Abuelitos Home, LLC.

“Based on record review, documentation review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the effect of the opioid administered, for one resident sampled. Findings include:  1. A review of R2’s medical record revealed a Medication Administration Record (MAR) for the month of March 2026. This MAR included the documentation for the opioid Tramadol HCL, 50 mg 1/2 tab by mouth twice a day. According to this MAR, R2 received this opioid two times a day, every day, at 8am and 8pm from March 8 - March 13, 2026. However, there was no documentation of R2's response and the effect of the opioid administered for each administration in March 2026. R2 did not have an end-of-life condition or an active malignancy. 2. A review of facility documentation revealed an opioid policy created on August 1, 2019 titled "Opioid Policy & Procedure". The policy stated "Before administer Opioid medications, make sure to verify the resident's name and his/her level of pain. > Document the Five Medication Rights (Resident, Medication, Dosage, Route, Time. > Log or chart the medication administration on the Narcotics Charting Form. > Observe the effectiveness of the Opioid administered after 2hours. • Each time the above pain level assessments are taken they will be recorded in the resident's medical record on the MAR, a PRN-MAR or an Opioid MAR. • The effectiveness of the opioid medication will be determined and document on Opioid PRN- MAR." 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”