Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dove Healthcare - Lodi during CMS and state inspections, most recent first.
Unsafe food handling and thermometer sanitizing practices were observed in the kitchen. A staff member touched food with gloves after contacting his neck, pants, papers, and other kitchen items, and another staff member touched food with contaminated gloves as well. Staff also temped multiple food items with the same thermometer and only rinsed it with water instead of sanitizing it between uses. The NSD and NHA acknowledged the proper practices for glove use and thermometer sanitation.
Improper wound cleansing and dressing application for a resident with stage 4 pressure injuries. Surveyors observed an LPN remove old dressings and packing, then wipe over the wound beds without cleansing them before redressing. For one wound, exudate remained on the wound bed when dakins-soaked packing was applied, and silicone border dressings were used instead of the ordered ABD pad. Staff interviews showed the LPN believed dakins alone cleansed the wound, while the MD, another LPN, the ADON, and the DON acknowledged the wound bed should be cleansed and the ordered dressing type should be followed.
A resident with PTSD and intact cognition did not have a trauma assessment or an active care plan addressing triggers, resident-specific approaches, or interventions to prevent re-traumatization. The resident’s PASRR noted she did not deal well with changes in routine and adjusted better when told ahead of time, but staff interviews showed CNAs were not aware of her PTSD triggers or interventions. Social Services and the NHA acknowledged the care plan did not list the resident’s triggers.
Care plan missing OCD triggers and interventions. A resident with OCD, cognitively intact and noted on PASRR to have difficulty adapting to change, had a comprehensive care plan that did not include her OCD, known triggers, resident-specific goals, or personalized interventions. CNAs described the resident as very particular, demanding, and upset when she had to repeat herself, and the NHA acknowledged her detailed routine and preferences were not reflected in the care plan.
Food and drink were not served at a safe and appetizing temperature for a resident and a surveyor test tray. A resident reported that hot meals were often delivered cold, especially because she was among the first to receive room trays, and said other residents had raised similar concerns. A surveyor’s test tray also measured below hot-holding temperatures, and the food was described as cold and not palatable. The NHA acknowledged that hot foods should be served hot and that food temperatures had been an issue.
Staff failed to prevent significant medication errors involving two residents, including administering the wrong insulin to one resident and giving incorrect anti-anxiety medications and dosages to another. In each case, staff did not properly verify resident identity or medication details, resulting in the administration of medications not prescribed for those residents. The facility did not conduct follow-up audits or additional monitoring after these errors.
The facility failed to document freezer, refrigerator, and dish machine temperatures, and did not date spices, impacting food safety for 47 residents. Observations revealed missing temperature logs over several months, undated spices, and cracked kitchen tiles. Staff interviews highlighted issues with training and staffing, despite a meeting to address these concerns.
The facility failed to prevent pressure ulcers and provide adequate catheter care for two residents. One resident developed a full-thickness wound due to improper catheter management, while another resident's pressure injuries went unidentified due to lack of weekly skin checks. The facility did not follow its policies on pressure injury prevention and catheter care, leading to immediate jeopardy findings.
A facility failed to maintain residents' privacy and confidentiality by having an unauthorized camera in the dining room, used for meals and visits. The NHA was unaware of the camera and confirmed its presence upon review. No signage was posted to inform residents or staff, and the facility lacked a camera surveillance policy.
A resident at risk for falls was not provided with adequate supervision and fall prevention measures, leading to a fall where the resident was found unresponsive. The facility did not update the care plan with hospice interventions, such as keeping the bed in a low position, and failed to conduct a post-fall investigation as required by policy.
Unsafe Food Handling and Thermometer Sanitizing Practices
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food was prepared, stored, and distributed. During observation, surveyors saw kitchen staff directly touch food while wearing gloves that had become contaminated after touching other items in the kitchen. One staff member washed his hands and put on gloves, then touched his neck, pants, and multiple papers before directly touching a hotdog with the same gloves. The same staff member later wore a different pair of gloves, touched the microwave and his pants, and then directly touched bread being served for lunch. Surveyors also observed improper thermometer use during food temperature checks. One staff member temped a hotdog and then directly temped a hamburger before rinsing the thermometer under running water and returning it to the case. Another staff member temped chicken, then rinsed the thermometer with running water and put it back in the case. Facility policy required staff not to touch food with bare hands and to use clean, sanitized, and calibrated thermometers for food temperature verification. The Nutritional Service Director and the Nursing Home Administrator both acknowledged that staff should use clean gloves or tongs when directly touching food and should sanitize thermometers after each use.
