Health inspection·August 17, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASRR) documents accurately identified resident diagnoses and medications. This affected three (Residents #5, #13, and #30) of three residents reviewed for PASRR's. The census was 76. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #13 revealed Resident #13 was admitted to the facility on [DATE]. Resident #13's diagnoses included but were not limited to dementia, obsessive compulsive disorder (12/27/16), osteoporosis, hypothyroidism, vitamin D deficiency, major depressive disorder (03/09/13), anxiety disorder (03/09/13), unspecified psychosis not due to a substance or known physiological condition (03/09/13). Review of Resident #13's Minimum Data Set (MDS) assessment, dated 07/14/23, revealed she had a mild cognitive impairment. Review of Resident #13's PASRR document, dated 02/15/12, revealed under Section D, the only diagnosis listed was mood disorder. Resident #13's PASRR document did not include Resident #13's diagnosis of obsessive compulsive disorder (added as a diagnosis on 12/27/16), and unspecified psychosis not due to a substance or known physiological condition (added as a diagnosis on 03/09/13). There was no evidence a new or updated PASRR document was completed for Resident #13's and included Resident #13's diagnosis of obsessive compulsive disorder and unspecified psychosis. Interview with Social Services Director #210 on 08/16/23 at 4:41 P.M. confirmed the PASRR documents provided were the most up to date. She confirmed all Resident #13 had diagnoses that were not listed on PASRR documents and should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (Residents #5, #13, and #30) of three residents reviewed for Pre-admission Screening and Resident Review (PASRR). The census was 76. Findings include: 1. Review of the medical record for Resident #13 revealed Resident #13 was admitted to the facility on [DATE]. Resident #13's diagnoses included but were not limited to dementia, obsessive compulsive disorder (12/27/16), osteoporosis, hypothyroidism, vitamin D deficiency, major depressive disorder (03/09/13), anxiety disorder (03/09/13), unspecified psychosis not due to a substance or known physiological condition (03/09/13). Review of Resident #13's Minimum Data Set (MDS) assessment, dated 07/14/23, revealed she had mild cognitive impairment. Review of Resident #13's PASRR document, dated 02/15/12, revealed under Section D, the only diagnosis listed was mood disorder. Resident #13's PASRR document did not include Resident #13's diagnosis of obsessive compulsive disorder (added as a diagnosis on 12/27/16), and unspecified psychosis not due to a substance or known physiological condition (added as a diagnosis on 03/09/13). There was no evidence a new or updated PASRR document was completed for Resident #13's and included Resident #13's diagnosis of obsessive compulsive disorder and unspecified psychosis. There was no evidence the state mental health agency was notified of Resident #13's significant change in mental health. Interview with Social Services Director #210 on 08/16/23 at 4:41 P.M. confirmed the PASRR provided for Resident #13 were the most up to date PASRR. She confirmed the facility did not notify the state mental health agency of Resident #13's significant change in mental health. 2. Review of the medical record for Resident #5 revealed an admission date of 11/14/21. Resident #5's medical diagnoses included schizoaffective disorder (09/15/22), bipolar disorder (07/18/21), obsessive-compulsive disorder (07/18/21), anxiety disorder (07/18/21), major depressive disorder (07/18/21), and mild intellectual disabilities (07/18/21). Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/15/23, revealed Resident #5 had intact cognition and scored 14 out of 15 on the brief interview for mental status (BIMS) assessment. Resident #5 required extensive assistance from two staff to complete activities of daily living (ADLs). Review of Resident #5's PASRR, dated 01/28/22, revealed the PASRR did not include Resident #5's diagnosis of anxiety disorder (added as a diagnosis on 07/18/21), obsessive-compulsive disorder (added as a diagnosis on 07/18/21), or schizoaffective disorder (added as a diagnosis on 09/15/22) diagnoses. There was no evidence the state mental health authority was notified of Resident #5's significant change in mental health. Interview on 08/16/23 at 4:41 P.M. with Social Services Director (SSD) #210 confirmed an updated PASRR had not been completed to reflect all of Resident #5's mental health diagnoses and medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few used to treat those diagnoses. SSD #210 confirmed the state mental health authority had not been notified of Resident #5's significant change in mental health. 3. Review of the medical record for Resident #30 revealed an original admission date of 02/05/20 and a readmission date of 07/01/20. Resident #30's medical diagnoses included dementia without behavioral disturbance (12/11/19), unspecified psychosis (01/07/22), generalized anxiety disorder (07/01/20), and bipolar disorder (05/19/20). Review of the quarterly MDS 3.0 assessment, dated 07/03/23, revealed Resident #30 had impaired cognition and scored a five out of 15 on the BIMS assessment. Resident #30 displayed physical behaviors towards others and verbal behaviors towards others one to three days during the review period. Resident #30 required extensive assistance from one to two staff to complete ADLs. Resident #30 received routine antipsychotic, anti-anxiety, and anti-depressant medications. Review of Resident #30's PASRR, dated 03/06/20, revealed the review did not include Resident #30's dementia diagnosis or any of Resident #30's mental health diagnoses including Resident #30's new diagnosis of unspecified psychosis on 01/07/22. There was no evidence the state mental health