Inspection Reports for Family Friendly Care Home
3784 Edison Ave, Las Vegas, NV 89121, NV, 89121
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 9
Dec 18, 2024
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted on 12/18/2024 to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including personnel file certification, oxygen tank safety, missed annual physicals, medication administration errors, missing TB tests, unlocked gates, and lack of audible alarms on exit doors. Corrective actions were planned or implemented for all deficiencies.
Severity Breakdown
D: 6
F: 3
E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Personnel file lacked current certification for first aid and CPR for a caregiver. | D |
| Oxygen tanks were not properly secured; corrective action taken to secure tanks. | F |
| Resident #4's annual physical examination was missed. | D |
| Residents #5 and #6 lacked documentation of a 6-month medication review. | D |
| Medication order discrepancies and missing physician-ordered medication for Resident #2 and Resident #3. | D |
| Resident #7 missing annual TB test for 2024. | D |
| Front screen door was unlocked and lacked an audible alarm. | F |
| Gate leading to the street was not locked during the survey. | F |
| Residents #4, #5, and #7 lacked documented evidence of initial and/or current placement. | E |
Report Facts
Facility licensed beds: 10
Resident census: 8
Severity 2 deficiencies: 6
Severity F deficiencies: 3
Severity E deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charo Dale | Supplier Representative | Signed the Statement of Deficiencies report |
Inspection Report
Annual Inspection
Census: 8
Capacity: 5
Deficiencies: 9
Sep 16, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the Family Friendly Care Home in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including failure to ensure CPR and first aid training compliance for one employee, unsecured oxygen tanks, missing annual physical and medication reviews for some residents, inaccurate medication administration records, missing annual TB testing, unsecured gate to the street, and lack of current placement assessments for several residents.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 employees received CPR and first aid training with required in-person component. | Level 2 |
| Failed to ensure oxygen tanks were secured in the facility. | Level 2 |
| Failed to ensure an annual physical examination was completed for 1 of 8 residents. | Level 2 |
| Failed to perform medication reviews every six months for 2 of 8 residents. | Level 2 |
| Failed to administer medications per physician's orders for 1 of 8 residents. | Level 2 |
| Failed to ensure the Medication Administration Record (MAR) was accurate for 1 of 8 residents. | Level 2 |
| Failed to ensure 1 of 8 residents met the requirements for annual tuberculosis testing. | Level 2 |
| Failed to lock a gate leading from the secured yard to the street. | Level 2 |
| Failed to ensure annual placement assessments and/or initial placement assessments were obtained for 3 of 8 residents. | Level 2 |
Report Facts
Residents present: 8
Total licensed capacity: 5
Employee files reviewed: 6
Resident files reviewed: 8
Severity 2 deficiencies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julia Asuncion G Dugay | Administrator | Named as responsible for oversight and corrective actions in multiple findings |
| Employee #3 | Caregiver | Failed CPR and first aid training compliance |
| Employee #6 | Acknowledged multiple deficiencies including CPR training, medication reviews, TB testing, and gate security |
Inspection Report
Original Licensing
Census: 7
Capacity: 8
Deficiencies: 0
Dec 7, 2023
Visit Reason
The inspection was conducted due to a bed increase and endorsement change State Licensure survey for the facility.
Findings
The facility requested and was approved for an increase of two beds and an Alzheimer's disease endorsement. The facility received a grade of A with no regulatory deficiencies identified and no further action required.
Report Facts
Licensed beds: 8
Bed increase: 2
Census: 7
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 1
Sep 20, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey of the Family Friendly Care Home in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A; however, a regulatory deficiency was identified related to failure to obtain a required bedfast exemption for one resident (Resident #4) who was bedfast and required assistance with repositioning.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain a bedfast exemption for Resident #4 who was bedfast and required assistance being turned and repositioned every two hours. | Severity: 1 |
Report Facts
Licensed beds: 10
Resident census: 5
Resident records reviewed: 5
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julia Asuncion G Dugay | Administrator | Named in relation to acknowledging lack of bedfast exemption and responsible for applying for waiver |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 10
Deficiencies: 0
Dec 20, 2022
Visit Reason
The inspection was conducted as a result of a State Licensure Complaint Investigation survey triggered by Complaint #NV00067267 with two allegations.
Findings
The investigation found no regulatory deficiencies. Both allegations were unsubstantiated: the food was found to be nutritious and tasteful, and there was no evidence that residents missed doctor's appointments.
Complaint Details
Complaint #NV00067267 with two allegations was investigated and found unsubstantiated. Allegation #1 regarding poor food quality was disproven by meal observation and resident interviews. Allegation #2 about missed doctor's appointments was disproven by record review and interviews with staff and residents.
Report Facts
Resident records reviewed: 5
Facility grade: A
Inspection Report
Original Licensing
Capacity: 8
Deficiencies: 0
Sep 6, 2022
Visit Reason
Initial State Licensure and infection control survey conducted to evaluate the facility's request for licensure for 10 Residential Facility for Groups beds for elderly and disabled persons and/or persons with Chronic Illness, Category II residents.
Findings
No regulatory deficiencies were identified. A window did not meet size measurement requirements for ambient light, resulting in approval for licensure for 8 beds instead of 10. The facility was provided guidance on having an Infection Control Plan.
Report Facts
Requested licensed beds: 10
Approved licensed beds: 8
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