Dove Healthcare - Lodi

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infection for 2 or 3 residents (R5 and R2) reviewed for infection control with personal cares out of the sample of 5 residents. CNA C (Certified Nursing Assistant) had a breach in infection control when performing pericare (cleansing of the genital area). LPN D (Licensed Practical Nurse) had a breach in infection control when performing perineal care for R2. Evidenced by: The facility's Hand Hygiene policy, dated 12/24, states, in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 46 residents who reside in the facility. Surveyor observed kitchen staff directly touching food with dirty gloves. Surveyor observed kitchen staff not properly disinfecting thermometer while taking the temperature of food. Evidenced by:The facility policy, Food Safety Requirements, dated 6/2025, states, in part;.7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. The facility policy, Record of Food Temperatures, dated 3/2024, states, in part;.14. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), and each resident with pressure injuries (PI) receives necessary treatment and services, consistent with professional SOP, to promote healing, and prevent infection for 1 of 3 residents (R1) reviewed for PI out of a sample of 16 residents. R1's PIs were not cleaned properly during wound care and R1's PI care was not completed per physician orders. This is evidenced by:The facility's policy Wound Treatment Management, dated 2/26, includes: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Reference: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 residents (R3) reviewed for trauma informed care out of a sample of 16 residents. R3 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. This is evidenced by:The facility's policy Trauma Informed Care, dated 12/24, includes:Purpose: To provide guidance to staff regarding provision of care and services to residents who have experienced trauma. Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents (R3) reviewed out of 16 sampled residents. R3 has a diagnosis of obsessive compulsive disorder (OCD) her comprehensive care plan does not include known triggers, resident specific goals, or personalized interventions related to her OCD.This is evidenced by:The facility's policy Trauma Informed Care, dated 12/24, includes: Purpose: To provide guidance to staff regarding provision of care and services to residents who have experienced trauma. Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was served in a manner that conserved palatability and temperature for 1 resident (R30) and one test tray. R30 voiced concern regarding hot food being served cold. Surveyor's test tray temped cold. Evidenced by:The facility policy, Record of Food Temperatures, dated 3/24, states, in part;.2. Hot foods will be held at 135 degrees Fahrenheit or greater.11. No food will be served that does not meet the food code standard temperatures. On 2/17/26 at 9:58 AM, R30 voiced concerns regarding food temperatures and palatability. On 2/18/26 at 12:31PM, Surveyor followed back up with R30. R30 indicated she eats in her bedroom, and she is down the hallway that gets served room trays first. [...]

Inspectors wroteBased on record review, interview, and facility document review, the facility failed to prevent significant medication errors for two out of a total of five residents reviewed for medication administration (R2, and R3) out of a total sample of 13 residents. This failure had the potential for R2 and R3 to experience adverse reactions from receiving a wrong medication or wrong dosage of medication that was not prescribed for R2 and R3.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility staff failed to document monitoring of the temperatures for the freezers and refrigerators located in the kitchen, document monitoring of the temperature and sanitizing solution for the dish machine, date numerous spices with open dates, and maintain the tile kitchen flooring. This failure had the potential to negatively impact all 47 residents currently residing in the facility who ate food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 3 residents (R) sampled out of a total sample of 9 (R2 and R8). R8 was admitted on [DATE], without a pressure injury or catheter. R8 was hospitalized on [DATE], returning on [DATE] with a foley catheter in place. The facility did not develop a care plan addressing the catheter until [DATE], after erosion to the penis was identified. The facility failed to ensure interventions to prevent medically related pressure injuries (PI) were implemented correctly to prevent PI development, failed to complete weekly measurements and assessments, and failed to get orders for treatments. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure each resident has the right to privacy and confidentiality for 7 of 9 residents (R) reviewed. (R3, R4, R5, R6, R7, R8, and R9) During the survey, a camera was observed to be used for surveillance in the facility dining room. The dining room is used throughout the day for meals and visits. Evidenced by: On 8/14/24 at 11:00 AM, Surveyor observed a camera in the dining room, just inside the doorway from the hallway. Surveyor noted the dining room is used throughout the day by residents for meals and visits. This includes R3, R4, R5, R6, R7, R8, and R9. Surveyor noted there was no signage or posted notification to any resident, family, or staff who may use the dining room that the room was under surveillance by a camera. On 8/14/24 at 12:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed for fall concerns out of a total sample of 9 residents. R1 had a fall on [DATE] and the facility did not ensure that R1's fall was investigated or that care planned fall interventions were placed on R1's plan of care and implemented. This is evidenced by: The facility's policy titled, Fall Prevention Program, last reviewed [DATE], states, in part: . Purpose: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: [...]

