Inspection Reports for Divinity Homecare
3944 Kentwood Ct, Reno, NV 89503, NV, 89503
Back to Facility ProfileDeficiencies per Year
12
9
6
3
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Severe
High
Moderate
Low
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Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 4
Aug 14, 2025
Visit Reason
The inspection was conducted as a combined annual and complaint investigation State Licensure survey in accordance with Nevada Administrative Code (NAC) 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One complaint was investigated but not substantiated due to lack of evidence. Deficiencies were identified related to incomplete resident clinical records, missing annual tuberculosis screening for an employee, failure to develop an annual person-centered service plan for one resident, and failure to obtain an annual standard physician assessment and placement determination for one resident.
Complaint Details
One complaint (#NV00074046) was investigated with six allegations including failure to ensure timely brief changes, accommodate diabetic diet, protect from verbal abuse, ensure medication administration training, medicate according to physician orders, and provide adequate food. None of the allegations were substantiated due to lack of evidence.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to ensure resident clinical records were complete for 3 of 7 residents, including missing or unsigned Pharmacy Reviews. | Level 2 |
| Facility failed to ensure annual tuberculosis (TB) screening was completed for 1 of 4 employees. | Level 2 |
| Facility failed to develop an annual Person-Centered Service Plan addressing all required focus areas and interventions for 1 of 7 residents. | Level 2 |
| Administrator failed to obtain an annual Standard Physician Assessment and Placement Determination for 1 of 7 residents with dementia. | Level 2 |
Report Facts
Residents files reviewed: 9
Employee files reviewed: 4
Complaint allegations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Vasquez | Owner | Confirmed deficiencies and provided interview statements related to clinical records and employee TB screening |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 7
Deficiencies: 0
Feb 26, 2025
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation regarding allegations related to improper use of bedrails and failure to provide required policies.
Findings
The complaint allegations could not be substantiated due to lack of sufficient evidence. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00073478 included three allegations: improper use of bedrails resulting in restraint, failure to provide dignity by not following proper bedrail protocol, and failure to provide required policies regarding resident use of bedrails. None were substantiated.
Report Facts
Complaint number: Complaint #NV00073478
Resident files reviewed: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 7
Deficiencies: 5
Jul 31, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation at the facility on 07/31/2024.
Findings
The facility received a grade of B with multiple deficiencies identified, including failure to prevent a resident's fall, retention of bedfast residents without proper waivers, lack of documented annual physical examinations and placement determinations for several residents, and failure to provide proper oversight by the administrator. Two complaints were investigated, with one substantiated regarding fall prevention.
Complaint Details
Two complaints were investigated. Complaint #NV00071795 was substantiated for failure to prevent a resident's fall. Other allegations in this complaint and Complaint #NV00071570 were not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure compliance with NAC 449.156 to 449.27706 and NRS Chapter 449. | Level 2 |
| Facility retained three bedfast residents without obtaining required bedfast exemption waivers. | Level 2 |
| Facility failed to ensure physical examinations were completed prior to admission or annually for 4 of 7 residents. | Level 2 |
| Facility failed to obtain initial and annual Standard Physician Assessment and Placement Determinations for 4 of 7 residents. | Level 2 |
| Failure to prevent a resident's fall resulting in death (substantiated complaint). | Level 2 |
Report Facts
Licensed beds: 7
Residents present: 5
Complaints investigated: 2
Residents lacking physical exams: 4
Residents retained without bedfast waiver: 3
Residents lacking physician assessment and placement determination: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 7
Deficiencies: 2
Jul 26, 2023
Visit Reason
This inspection was a State Licensure annual grading survey conducted to assess compliance with Nevada Administrative Code for Residential Facility for Groups.
Findings
The facility received a grade of A. Two deficiencies were identified: failure to ensure medication profile reviews were conducted every six months for one resident, and failure to properly secure medications resulting in potential unauthorized access.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a medication profile review was performed by a physician, pharmacist, or registered nurse at least once every six months for 1 of 5 residents. | Severity: 2 |
| Failure to ensure medications were secured properly, resulting in potential access by residents, unauthorized staff, and visitors. | Severity: 2 |
Report Facts
Residents present: 5
Licensed capacity: 7
Medication review deficiency scope: 1
Medication storage deficiency scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Vasquez | owner | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 7
Capacity: 7
Deficiencies: 4
Aug 9, 2022
Visit Reason
The inspection was conducted as a complaint survey performed in conjunction with the annual State Licensure Survey to investigate one complaint regarding alleged verbal abuse, untimely pain medication, and overmedication of a resident.
