Inspection Reports for
Family Friendly Care Home
3784 Edison Ave, Las Vegas, NV 89121, NV, 89121
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
80% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted in response to a complaint (#2591137) regarding failure to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically related to nursing staff's failure to document physician notification and interventions for a resident's high temperature.
Complaint Details
Complaint #2591137 involved substantiated findings that nursing staff failed to document physician notification and interventions for a resident's high temperature, and the facility failed to maintain complete and accessible medical records for the resident.
Findings
The facility failed to document physician notification, change in condition, nursing interventions, or attempts to obtain physician orders for managing a resident's high temperature, placing the resident at risk for harm. Additionally, medical record documentation was incomplete and not accessible as required, lacking evidence of nursing interventions and physician notifications related to the resident's fever and condition changes.
Deficiencies (2)
Failure to document physician notification, change in condition, nursing interventions, or attempts to obtain physician orders for managing a resident's high temperature.
Failure to safeguard resident-identifiable information and maintain complete and accessible medical records in accordance with accepted professional standards.
Report Facts
Resident sample size: 5
Temperature readings: 102.9
Temperature readings: 98.6
Temperature threshold: 100.3
Temperature threshold: 99.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Provided explanation of interventions for high temperature and documentation requirements | |
| Certified Nursing Aide (CNA 1) | Explained vital signs monitoring and notification procedures | |
| Certified Nursing Aide (CNA 2) | Explained temperature rechecking and nurse notification procedures | |
| Registered Nurse (RN) | Explained vital signs monitoring, interventions, and physician notification process | |
| Director of Nursing (DON) | Explained facility policies on temperature monitoring, physician notification, and documentation | |
| Physician | Explained expectations for documentation and physician orders related to fever management |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 25, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage and food safety standards in the facility.
Findings
The facility failed to ensure syringes used for flushing IV catheters were not left unattended in resident rooms, posing infection control risks. Additionally, expired and unlabeled food products, dented cans, and improper food storage were observed, increasing the risk of foodborne illness.
Deficiencies (2)
Syringes filled with normal saline used to flush IV catheters were left unattended in resident rooms, posing potential infection control and safety risks.
Expired food products were not discarded, food was unlabeled, dented cans were used, and perishable foods were improperly stored in the walk-in refrigerator and freezer.
Report Facts
Expired food product: 1
Expired food product: 1
Dented cans: 4
Prefilled syringes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Confirmed observations regarding unattended syringes and infection control concerns | |
| Assistant Director of Nursing (ADON) | Acknowledged syringes should not be left in resident rooms and emphasized patient safety risks | |
| Cook | Acknowledged food storage and labeling deficiencies in the kitchen |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding coordination of care failures with a referred home health agency for a discharged resident.
Complaint Details
Complaint #NV00073111 regarding failure to coordinate care with a referred home health agency; substantiation status not explicitly stated.
Findings
The facility failed to ensure coordination of care with the referred home health agency for one resident, failed to secure medication and treatment carts, failed to protect resident health information, and failed to maintain proper linen handling procedures, all posing potential risks to resident safety and privacy.
Deficiencies (4)
Failed to ensure coordination of care with the referred home health agency for one resident, risking unsafe discharge.
Failed to secure 2 of 4 medication carts and 1 of 2 treatment carts, risking unauthorized access to controlled substances.
Failed to protect resident protected health information by leaving a medication cart unattended with an open laptop displaying resident information.
Failed to maintain proper linen handling procedures, risking exposure to infections.
Report Facts
Medication carts unsecured: 2
Treatment carts unsecured: 1
Medication cart intravenous bag volume: 50
Medication dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (Case Manager Director) | Identified role and responsibilities related to discharge planning and coordination of care | |
| Registered Nurse (Case Manager) | Provided information about home health agency contact and follow-up procedures | |
| Office Manager, referred home health agency | Reported resident was never under the agency's care | |
| Director of Nursing (DON) | Confirmed importance of follow-up calls to sustain continued care | |
| Certified Nursing Assistant (CNA) | Verified treatment cart was unlocked and discussed safety concerns | |
| Registered Nurse (RN) | Confirmed medication cart was unlocked and discussed lock system issues | |
| Wound care nurse | Confirmed treatment cart contains medications | |
| Assistant Director of Nursing (ADON) | Confirmed medication cart should have been locked and was unaware of locking issues | |
| Licensed Practical Nurse (LPN) | Stated nurses are trained to lock laptops to protect PHI |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 9
Date: 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.
Deficiencies (9)
Personnel file lacked current certification for first aid and CPR for a caregiver.
Oxygen tanks were not properly secured; corrective action taken to secure tanks.
Resident #4's annual physical examination was missed.
Residents #5 and #6 lacked documentation of a 6-month medication review.
Medication order discrepancies and missing physician-ordered medication for Resident #2 and Resident #3.
Resident #7 missing annual TB test for 2024.
Front screen door was unlocked and lacked an audible alarm.
Gate leading to the street was not locked during the survey.
Residents #4, #5, and #7 lacked documented evidence of initial and/or current placement.
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
Complaint Investigation
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure a resident was discharged to a licensed group home per physician order.
Complaint Details
Complaint NV00071314 regarding improper discharge of Resident 161 to an unlicensed location instead of a licensed group home as ordered.
Findings
The facility failed to discharge Resident 161 to a licensed group home as ordered by the physician, instead discharging the resident to an unlicensed private residence with hospice services. The medical record lacked documentation confirming discharge to a licensed group home, and the facility case manager did not verify the discharge location's licensing status.
