Terravella Assisted Living Care, LLC

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states: "1. The department shall: (d) Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R2's medical record revealed no documentation of the notification of R2 of the availability of vaccination for influenza and pneumonia. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R2's medical records did not include current documentation showing the influenza and pneumonia vaccination was offered or received.