Capri Gardens: Medication Order Errors Found in Inspection - OH
The problems surfaced during a May 28 inspection of Capri Gardens, a nursing facility at 6975 Graphics Way in Lewis Center. Inspectors documented two medication management failures involving different residents and different drugs, both traced to pharmacy recommendations that staff acknowledged receiving and did not fully act on.
The first involved trazodone, an antidepressant commonly prescribed for insomnia. The resident was receiving a 150-milligram tablet each night from the medication supplier. The physician order said something different: one 50-milligram tablet at bedtime. The gap between what the order said and what the resident was actually swallowing was 100 milligrams.
The pharmacy flagged it on February 20, 2026. The recommendation was to separate the existing 50-milligram and 100-milligram components into distinct orders, documented together as a nighttime dose, and to update the records to reflect what was actually being given. The facility did not make the change.
The pharmacy flagged it again on March 16, 2026.
The facility still did not make the change.
The Director of Nursing, interviewed on May 27, confirmed the sequence. She told inspectors the order should have been corrected to read "Trazodone HCl oral tablet 150 mg, one tablet by mouth at bedtime" when the pharmacy first raised it in February. She confirmed it wasn't accurately updated until May 27, 2026, the day before the inspection concluded, and more than three months after the first warning arrived.
The inspection classified the harm level as minimal, with few residents affected. But the Director of Nursing's own account made clear the gap was not a clerical oversight caught quickly. The facility had two explicit, documented prompts from its pharmacy. Neither produced a corrected order.
The second finding involved a resident with a significantly heavier medical burden. The resident, identified in inspection records as Resident 3, was admitted with cerebral infarction, diabetes, hypertension, dementia, anxiety, major depressive disorder, and heart failure. A quarterly assessment had found severely impaired cognition.
Resident 3 was on four separate eye drop medications, administered at various points throughout the day: Latanoprost, Systane Ultra, Timoptic, and Trusopt. On March 17, 2026, the facility's pharmacist issued a recommendation to add a five-minute waiting interval between each different eye drop to all applicable orders. Administering multiple eye drops back to back without a waiting period reduces the effectiveness of each medication, as the eye cannot adequately absorb one solution before the next is introduced.
Inspectors reviewed the physician orders. None of them contained the five-minute instruction. The pharmacist's recommendation had not been added to a single one.
The Director of Nursing, interviewed on May 28, confirmed that too. She said she had provided education to all nurses in March about waiting five minutes between eye drop administrations. The orders themselves, however, remained unchanged.
What the nurses were told in a training session and what the orders directing their work actually said were two different things. For a resident with severely impaired cognition, one who cannot track her own medications or flag a discrepancy to staff, the orders are the safeguard. They were not updated.
Together, the two findings describe a facility where pharmacy recommendations arrived, were acknowledged, and sat. The trazodone order went uncorrected through two pharmacy interventions and more than three months of nightly administration. The eye drop instructions went into a staff education session but not into the documents that govern how a woman with dementia and heart failure receives her medications each day.
The Director of Nursing confirmed both failures herself. The corrections, where they were made at all, came only after inspectors arrived.
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 8, 2026 · Our methodology
CAPRI GARDENS in LEWIS CENTER, OH was cited for violations during a health inspection on May 28, 2026.
The problems surfaced during a May 28 inspection of Capri Gardens, a nursing facility at 6975 Graphics Way in Lewis Center.
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.