Inspectors wroteBased on record review and interviews, during an investigation of [NAME] ncident of verbal abuse of R3, the facility did not conduct interviews for potential abuse for other residents, and did not monitor R3 for potential negative psychosocial outcomes following incident.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 40 residents residing at the facility. Surveyor observed: -An unknown matter in dishwasher area. -Machine washing and sanitation. The facility did not monitor dishwasher readings consistently. -Two instances of cross contamination. -Two instances of improper food storage. -Three instances of improper containment of garbage and refuse. The facility policy, entitled Sanitation Inspection, dated 6/15/23, states: It is the policy of this facility, as a part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations . 5. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 40 Residents residing within the facility. QAPI meetings did not consist of the required attendees/members for the month of January 2023, April 2023, and July 2023. This is evidenced by: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI), dated 7/01/22, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not conduct care conferences which included the participation of the Interdisciplinary Team (IDT) and the resident or resident's representative after completion of each comprehensive assessment (at least quarterly) or include an explanation in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for 10 of 12 residents (R) sampled (R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8). R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8 did not have quarterly care conferences completed. This is evidenced by: The facility policy, entitled Care Planning-Resident Participation, dated 8/02/22, states, in part: . Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe environment and adequate supervision to prevent accidents. This had the potential to affect 1 out of 12 sampled residents (R40) and 4 out of 4 supplemental residents (R22, R19, R37, R27). Surveyor observed the stove/oven unit in the facility's activity room to be connected to a power source and was able to turn on the burners and the oven. Surveyor also observed R40, R22, R19, R37, and R27 in the activity room unsupervised. Evidenced by: Facility policy entitled Activity Department Stove/Oven, undated, includes the following, in part: date implemented: (blank), date reviewed/revised: (blank), reviewed/revised by: (blank) . Policy: A safe and healthful work environment will be provided for all employees, residents, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the Resident's Physician when there was need to alter treatment for 2 of 15 residents (R42, R23). R42 experienced a change in condition and the facility did not notify NP U (Nurse Practitioner) of R42's change in condition so that NP U could direct the care of R42. R23 had an abnormal x-ray and staff did not notify the medical doctor timely. Evidenced by: The facility policy, entitled Notification of Changes, date implemented 7/6/23, includes in part: The facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring such notification: Circumstances requiring notification include: Circumstances that require a need to alter treatment . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 12 residents (R38) out of a total sample of 15. Surveyor observed R38's room to be unclean and odorous. This is evidenced by: The facility policy, entitled Routine Cleaning and Disinfection, dated 6/1/23, states, in part: . POLICY: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not follow their grievance process for 1 of 15 Residents (R38). VTR G (R38's visitor) and R38 voiced concern to staff regarding odor in R38's room and facility did not follow the grievance process. This is evidenced by: The facility policy, entitled Resident and Family Grievances, dated 7/01/23, states, in part: . Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . Policy Explanation and Compliance Guidelines: . 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all staff had background checks completed every four years which is part of preventing abuse. This affected 2 of 9 staff reviewed. CNA H (Certified Nursing Assistant) did not have a background check completed every four years. CNA/MT I (Med Tech) did not have a background check completed every four years. This is evidenced by: The facility's Policy and Procedure entitled Background Investigations dated 7/2023 does not speak to completing background checks every four years, only speaks to upon hire. Example 1 CNA H's hire date was 2/21/19. Her last completed background check was completed on 2/21/19. CNA H should have had a background check completed by 2/21/23. Example 2 CNA/MT I's hire date was 2/15/19. Her last background check was completed on 2/15/19. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain or enhance the resident's physical abilities for 1 (R30) of 12 residents reviewed for activities of daily living (ADLs) out of a total sample of 15 residents. R30 depends on staff to meet her needs in toileting, transfer, and bed mobility. R30 voiced concerns of stiffness, weakness, incontinence, and pain due to staff not allowing her to use the standing lift and only using the Hoyer lift with her during transfers. Surveyor observed staff use the Hoyer lift with R30 and not offer her to use the standing lift, a bedpan, or to sit on the toilet with morning cares. Evidenced by: R30 admitted to the facility 7/1/20 and has the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility did not ensure assessments were completed following a change of condition for 1 of 12 of 15 total residents reviewed for change of condition. The facility did not monitor, assess, or document R24's bowel sounds during an exacerbation of R24's chronic bowel conditions including ileus (when intestine stops making wave-like movements) and neurogenic bowel (loss of normal bowel function due to a nerve problem). This is evidenced by: On 8/29/23 at 12:01 PM, Surveyor requested a bowel policy from the facility. Surveyor reviewed the facility policy, entitled Bowel and Bladder Incontinence Policy dated 9/2/22, the facility policy, entitled Notification of Changes dated 7/6/23, and the facility protocol, entitled Bowel Protocol not dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor behaviors and symptoms of mental illness for 1 of 5 sampled residents out of a total sample of 15 (R40). R40 was diagnosed with dementia and is prescribed and administered anti-psychotic medications without targeted behavioral monitoring or use of non-pharmaceutical interventions to support or understand them or to prevent, relieve, or accommodate distress. This is evidenced by: Facility policy, entitled Psychotropic Medication Prescribing Guidelines, implemented 8/22, includes, in part: Antipsychotics Require clear documentation of diagnosis and indication for use, multiple attempts at care-planned non-drug interventions ., and ongoing evaluation of these approaches. Diagnoses alone do not warrant use. Indication may be warranted if: [...]