Capri Gardens: Unsecured Insulin Left in Resident Room - OH
The resident, identified in inspection records only as Resident #60, was admitted to the 78-bed facility on May 22, 2026. His medical history included a diffuse traumatic brain injury, hemiplegia, seizures, chronic kidney disease, chronic systolic heart failure, and type 2 diabetes. He was assessed as moderately cognitively impaired.
His insulin regimen was not simple. A physician order directed staff to inject 54 units of Tresiba, a long-acting insulin, subcutaneously at bedtime, with instructions to drop the dose to 48 units if his blood sugar fell below 80. Blood sugar was to be checked before every administration.
When inspectors entered his room at 11:40 a.m. on May 26, the Tresiba FlexTouch pen was sitting in the open, on the dining table. No open date had been written on it. The pen's expiration date was July 21, 2026.
Resident #60 could not confirm whether he had received the medication that morning or whether it had been left there by the night shift.
Four minutes later, a Licensed Practical Nurse identified as LPN #227 was interviewed at the scene. She confirmed the insulin was sitting out, unsecured and unattended. Her explanation: she believed the resident's daughter had returned the pen to the room after Resident #60 left for a leave of absence the previous night.
That explanation did not account for who, if anyone, had given him insulin that morning, or what dose.
The Director of Nursing was interviewed at 11:57 a.m. She confirmed the insulin should not have been left unsecured. She also acknowledged something more fundamental: the facility did not have a medication storage policy.
Not a policy that was outdated. Not a policy that staff had failed to follow. No policy at all.
Tresiba is a concentrated insulin, dosed at 200 units per milliliter. The pen found on the table contained enough medication to cause serious harm if accessed by someone other than the intended patient, or if administered without the required blood sugar check. For a resident with chronic kidney disease and heart failure, a hypoglycemic episode carries compounded risk.
Resident #60, moderately cognitively impaired, was in no position to manage or safeguard his own medication. He could not confirm whether he had received a dose. He could not say who had last touched the pen or when.
The inspection, conducted May 28, 2026, cited the deficiency as having the potential for actual harm, affecting one of five residents reviewed for medication storage during the survey. CMS classified the level of harm as minimal harm or potential for actual harm.
The Director of Nursing's acknowledgment during the interview closed the loop on what inspectors found: a facility that had not established the most basic written expectation for how medications should be handled, stored, or secured, and a resident whose insulin, a drug requiring precise dosing and blood sugar monitoring before each use, was left on a table in an unsupervised room.
Whether Resident #60 received his bedtime dose on May 25 before his leave of absence, and whether he received his morning dose on May 26 before inspectors arrived, the inspection report does not resolve. Nobody at the facility could resolve it either.
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 12, 2026 · Our methodology
CAPRI GARDENS in LEWIS CENTER, OH was cited for violations during a health inspection on May 28, 2026.
The resident, identified in inspection records only as Resident #60, was admitted to the 78-bed facility on May 22, 2026.
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.