlled medication (drug that is regulated by the government for its manufacture, possession, and use) audit for Resident 131 did not reconcile. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate labeling and storage of drugs for a census of 134 residents when: 1. An expired medication was stored in a treatment cart with all active medications. 2. An emergency medication did not have a label with resident's name affixed to medication. 3. An open date label (a label that captures the date a new bottle was opened) was not affixed to an open bottle of glucose test strips (small, disposable plastic strips that collect a blood sample to measure blood sugar levels). These failures increased the risk to administer medication that had lost its potency due to being expired or give medication to the wrong resident and to have inaccurate readings of glucose.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store raw meat and dry foods in accordance with safe food practices and failure to wear hair restraints in the kitchen for a census of 134 residents when: 1. raw ground beef was found stored above the vegetables; 2. uncooked lasagna pasta, polenta powder and chocolate chips stored unsealed; 3. Restorative Nursing Assistant (RNA) did not wash his hands, wear a hair and facial hair restraint before entering the kitchen; and 4. Dietary Aide's (DA) facial hair was not covered with hair restraints. This deficient practice had the potential to cause cross contamination of harmful bacteria; attract pests or rodents to unsealed dry foods; and transfer harmful germs onto food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 134 residents when: 1. Two facility staff removed their N95 mask respirators (a type of mask that filters up to 95% of particles in the air) inside a droplet isolation precaution room (an isolation precaution implemented when a patient infected with a pathogen which is transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing) before exiting the room; 2. Two resident visitors entered a COVID (an infectious disease) isolation precaution room without using all the required personal protective equipment (PPE); 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an accurate Minimum Data Set (MDS- an assessment tool used to guide care) assessment for one out of 28 sampled residents (Resident 131) when Resident 131's admission MDS pain management was inaccurate. This failure caused the facility to have inaccurate health status data for Resident 131 and potential for Resident 131 to not achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 28 sampled residents (Resident 396) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 396's physician's order for intake and output monitoring for tube feeding was not consistently followed. This failure increased the potential for inadequate monitoring of Resident 396 intake and output, failure to recognize early signs of fluid imbalance, and for Resident 396 to not achieve the highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 28 sampled residents (Resident 69) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 69's physician's order of pain medication was not followed. This failure had the potential for Resident 69 to not achieve relief from pain and not attain her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1's) rights were exercised timely when the facility discontinued an antipsychotic medication (used for treating psychosis or disconnection from reality) for Resident 1 without notifying the resident's representative (RR). This failure resulted in Resident 1's family members being frustrated and baffled by the resident's change in behaviors.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the safety for one resident (Resident 1) when Resident 1 did not receive adequate supervision and assistance during breakfast. This failure resulted in burns and blisters to two of Resident 1's fingers and pain to the affected area.

Inspectors wroteBased on interviews and record review the facility failed to promptly notify Resident 1's Responsible Party (RP) or Family Member (FM) when Resident 1 experienced burns to two fingers. This failure resulted in Resident 1 feeling as if the facility did not take her injury seriously.

Inspectors wroteBased on interviews and record review the facility failed to ensure the accuracy of assessments for one resident (Resident 1) when Resident 1 did not receive timely and adequate assessments of her injuries. This failure resulted in Resident 1's inaccurate and inconsistent assessments of her injuries, a lack of diagnosis for her injuries, and a delay in appropriate treatment.

Inspectors wroteBased on interviews and record review the facility failed to revise Resident 1's care plan within a timely manner after Resident 1 sustained an injury after an accident. This failure decreased the facility's potential to ensure residents receive appropriate and person-centered care.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure physician orders were followed when Resident 1 did not receive wound care treatment as ordered. This failure decreased the facility's potential to assist Resident 1's wound to heal.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents received proper foot care when: 1. Lack of documentation indicating Resident 1's wound on the right foot second toe was being assessed per nursing standards; and 2. Transportation services were not provided to Resident 1's podiatry (the medical care and treatment of the human foot) appointments. These failures resulted in Resident 1 not receiving foot care per nursing standards which led to a partial right foot amputation (surgical removal of part of the body).

Inspectors wroteBased on interview and record review, the facility failed to ensure an Infection Preventionist (IP: a nurse responsible for the facility's Infection Prevention and Control Plan) was available to meet all the requirements of the position for a census of 141 residents. This failure decreased the facility's potential to prevent the spread of infection among staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention program for one resident (Resident 1) out of three sampled residents, when the Treatment Nurse 1 (TN 1): did not clean bandage scissors prior to or after cutting a soiled wound dressing, placed treatment supplies directly on Resident 1's bed and returned supplies to the treatment cart, and did not perform hand hygiene (simple act of cleaning hands to present the spread of germs) during a wound treatment. These failures increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another) and the potential for infection.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for the prohibition and prevention of abuse for a census of 142 residents when 22 out of 26 sampled facility staff hired in December 2023 (Certified Nurse Assistant [CNA] 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, CNA 17, CNA 18, CNA 19, CNA 20, CNA 21, Licensed Nurse [LN] 4, LN 5, and Housekeeping Staff [HKS]) started working with residents in the facility without an employee background check (a formal process that verifies an upcoming employee's personal and professional information such as identity, work history, criminal record, and any other relevant information) done. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and complete a baseline care plan (BCP) within 48 hours of admission for one of two sampled residents (Resident 1). This failure decreased the ability to address Resident 1's specific health needs and communicate his initial plan of care.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's Nothing By Mouth (NPO) diet order for one of two sampled residents (Resident 1), when Resident 1 was served and fed a meal at dinner time. This failure increased Resident 1's potential to inhale food into his lungs and develop pneumonia (lung infection).

