Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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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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 August 2026) and official state health department websites.