authority was notified of Resident #5's significant change in mental health. Interview on 08/16/23 at 4:41 P.M. with SSD #210 confirmed an updated PASRR had not been completed to reflect all of Resident #30's mental health diagnoses, dementia diagnosis, or medications used to treat those diagnoses. SSD #210 confirmed the state mental health authority had not been notified of Resident #30's significant change in mental health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident care plans were revised to reflect changes in advanced directives. This affected one (Resident #7) out of 18 residents reviewed for advanced directives. The facility census was 76. Findings include: Review of the medical record for Resident #7 revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to major depressive disorder, anxiety, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/27/23, revealed Resident #7 was cognitively intact. Resident #7 was receiving hospice care. Review of the physician orders for Resident #7 revealed an order dated 06/09/23 for Do Not Resuscitate Comfort Care - Arrest (DNR-CC-Arrest). Review of the paper chart for Resident #7 revealed the first page was a label in bold print which indicated DNR-CC-Arrest. Review of the care plan for Resident #7 revealed a problem that outlined Resident #7 was at risk for alteration in code status and Resident #7 was a Full Code with a last revision date of 07/03/23 and a next target date of 10/04/23. Interventions included call 911 immediately and effectively communicate full code status wishes by placing in the front of the chart, and/or when resident must be transferred out of the facility. Intercede rapidly and begin immediate resuscitative efforts utilizing all life - sustaining measures available if the heart stops beating or breathing stops, notify family and physician of changes promptly. Interview on 08/16/23 at 3:47 P.M. with the Director of Nursing verified Resident #7's care plan indicated Resident #7 was a full code however Resident #7 had an order for DNR-CC-Arrest. The interview verified Resident #7's care plan was not revised when Resident #7's code status was changed to DNR-CC-Arrest. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interviews, and facility policy review, the facility failed to ensure dietary recommendations to address weight loss were implemented in a timely manner. This affected one (Resident #64) of four residents reviewed for nutrition. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #64 revealed an admission date of 07/14/23. Resident #64's medical diagnoses included fracture of right femur (lower leg bone), chronic obstructive pulmonary disorder (COPD), Type II Diabetes Mellitus with hyperglycemia (high blood sugar levels), dementia without behavioral disturbance, and dysphagia (difficulty swallowing). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/21/23, revealed Resident #64 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #64 required supervision from one staff with eating. Review of the care plan, dated 07/18/23, revealed Resident #64 had a potential to be at nutritional risk. Interventions included to provide supplements as ordered and the Registered Dietitian (RD) was to evaluate and make diet change recommendations as needed. Review of Resident #64's weights dated from 07/15/23 to 08/16/23 revealed Resident #64 weighed 135.6 lbs on 07/15/23, 121.4 lbs on 08/01/23, 116.8 lbs on 08/10/23, and 117.4 lbs on 08/16/23. Resident #64 experienced a severe weight loss of 10.5% from 07/15/23 to 08/01/23 and a non-significant weight loss of 3.8% from 08/01/23 to 08/10/23. Review of Resident #64's physician orders, dated August 2023, revealed Resident #64 did not have an order for a frozen supplement. Review of Resident #64's Nutrition Assessment for Significant Weight Loss progress note, dated 08/01/23 at 1:27 P.M., revealed Resident #64 experienced a significant weight loss of 10.9% (15 lbs) in one week. It was recommended for Resident #64 to receive a Frozen Supplement (Thrive Gelato) daily to further supplement intake. Review of the dietary progress note, dated 08/14/23 at 11:24 A.M., revealed Resident #64's weight on 08/10/23 was 116.8 lbs. Resident #64 had lost a total of 18.8 lbs since admission. Resident #64 was ordered to receive a Glucerna supplement eight ounces daily. The note indicated to increase Resident #64's Glucerna to eight ounces two times a day. The note did not indicate whether Resident #64's frozen supplement had been implemented as recommended on 08/01/23. Interview on 08/16/23 at 4:35 P.M. with the Director of Nursing (DON) confirmed the dietary recommendation to add a Frozen Supplement daily for Resident #64 had not been ordered as recommended. Interview on 08/17/23 at 8:35 A.M. with the DON revealed Resident #64 had been receiving the frozen supplement on her meal trays but there was not an order in place for the supplement until the DON added an order on 08/17/23. The DON confirmed there was no documentation to confirm the frozen supplement had been provided and no monitoring of acceptance of the supplement for the dietitian to consider during evaluations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/17/23 at 9:50 A.M. with State Tested Nurse Aide (STNA) #130 revealed she noticed Resident #64 started receiving a frozen supplement on lunch and dinner trays last weekend, around 08/12/23. Interview via telephone on 08/17/23 at 10:09 A.M. with Registered Dietitian (RD) #168 revealed she had recently taken over the dietary services at the facility last week and had documented on Resident #64. RD #168 confirmed Resident #64 had a significant weight loss of 18 or 19 lbs since she was admitted to the facility. RD #168 confirmed the Frozen Supplement had not been ordered for Resident #64 so she assumed the resident had not been receiving the supplement. RD #168 stated she had not included any intake or calories related to a Frozen Supplement in her dietary assessment of Resident #64 because there was no documented evidence the supplement was provided to Resident #64. Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised 09/2012, revealed the policy stated, the threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month 5% weight loss is significant; greater than 5% is severe. The physician will authorize and the staff will implement appropriate general or cause specific interventions as indicated. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk for developing impaired nutrition. Such monitoring may include: evaluating the care plan to determine if the interventions are being implemented and whether they are effective and evaluating the resident's response to interventions for example, food/fluid intakes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #30 revealed an original admission date of 02/05/20 and a readmission date of 07/01/20. Medical diagnoses included dementia without behavioral disturbance, chronic obstructive pulmonary disorder, Type II Diabetes Mellitus without complications, and essential (primary) hypertension (high blood pressure). Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/03/23, revealed Resident #30 had impaired cognition and scored a five out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the care plan, revised 07/28/23, revealed Resident #30 was at risk for developing complications secondary to having hypertension. Interventions included give anti-hypertensive medications as ordered. Review of Resident #30's physician orders, dated August 2023, revealed Resident #30 had the following orders: An order with a start date of 02/04/23 for Doxazosin Mesylate (medication used to treat high blood pressure) tablet two milligrams (mg) daily with instructions to hold for a systolic blood pressure (SBP) less than 100 millimeters of mercury (mm Hg), diastolic blood pressure less than 60 mm Hg, or pulse less than 60 beats per minute. An order with a start date of 02/04/23 for Metoprolol Tartrate Tablet (medication used to treat high blood pressure) 25 mg two times a day with instructions to hold for a SBP less than 100 mm Hg, diastolic blood pressure less than 60 mm Hg, or pulse less than 60 beats per minute. An order with a start date of 02/04/23 for Norvasc Tablet (medication used to treat high blood pressure) five mg daily with instructions to hold for a SBP less than 100 mm Hg, diastolic blood pressure less than 60 mm Hg, or pulse less than 60 beats per minute. Review of the Medication Administration Record (MAR), dated August 2023, revealed Resident #30's Doxazosin Mesylate Tablet, Metoprolol Tartrate Tablet, and Norvasc Tablet were administered to Resident #30 on 08/02/23 when Resident #30's blood pressure was 106/59 mm Hg as well as on 08/14/23 when Resident #30 had a blood pressure of 109/56 mm Hg. Interview on 08/16/23 at 4:50 P.M. with the Director of Nursing (DON) confirmed Resident #30's blood pressure medications (Doxazosin Mesylate, Metoprolol Tartrate, and Norvasc) were administered outside of the parameters ordered by the physician. Review of the facility policy, Medication Therapy, revised 04/2007, revealed the policy stated, medication use shall be consistent with an individual's condition, prognosis, and responses to such treatments. All medication orders will be supported by appropriate care processes and practices. The staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. Based on medical record review, staff interviews, and facility policy review, the facility failed to ensure medications were administered according to the physician ordered parameters. This affected two residents (Resident #30 and Resident #34) out of six residents reviewed for unnecessary medications. The facility census was 76. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #34 revealed Resident #34 was admitted on [DATE] with diagnoses which included but were not limited to metabolic neuropathy, polyneuropathy, low back pain, chronic pain, depression, rhabdomyolysis, thrombocytopenia, and edema. Residents Affected - Few Review of Resident #34's quarterly Minimum Data Set (MDS) assessment, dated 05/16/23, revealed Resident #34 was cognitively intact. Review of Resident #34's physician orders revealed an order, dated 04/20/23, for Norco (narcotic medication) oral tablet 5-325 milligrams (mg), give one tablet every six hours as needed for a pain level of six to 10 out of 10, not to exceed three grams (gm) in 24 hours. Resident #34 also had a physician order, dated 04/20/23, for Tylenol 325 mg, give 650 mg every six hours as needed for a pain level of one to five out of 10, not to exceed three gm in 24 hours. Review of the Resident #34's August 2023 Medication Administration Record revealed Resident #34's Norco oral tablets 5-325 mg with instructions to give one tablet every six hours as needed for a pain score of six to 10 out of 10 was administered on 08/01/23 at 10:29 A.M. for a pain score of zero, on 08/05/23 at 4:28 P.M. for a pain score of four, on 08/05/23 at 11:30 P.M. for a pain score of five, on 08/06/23 at 5:27 P.M. for a pain score of five, on 08/08/23 at 5:46 A.M. for a pain score of five, on 08/08/23 at 12:30 P.M. for a pain score of zero, on 08/12/23 at 1:42 P.M. for a pain score of five, on 08/12/23 at 11:31 P.M. for a pain score of four, on 08/16/23 at 12:13 P.M. for a pain score of four, and on 08/17/23 5:30 A.M. for a pain score of four. Resident #34's Tylenol 325 mg tablet, give 650 mg every six hours as needed for pain one to five had not been administered. Interview on 08/17/23 at 2:53 P.M. with the Director of Nursing (DON) verified Resident #34's Norco 5-325 mg was administered on the above dates for pain levels which were outside of the physician ordered parameters for the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 9 of 9