Improper wound cleansing and dressing application for resident with stage 4 pressure injuries
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after surveyors observed that R1’s stage 4 pressure injuries were not cleaned properly during wound care and that wound care was not completed per physician orders. R1 was admitted with a diagnosis of pressure ulcer and had a BIMS score of 15, indicating cognitive intactness. R1 had three long-standing stage 4 pressure injuries: the left ischium, coccyx, and right hip, with wound care orders that included cleansing with antibacterial soap and water or patting dry, packing with dakins-moistened kerlix, and using an ABD pad or silicone border dressing depending on the wound order. On 2/17/26, surveyors observed LPN F and LPN C providing wound care to R1. For the left ischium and coccyx wounds, LPN F removed the old dressings and packing, then used a soapy washcloth to wipe over the top of the wounds without cleansing the wound beds, and then covered both wounds with silicone border dressings. For the right hip wound, surveyors observed a moderate amount of exudate on the old dressing and exudate still present on the wound bed; LPN F again used a soapy washcloth to wipe over the wound, packed it with dakins-soaked kerlix while exudate remained on the wound bed, and covered it with a silicone border dressing. During interviews, LPN F stated dakins cleanses the wound bed because it has bleach in the solution and said she did not cleanse the wound bed because that was what the order stated. MD I stated the wound bed should be cleansed prior to dressing the wounds and described cleansing before dressing as fundamentals of wound care. LPN C stated the wound bed should be cleansed prior to applying the new dressing and that R1 should have had an ABD applied rather than a silicone border dressing. ADON E stated she misunderstood MD I’s order for ABD pad versus silicone border dressing and entered the order incorrectly, and DON B stated the standard of practice is in the PI policy and that the wound bed should be cleansed prior to applying a dressing and the facility should follow doctor’s orders including the types of dressings used.
Failure to Assess and Care Plan PTSD Triggers
Penalty
Summary
The facility did not ensure trauma survivors received culturally competent, trauma-informed care for a resident with PTSD. The resident, R3, was admitted with diagnoses including PTSD and had a BIMS score of 15, indicating she was cognitively intact. Her level II PASRR stated she did not deal well with change in routine and was very particular about how things were done, and that she adjusted better if told ahead of time. The facility’s policy required identifying trauma history, triggers, and resident-specific interventions through assessment tools and resident input, but the resident did not have a trauma assessment. On 2/18/26, Social Services stated R3 did not have a trauma assessment. R3’s comprehensive care plan did not include PTSD, triggers, or interventions to prevent re-traumatization. The facility provided a resolved care plan that listed anxiousness, restlessness, panic, depression, chronic pain, new living environment, agoraphobia, and PTSD, with an intervention to explain all procedures before starting and allow adequate time to adjust to changes, but this plan had a discontinued date and was not the active comprehensive care plan. During interviews, CNA G stated R3 likes things done a particular way, becomes upset if she has to repeat herself, and can be very stressed by this, but was not aware of R3’s PTSD, triggers, or interventions. CNA H stated R3 had mentioned past experiences but did not discuss her PTSD in detail, and he was also not aware of any triggers or interventions. The NHA and Social Services stated they did not know R3’s triggers and acknowledged the care plan did not list them, while also stating the resident’s PTSD, triggers, and interventions should be part of the care plan.
Care Plan Missing OCD Triggers and Interventions
Penalty
Summary
The facility did not ensure that a resident with obsessive compulsive disorder (OCD) received appropriate treatment and services to address the assessed psychosocial need. R3 was admitted with a diagnosis including OCD, had a BIMS score of 15 indicating cognitive intactness, and a level II PASRR that identified OCD and noted that adaptation to change was limited because she did not deal well with changes in routine and was very particular about how things were done, adjusting better when told ahead of time. R3’s comprehensive care plan, printed 2/18/25, did not include her OCD, known triggers, resident-specific goals, or personalized interventions related to the diagnosis. During interviews, CNA G stated R3 likes to micromanage her care, wants things done a particular way, and becomes upset if she has to repeat herself. CNA H stated R3 can be demanding, displays OCD behaviors, and is particular about how things should be done. The NHA and SS D acknowledged that R3 has a routine that can take staff more than an hour to complete in the morning, that she has detailed preferences such as how socks, pillows, and hand placement should be arranged, and that her OCD behaviors and interventions should have been included in the care plan.