Inspectors wroteBased on interview and record review, the facility failed to administer medication as ordered for one resident (Resident 1) of three sampled residents. This failure had the potential for Resident 1 to have complications related to hypertension.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control guidelines for the residents of the facility, when: 1. Certified Nursing Assistant (CNA 1) did not wear required Personal Protective Equipment (PPE- mask, gown and gloves) while inside a resident's room that was under contact isolation precautions; and 2. An uncovered linen cart from laundry with resident's clean personal clothes was seen parked in the A wing hallway. These deficient practices had the potential to spread infection and disease among residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one resident (Resident 1) of two sampled residents when: 1. Resident 1's pain medication was not administered timely and per physician order; and, 2. A lidocaine patch (a topical patch that applies pain relief) was documented as administered when it was not. This failure had the potential to increase Resident 1's pain above a tolerable threshhold and allow for accurate pain remedies to be administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for nine of 130 residents when: 1. Residents' identification was not verified at the time of medication administration for Resident 31, Resident 81, and Resident 83, which put residents 31, 81 and 83 at risk of receiving the wrong medication, 2. Disposed non-controlled medications (prescription medications with less risk of addiction and harm) were retrievable or were destroyed in sharp containers (a hard plastic container that is used to safely dispose of hypodermic needles and other sharp medical instruments), which could result in drug diversion, 3. Two expired medications were available for use for Resident 44 and 99 in the medication cart, which put residents 44 and 99 at risk of receiving expired medication, 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly for the census 130, when: 1. A medication cart was not locked and left unattended during medication pass, 2. Two medication bottles were left on top of the medication cart unattended and accessible to unauthorized personnel, 3. Disposed non-controlled medications (prescription medications with less risk of addiction and abuse) were retrievable and not properly destroyed, 4. Loose pills were found in the medication carts on wing B, C and D, and; 5. Temperature of a medication refrigerator on wing C was out of range. 6. A medication cart drawer was left open and unattended, These failures had the potential for medication misuse, drug diversion and medication ineffectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare meals that conserve nutritive value, flavor, and appearance when recipes were not followed for meal production. This failure had the potential for 124 residents of a census of 130 not receiving the nutritional value of their meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food production and minimize the potential for food borne infections when: 1. Open food packages (various cereals, dill weed seasoning, and sliced cheese) were not labeled with open dates; and, 2. Kitchen equipment and floors were dirty and/or worn (steam table pans, fan, cutting boards and meat slicer), and metal shelves were rusty. These failures had the potential to expose 124 residents of a census of 130 to expired foods and placed these residents at risk for food borne infections (illness caused by consuming contaminated foods or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices to prevent the development and transmission of communicable (contagious) diseases and infections when: 1. Five Residents (Resident 44, Resident 49, Resident 89, Resident 185, and Resident 320) were not offered hand hygiene prior to meals; and, 2. One staff entered the kitchen and did not wash hands prior to touching equipment. These failures had the potential to spread germs and make the residents ill in the facility for a census of 130.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Department, for a census of 130. This failure had the potential for abuse allegations to not be investigated thoroughly and in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the professional standards of nursing practice when Licensed Nurse (LN) did not ensure Resident 183 swallowed the medications after administration for a census of 130. This failure placed the resident at risk for ineffective medication therapy and increased the potential for choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a skin assessment was conducted and documented for one resident (Resident 3), for a census of 130. This failure had the potential for Resident 3 to not receive adequate care and monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environment remained free from accident hazards as possible when Resident 5's smoking materials were not kept in a secure location, for a census of 130. This failure had the potential for residents to have access to smoking materials without supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent with 27 observed opportunities for one of six sampled residents (Resident 49), when: 1. Resident 49 was administered calcium carbonate (used to treat gas and stomach pain) 750 mg (milligram is a unit of measuring weight) instead of prescribed calcium carbonate 500 mg, 2. Resident 49's lidocaine patch (medication used to treat pain) was administered instead of notifying the physician when the nurse knew that the previous patch was not removed as prescribed the night before. These failures resulted in 2 medication errors identified out of 27 opportunities during Medication pass observation. This resulted in the facility having a medication error rate of 7.41 percent.