Findings
The complaint allegations were not substantiated due to lack of evidence. Deficiencies were identified related to facility maintenance, medical care documentation, medication administration reviews, and resident tuberculosis testing compliance.
Complaint Details
Complaint #NV00066385 alleged verbal abuse by a caregiver, untimely provision of pain medication, and overmedication of a resident. These allegations were not substantiated due to lack of evidence after observation, interviews, and record reviews.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The hallway bathroom shower was not kept clean and maintained, with missing caulking and mold/mildew present. | Severity: 2 |
| Two residents lacked documented evidence of an initial History and Physical signed by a physician. | Severity: 2 |
| One resident's medication profile review was not completed at least once every six months as required. | Severity: 2 |
| Two residents did not have documented evidence of annual tuberculosis testing completed on time. | Severity: 2 |
Report Facts
Resident files reviewed: 7
Employee files reviewed: 3
Complaint count: 1
Medication review dates: 2
TB test dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Vasquez | Owner | Caregiver/Owner who provided interviews and confirmed findings related to shower cleanliness, medical record deficiencies, medication review, and TB testing. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 5
Aug 26, 2021
Visit Reason
This inspection was conducted as an annual State Licensure Survey of the residential facility for groups to assess compliance with NAC 449 regulations.
Findings
The facility received a grade of A but was found deficient in several areas related to caregiver qualifications and training, including missing annual caregiver training, medication management training, elder abuse prevention training, and expired CPR and first aid certification for one employee. Additionally, the facility failed to have a required medication onsite for one resident.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 sampled employees obtained annual caregiver training for 2021. | Severity: 2 |
| Facility failed to ensure 1 of 3 employees completed the required 8 hours of annual medication management training on a timely basis. | Severity: 2 |
| Administrator failed to ensure 1 of 3 employees completed the required annual elder abuse prevention training for 2021. | Severity: 2 |
| Facility failed to ensure caregivers were certified to perform CPR and first aid for 1 of 3 sampled employees; training had expired and no evidence of renewal was provided. | Severity: 2 |
| Facility failed to ensure a medication was available onsite for 1 of 6 residents (Resident #6). | Severity: 2 |
Report Facts
Resident census: 6
Total licensed capacity: 7
Number of resident files reviewed: 6
Number of employee files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael J Vasquez | Owner | Confirmed missing training and medication deficiencies during inspection |
| Employee #1 | Administrator | Named in multiple deficiencies including missing annual caregiver training, medication management training, elder abuse training, and expired CPR/first aid certification |
Inspection Report
Follow-Up
Census: 4
Capacity: 5
Deficiencies: 1
Jan 12, 2021
Visit Reason
This inspection was a State Licensure follow-up bed increase survey conducted to evaluate the facility's request for licensure of two additional Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility failed to maintain room temperatures within the required range of 68 to 82 degrees Fahrenheit, specifically in Bedroom #5 where temperatures were observed as low as 59 degrees Fahrenheit and even lower readings were recorded. The electric heater in Bedroom #5 was not functioning properly, and the facility's application for additional beds was not approved due to these regulatory deficiencies.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure temperatures in Bedroom #5 were maintained between 68 and 82 degrees Fahrenheit, with observed temperatures as low as 59 degrees Fahrenheit and below. |
Report Facts
Census: 4
Total licensed capacity: 5
Temperature readings: 59
Temperature readings: -52
Temperature readings: -56.1
Temperature readings: -60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Vasquez | Owner | Named in relation to the inspection and findings regarding heating deficiencies |
Inspection Report
Re-Inspection
Census: 5
Capacity: 5
Deficiencies: 9
Sep 1, 2020
Visit Reason
This inspection was a State Licensure grading re-survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to medication management training validity, medication administration procedures, maintenance of resident files, and health and sanitation. Corrective actions and plans of correction were provided with completion dates mostly by 09/23/2020.
