Capri Gardens
CAPRI GARDENS in LEWIS CENTER, OH — inspection on May 28, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition.
Review of Resident #3's physician orders revealed the following orders: Latanoprost Solution 0.005 % Place one drop in both eyes every day at bedtime; Systane Ultra Ophthalmic Solution 0.4-0.3 % Instill 2 drop in both eyes two times a day for dry eyes; Timoptic Solution 0.5 % Instill 1 drop in both eyes two times a day; Trusopt Solution 2 % Instill 1 drop in both eyes two times a day.
Review of Resident #3's pharmacist recommendation dated 03/17/26 revealed a recommendation to add the instruction allow 5 minutes between administration of different drops to all eye drop orders.
Review of Resident #3's physician orders did not reveal the added instructions to allow five minutes between administration of different drops to any of the applicable orders.
During an interview on 05/28/26 at 4:11 P.M. with the Director of Nursing, she confirmed the instructions had not been added to any of the eye drop orders.
She explained that she did provide education to all of the nurses in March of 2026 concerning allowing five minutes between eye drop administrations.
366472 05/28/2026
Capri Gardens 6975 Graphics Way Lewis Center, OH 43035
Review of a physician order dated 07/25/25 revealed Tresiba FlexTouch Subcutaneous Solution PenˆInjector 200 UNIT/ML (Insulin Degludec).
The order directed to inject 54 units subcutaneously at bedtime for diabetes mellitus and to decrease the dose to 48 units if blood sugar was less than 80.
Blood sugar was to be checked prior to administration.Observation on 05/26/26 at 11:40 A.M. of Resident #60's room revealed a Tresiba longˆacting insulin pen with an expiration date of 07/21/26 and no open date documented.
The insulin was sitting out on a small dining room table in the resident's room. Resident #60 was unable to confirm if he had received the medication that morning or if it was left by night shift.Interview and observation on 05/26/26 at 11:44 A.M. with Licensed Practical Nurse (LPN) #227 confirmed the Tresiba insulin was sitting unattended in the resident's room on the dining table. LPN #227 stated she believed the insulin had been returned to the room by the resident's daughter after the resident left for a leave of absence on the night of 05/25/26.Interview on 05/26/26 at 11:57 A.M. with the Director of Nursing confirmed the facility did not have a medication storage policy and acknowledged that insulin should not be left out unsecured.
366472 05/28/2026
Capri Gardens 6975 Graphics Way Lewis Center, OH 43035
Review of the urinalysis report received by laboratory 05/26/26 at 11:32 A.M., reported 05/28/26 at 12:57 P.M., revealed three or more isolates were present, suggesting contamination.Review of a progress note dated 05/27/26 at 3:22 P.M. revealed a urine specimen was collected, the specimen was contaminated and results could not be obtained.
The resident was assessed and denied pain and dysuria.
The nurse practitioner discontinued the order for urinalysis.Review of a progress note dated 05/27/26 at 4:14 P.M. revealed Resident #6's daughter expressed concern about resident confusion and requested that a urinalysis and culture and sensitivity be completed for a possible urinary tract infection.
The nurse practitioner's order was reviewed.Interview on 05/28/26 at 11:21 A.M. with RN #201 confirmed she was able to collect Resident #6's urine on 05/22/26.
She stated it was unusual for the resident to refuse collection. RN #201 reported RN #274 was notified the lab would need to be contacted for pickup.An attempted interview on 05/28/26 at 12:49 P.M. with RN #274, was unsuccessful.Interview on 05/28/26 at 12:53 P.M. with RN #249 confirmed he worked 05/23/26 during the day shift and denied night shift staff informed him the laboratory needed to be contacted to pick up Resident #6's urine.Interview on 05/28/26 at 2:30 P.M. with the Director of Nursing confirmed the facility was unable to determine whether the urine specimen was picked up by the laboratory in a timely manner, and no evidence was found in the medical record supporting additional attempts to contact laboratory services for pickup.
366472 05/28/2026
Capri Gardens 6975 Graphics Way Lewis Center, OH 43035
7:30 A.M. and 4:00 P.M., 05/23/26 at 9:30 A.M. and 5:11 P.M., and on 05/26/26 at 6:30 P.M., the MAR
An interview with the Director of Nursing (DON) on 05/28/26 at 2:20 P.M. confirmed that the nurses
administration.
The DON confirmed that it is her expectation that medication administration would be immediately documented accurately on the MAR after administration.
366472 05/28/2026
Capri Gardens 6975 Graphics Way Lewis Center, OH 43035
Review of Resident #59's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #59 was assessed as having moderate cognitive impairment. He was assessed as having no upper body impairment and being on an anticoagulant.
Review of Resident #59's care plan dated 10/20/23 revealed that Resident #59 was at risk for bleeding related to use of anticoagulant medications.
Observation on 05/26/26 at 9:43 A.M. revealed Resident #59's bedside table was within reach of the resident.
The bedside table's edge was observed to be unfinished, broken, and had approximately three inches of exposed particle board with splinters and wood chips on the tabletop.
Interview with Certified Nursing Aide (CNA) #205 on 05/26/26 at 10:02 A.M. confirmed Resident #59's bedside table was broken with rough, exposed particle board and wood chips, within reach of Resident #59.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.