Food Served Cold
Penalty
Summary
Food and drink were not served in a manner that conserved palatability and temperature for one resident and a surveyor test tray. The facility policy stated that hot foods must be held at 135 degrees Fahrenheit or greater and that no food should be served that does not meet food code standard temperatures. On 2/17/26, R30 voiced concern that hot food was being served cold. On 2/18/26, R30 stated she eats in her bedroom, is among the first residents served on her hallway, and that her hot food is often served cold; she also said she had heard other residents voice similar concerns. Later that day, the surveyor received a test tray in which the meat/peppers/cheese sandwich measured 110.4 degrees and the potatoes measured 107.9 degrees, and the food was described as not palatable and tasting cold. The NHA stated that hot foods should be served hot and acknowledged that food temperatures had been an issue.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for two out of five residents reviewed for medication administration. In one instance, a registered nurse administered Insulin Lispro to a resident with diabetes, chronic respiratory failure, and stroke, instead of the intended recipient, after misidentifying the resident. The nurse relied on a certified nursing assistant's identification and did not verify the resident's identity according to the facility's medication administration policy. The error was discovered after the medication was given, and the resident's blood sugar was subsequently monitored. In another case, a registered nurse administered Lorazepam, intended for a different resident, to a resident with Alzheimer's disease and anxiety disorder. The nurse mistakenly pulled the medication from the wrong medication card during a busy and distracting medication pass. The error was realized later during a medication count, and the nurse confirmed the mistake during an interview. Additionally, a licensed practical nurse administered Alprazolam 0.5 mg, intended for another resident, to the same resident with Alzheimer's disease and anxiety disorder, instead of the prescribed 0.25 mg dose. The nurse took the medication from the wrong medication card and only realized the error after the fact. The facility's policy required staff to follow the six rights of medication administration, including verifying the right resident, drug, dosage, route, time, and documentation. However, in these incidents, staff failed to properly verify resident identity and medication details, resulting in the administration of incorrect medications or dosages. There was no documentation of further monitoring or physician orders following the errors, and the Director of Nursing confirmed that no audits or medication administration observations were conducted after the incidents.
Failure to Document Kitchen Temperature and Maintain Food Safety Standards
Penalty
Summary
The facility staff failed to document the monitoring of temperatures for freezers and refrigerators in the kitchen, as well as the temperature and sanitizing solution for the dish machine. Over several months, there were numerous instances where temperature logs for the freezers and refrigerators were not completed for both AM and PM shifts. Similarly, the dish machine's temperature and chemical logs were not consistently recorded, with several days each month missing entries. This lack of documentation was confirmed through observations and interviews with kitchen staff, including cooks and dietary aides, who were responsible for these tasks. Additionally, the facility did not date numerous spices with their open dates, which is a requirement for maintaining food safety standards. During an observation, 12 different spices were found without open dates, indicating a lapse in the facility's adherence to its own policies. The Dietary Manager, who had been at the facility since May 2024, acknowledged the oversight and attributed it to the spices always being present and not noticing they were outdated. The Dietary Manager also mentioned that the responsibility for recording temperatures was assigned to the cooks and dietary aides, but issues with staffing and training were noted. The facility's kitchen also had maintenance issues, with numerous cracked floor tiles observed, which could impede proper cleaning. The Administrator confirmed the presence of undated spices and acknowledged the plan to replace the kitchen floor in 2025. Despite a meeting held in July 2024 to address the process of taking temperatures, the problem persisted, indicating a gap in compliance with food safety protocols.
Failure to Prevent Pressure Ulcers and Inadequate Catheter Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. One resident, who was admitted without a pressure injury or catheter, returned from hospitalization with a Foley catheter. The facility did not develop a care plan addressing the catheter until after erosion to the penis was identified. The facility failed to implement interventions to prevent medically related pressure injuries, did not complete weekly measurements and assessments, and did not obtain orders for treatments. This resulted in the resident developing a full-thickness wound extending from the tip of the penis through the meatus and down to the shaft. Another resident was admitted without a pressure injury, but the facility did not complete weekly skin checks and failed to identify new pressure injuries. The facility's policies on pressure injury prevention and catheter care were not followed, leading to the development of pressure injuries related to medical devices. The facility's failure to implement interventions and complete assessments created a finding of immediate jeopardy. The facility's documentation and communication were inadequate, as evidenced by the lack of weekly assessments, measurements, and treatment implementation. The facility's policies on hand hygiene and catheter care were not consistently followed, contributing to the development of pressure injuries. The facility's inaction and failure to adhere to professional standards of practice resulted in harm to the residents.