Severity Breakdown
Level 2: 1
Level F: 1
Level D: 7
Deficiencies (9)
| Description | Severity |
|---|---|
| Administrator failed to maintain current valid Medication Management training; training was provided by an expired instructor. | Level 2 |
| Qualifications and training of caregivers in medication management were not fully compliant. | Level F |
| Health and sanitation issues including maintenance of fence and water cooler. | Level D |
| Medical care of resident after illness not fully documented timely. | Level D |
| Medication administration procedures including verification of orders and double checking medications. | Level D |
| Administration of medication maintenance and record keeping not fully compliant. | Level D |
| Administration of medication restrictions concerning 'as needed' medications not fully documented. | Level D |
| Maintenance and contents of separate resident files not fully compliant. | Level D |
| Training and competency for vital signs and glucose monitoring not fully documented. | Level D |
Report Facts
Licensed beds: 5
Resident census: 5
Completion date: Sep 23, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Vasquez | Owner/Operator | Signed the report and involved in monitoring corrective actions |
| Employee #3 | Completed medication course, confirmed invalid medication management training for Administrator, involved in monitoring medication administration and documentation | |
| Employee #2 | Involved in medication administration monitoring and training verification | |
| Employee #1 | Involved in medication double checking and monitoring |
Inspection Report
Follow-Up
Census: 5
Capacity: 5
Deficiencies: 0
Aug 6, 2020
Visit Reason
This visit was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Follow-Up Survey to assess the facility's compliance with infection control requirements.
Findings
The facility had documented and ready components of an Infection Control and Prevention Plan including staff training, PPE inventory, screening practices, and response plans. No regulatory deficiencies were identified during this follow-up survey.
Report Facts
Licensed beds: 5
Census: 5
Inspection Report
Annual Inspection
Census: 5
Capacity: 5
Deficiencies: 9
Jul 23, 2020
Visit Reason
Annual State Licensure Survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including caregiver medication training, facility maintenance, resident medical care documentation, medication administration, and training related to diabetic care. The facility received a grade of C and was required to submit a plan of correction.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure caregivers completed annual medication management courses taught by an instructor approved by the Bureau of Health Care Quality and Compliance. | Level 2 |
| Failed to maintain the exterior of the facility in good repair, including broken fence slats and water dripping from air conditioner. | Level 2 |
| Failed to ensure residents received annual physical examinations for 1 of 5 residents. | Level 2 |
| Failed to ensure the Administrator completed an annual medication management course taught by an approved instructor. | Level 2 |
| Failed to ensure physician orders for medication were on file for 1 of 5 residents. | Level 2 |
| Failed to ensure physician orders were transcribed correctly and medication administration was documented correctly on the MAR for 1 of 5 residents. | Level 2 |
| Failed to clarify a range order requiring assessment for the exact amount of daily medication for 1 of 5 residents. | Level 2 |
| Failed to maintain and complete initial and annual assessments of activities of daily living (ADL) for residents. | Level 2 |
| Failed to ensure caregivers assisting with resident self-administration of insulin received training in the process. | Level 2 |
Report Facts
Licensed beds: 5
Resident census: 5
Survey date: Jul 23, 2020
Resurvey fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Vasquez | Owner | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Employee #1 | Named in medication training and facility maintenance deficiencies and corrective actions | |
| Employee #2 | Named in medication training and facility maintenance deficiencies and corrective actions | |
| Employee #3 | Named in medication training deficiency | |
| Owner/Caregiver #1 | Named in medication administration and documentation deficiencies | |
| Owner/Caregiver #2 | Named in medication administration and training deficiencies |
Inspection Report
Original Licensing
Capacity: 5
Deficiencies: 0
Jan 12, 2016
Visit Reason
This State Licensure survey was conducted as an initial licensing survey for the facility requesting to be licensed for five Residential Facility for Group beds for elderly and disabled persons.
Findings
The survey included review of one resident file and two employee files. No deficiencies are explicitly stated in this document.
Report Facts
Licensed capacity: 5
Census at time of survey: 0
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