Capri Gardens: Lab Specimen Delays Leave UTI Untreated - OH
The resident at Capri Gardens, a 78-bed nursing home on Graphics Way, had already been through a frustrating week of failed collections. She is cognitively intact and always incontinent of urine, dependent on staff for toileting hygiene, and had been living at the facility since November 2025 with a list of conditions that included diabetes, a history of transient ischemic attack, and urinary retention. On May 21, a nurse practitioner ordered a urine culture and urinalysis after a prior lab result came back without a sensitivity test, leaving the clinical picture incomplete. Abnormal leukocytes, a marker of possible infection, had already shown up.
The resident refused collection multiple times on May 21. She refused again on May 22, despite staff providing education about why the test mattered. A registered nurse identified in inspection records as RN #201 eventually obtained a sample on the evening of May 22 at 6:09 p.m. She put it in the refrigerator and called the laboratory. No one answered.
That was the last documented attempt to reach the lab.
Progress notes from May 22 through May 26 contained no record of anyone calling the laboratory again to arrange pickup. RN #201 told inspectors she had notified another nurse, RN #274, that the lab would need to be contacted. RN #274 was unavailable for interview on the day of inspection. A third nurse, RN #249, said he worked the day shift on May 23 and was never told by night staff that a specimen was waiting for pickup.
The sample finally reached the laboratory on May 26, four days after collection. The lab reported results on May 28: three or more isolates were present. The specimen was contaminated and could not be used.
A progress note from May 27 recorded that a new specimen had been collected, that the contamination made results unobtainable, and that the resident denied pain and dysuria. The nurse practitioner discontinued the order for urinalysis.
That same afternoon, the resident's daughter called. She told staff she was concerned about her mother's confusion and asked that a urinalysis and culture and sensitivity be completed for a possible urinary tract infection. The nurse practitioner's order, the one that had just been discontinued, was reviewed.
The Director of Nursing confirmed to inspectors on May 28 that the facility could not determine whether the specimen had been picked up in a timely manner and that the medical record contained no evidence of additional attempts to contact the laboratory after the unanswered call on May 22.
Federal inspectors cited the deficiency at a level of minimal harm or potential for actual harm, the lower end of the severity scale. One resident was reviewed for urinary tract infections.
The gap between what the record showed and what staff believed had happened ran through every interview. RN #201 thought she had handed off the responsibility. RN #249 said no one handed it to him. RN #274 did not speak with inspectors. The Director of Nursing was left confirming, on the day of inspection, that no one could account for what happened to the specimen in between.
Meanwhile, a woman whose confusion was worrying her daughter enough to prompt a phone call had spent a week without a completed test, and the order to find out what was wrong with her had been discontinued the day before her daughter asked why no one had found out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Capri Gardens from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
CAPRI GARDENS in LEWIS CENTER, OH was cited for violations during a health inspection on May 28, 2026.
The resident at Capri Gardens, a 78-bed nursing home on Graphics Way, had already been through a frustrating week of failed collections.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.