Removal Plan
- The facility conducted a sweep of all residents with an indwelling Foley catheter to ensure robust interventions are in place to prevent PI development.
- The facility completed skin assessments on all residents with an indwelling Foley catheter.
- Education will be provided to nursing staff on the following.
- All Nursing Staff (nurses, nurse aides and ha (hospitality aides)): All residents with an indwelling foley will wear a leg strap or utilize a stat lock. Education and competency checks for nurses and nurse aides will be completed to ensure correct positioning to prevent tubing from being taunt or causing pressure on the urethra.
- Monitoring of skin integrity on residents with catheters during cares paying special attention to skin impairment. Immediately reporting any skin impairment to licensed nurse.
- Licensed Nurses: Documentation of any skin impairment. Wound documentation to include weekly measurements and assessments.
- Obtain treatment orders upon discovery.
- The Facility reviewed the Policy and Procedure for Prevention of Pressure Injury F686.
- The Facility reviewed the Policy and Procedure for Change of Condition notification.
- The Facility initiated re-education with all Licensed Nursing Staff and nurse aides on identifying and reporting Changes of Condition when newly identified changes in health status are identified.
- The Facility initiated re-education with all Licensed Nursing Staff on completion of a comprehensive assessment on all skin events with a noted change in size, shape, and clinical presentation at the time of discovery.
- The Licensed Nursing Staff and nurse aide were re-educated on catheter care including but not limited to pressure ulcer prevention and treatment.
- The Facility will complete random audits with Licensed Nurses to gauge understanding related to completion of Changes of Condition. Remedial education will be provided at the time of completion of audits if indicated.
- The Facility will complete random audits on catheters to ensure care is provided per clinical standards. To include proper placement of leg strap/stat loc to prevent pressure. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits on pressure ulcers to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits on treatment records and weekly skin assessments to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will audit residents with medical device pressure injuries to ensure weekly assessments are documented in the medical record including measurements.
- The results of the audits will be reported to the quality assurance and performance improvement (QAPI) committee and adjustments will be made to frequency of audits based on findings.
Privacy Breach Due to Unauthorized Camera Surveillance
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records for seven out of nine residents reviewed. During a survey, a camera was observed in the dining room, which is used by residents throughout the day for meals and visits. There was no signage or notification to inform residents, family, or staff about the surveillance. The Nursing Home Administrator (NHA) was unaware of the camera's presence and confirmed its existence upon reviewing the camera feed. The NHA acknowledged that there should not be a camera in the dining room and was unable to provide a camera surveillance policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall prevention measures for a resident identified as R1, who was at risk for falls. R1, who had a history of chronic obstructive pulmonary disease, lung cancer, hypertension, and major depressive disorder, was admitted to the facility and assessed as being at risk for falls. Despite this, the facility did not update R1's care plan with necessary interventions from the hospice care plan, such as keeping the bed in a low position, which was a critical oversight. R1 experienced a fall and was found unresponsive on the floor next to her bed, which was at waist level, contrary to the hospice care plan's recommendation. The facility's policy required a post-fall assessment and investigation, but these were not conducted. The Assistant Director of Nursing acknowledged that a fall investigation should have been completed, and the hospice care plan should have been integrated into the facility's care plan. Interviews with staff revealed that R1 was being monitored every 15 minutes due to being at the end of life, but there was no documentation indicating R1 was terminally restless, as suggested by the Assistant Director of Nursing. The Certified Nursing Assistant who found R1 stated that no instructions were given regarding the bed's position. The facility's failure to investigate the fall and update the care plan with hospice interventions contributed to the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lodi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waunakee Valley Senior Living | 10 mi | ★★★★★ | 15 | 0 |
| Maplewood Of Sauk Prairie | 11 mi | ★★★★★ | 14 | 0 |
| Complete Care At Jefferson Meadows Llc | 15 mi | ★★★★★ | 0 | 0 |
| Columbia Health Care Center | 15.9 mi | ★★★★★ | 4 | 0 |
| Middleton Village Nursing And Rehab | 16.2 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.