Deficiencies (1)
Failure to ensure a resident was discharged to a licensed group home per physician order for 1 of 26 sampled residents (Resident 161).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Case Manager | Facility Case Manager indicated the resident was alert and oriented and chose to go to the discharge address but did not verify if it was a licensed group home. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Sep 20, 2024
Visit Reason
The inspection was conducted based on complaints and observations related to resident care, privacy, discharge planning, medication administration, and facility sanitation.
Complaint Details
Complaint NV00071314 related to improper discharge planning for Resident 161, discharged to an unlicensed home instead of a licensed group home as ordered.
Findings
The facility was found deficient in honoring resident rights related to repositioning and use of incontinent briefs, safeguarding resident privacy, ensuring qualified staff administered total parenteral nutrition, proper discharge planning to licensed group homes, appropriate use of assistive devices for fractures, and maintaining sanitary conditions in the kitchen.
Deficiencies (6)
Failed to honor resident rights related to repositioning and use of incontinent briefs for 1 of 26 sampled residents (R252).
Failed to safeguard privacy by posting resident's body weight on a room's board visible from the hallway for 1 of 26 sampled residents (R203).
Failed to ensure total parenteral nutrition (TPN) was administered by qualified Registered Nurses for 1 of 26 sampled residents (R29).
Failed to ensure a resident was discharged to a licensed group home per physician order for 1 of 26 sampled residents (R161).
Failed to ensure an arm brace and sling were placed for a resident with arm fracture for 1 of 26 sampled residents (R98).
Failed to maintain sanitary conditions in the kitchen, including improper food storage and employee hygiene.
Report Facts
Residents sampled: 26
Repositioning failures: 13
TPN administration dates by LPNs: 5
Discharge date: Feb 16, 2024
Brace placement order date: Sep 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Notified about repositioning issues and TPN administration concerns | |
| Certified Nursing Assistant | Provided information about resident R252's care and repositioning | |
| Licensed Practical Nurse | Documented TPN administration but denied administering it | |
| Physical Therapy Director | Confirmed order and need for arm brace placement | |
| Kitchen Manager | Acknowledged kitchen sanitation deficiencies |
Inspection Report
Annual Inspection
Census: 8
Capacity: 5
Deficiencies: 9
Date: 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.
Deficiencies (9)
Failed to ensure 1 of 6 employees received CPR and first aid training with required in-person component.
Failed to ensure oxygen tanks were secured in the facility.
Failed to ensure an annual physical examination was completed for 1 of 8 residents.
Failed to perform medication reviews every six months for 2 of 8 residents.
Failed to administer medications per physician's orders for 1 of 8 residents.
Failed to ensure the Medication Administration Record (MAR) was accurate for 1 of 8 residents.
Failed to ensure 1 of 8 residents met the requirements for annual tuberculosis testing.
Failed to lock a gate leading from the secured yard to the street.
Failed to ensure annual placement assessments and/or initial placement assessments were obtained for 3 of 8 residents.
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
Date: 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
Routine
Deficiencies: 14
Date: Sep 29, 2023
Visit Reason
The inspection was a routine regulatory survey conducted to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident rights acknowledgment, medication administration, care planning, IV and respiratory care, medication error rates, food storage, and arbitration agreement processes. Deficiencies were generally of minimal harm but had potential risks for residents.
Deficiencies (14)
Failed to ensure a resident who lacked decisional capacity did not acknowledge receipt of and sign information acknowledgment sheets.
Failed to ensure a resident who was not clinically appropriate to self-administer medications did not receive an ordered medication by a family member.
Failed to create a baseline care plan for residents with post knee surgery and lower extremity edema.
Failed to ensure care plan revisions were completed upon readmission of a resident.
Failed to update dialysis transportation arrangements in care plan for a resident.
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, including medication refusals and abnormal assessments.
Failed to provide feeding assistance as ordered for a resident with swallowing precautions.
Failed to ensure IV line insertion and care orders were obtained and implemented, and proper IV dressing changes and discontinuations were made.
Failed to ensure oxygen orders were followed or clarified for residents.
Failed to ensure blood pressure ordered parameters were followed for administration of diuretic medication.
Failed to ensure consent for psychotropic medication was obtained for a resident.
Medication error rate was 7.14%, exceeding the 5% threshold, including missed medications due to unavailability.
Failed to ensure food stored in kitchen and nourishment refrigerators were labeled and dated.
Failed to ensure arbitration agreement was explained in a form and manner that residents could understand.
Report Facts
Medication error rate: 7.14
Medication doses administered below ordered blood pressure parameters: 3
Medication doses missed due to unavailability: 2
Medication deliveries: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed multiple deficiencies including medication administration, care planning, oxygen order clarifications, and medication error processes |
| Admission's Assistant | Admission's Assistant | Acknowledged not explaining arbitration agreement fully and not providing it for review prior to signing |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Acknowledged medication administration errors and unavailability of medications |
| Registered Nurse | Registered Nurse (RN) | Confirmed lack of consent for psychotropic medication and lack of physician notification for medication refusals |
| Infection Preventionist | Infection Preventionist (IP) | Confirmed lack of IV line care orders and dressing changes |
| Case Manager | Case Manager | Acknowledged failure to update dialysis transportation information |
| Director of Staff Development | Director of Staff Development (DSD) | Confirmed findings related to IV line care and unused saline flushes |
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to obtain a bedfast exemption for Resident #4 who was bedfast and required assistance being turned and repositioned every two hours.
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
Date: 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.
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.
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.
Report Facts
Resident records reviewed: 5
Facility grade: A
Inspection Report
Original Licensing
Capacity: 8
Deficiencies: 0
Date: 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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