Dahlia Care LLC

Based on record review and interview, the manager failed to ensure any care instructions for a resident provided to the assisted living facility by the home health agency was documented in the resident's service plan, for one of two resident receiving services from home health. Findings include: 1. A review of R1's medical record revealed pre-admission paperwork dated October 2023 that revealed R1 was admitted with a wound to the left heel. The record contained a signed medication order dated October 5, 2023 for Cavilon Spray. The order identified wound care and stated "One spray to left heel twice a day." However, R1's service plan dated October 11, 2023, did not include instructions for care for R1's wound. 2. In an interview, E1 acknowledged R1's service plan did not include instructions for R1's wound care.