Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capri Gardens during CMS and state inspections, most recent first.
Pharmacy recommendations were not accurately carried out for two residents. One resident with multiple neuropsychiatric diagnoses had trazodone orders that did not match the actual 150 mg tablet being supplied, despite repeated pharmacist recommendations to update the order. Another resident with dementia and other chronic conditions had multiple eye drop orders, but the pharmacist’s instruction to allow 5 minutes between different drops was not added to the MAR/orders, and the DON confirmed the omission.
A resident with diabetes, cognitive impairment, and multiple chronic conditions had a Tresiba insulin pen left unattended on a dining table in the resident's room. An LPN confirmed the insulin was unsecured, and the DON acknowledged the facility had no medication storage policy and that insulin should not be left out unsecured.
Delayed urine specimen processing and lab submission: A resident with diabetes, urinary retention, and incontinence had a urine culture and urinalysis ordered after abnormal UA findings. The resident refused collection multiple times, then an RN collected the specimen and refrigerated it, but there was no documentation that the lab was contacted for pickup for several days. The specimen later resulted as contaminated, and a later urine sample was also contaminated and could not be processed.
Incomplete and inaccurate documentation was found for two residents. One resident had ordered weekly weights and BID blood glucose checks, but refusals, reattempts, and multiple glucose results were not entered into the EMR even though some information appeared on handwritten sheets and dietitian reports. Another resident’s MAR did not reflect multiple documented administrations of PRN hydromorphone shown on narcotic count sheets, and the DON confirmed medication administration was not being accurately documented on the MAR.
A resident with moderate cognitive impairment and anticoagulant use had a bedside table within reach that was observed to be broken, with an unfinished edge, exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed the table was in poor repair and accessible to the resident.
A resident with a diagnosis of acute bilateral subdural hemorrhage was improperly administered Coumadin despite hospital orders to hold anticoagulation therapy. The CNP ordered the medication without consulting necessary specialists or reviewing the complete hospital discharge summary. This oversight led to the resident's readmission to the hospital for a craniotomy due to increased hemorrhage.
Pharmacy Recommendations Not Reflected in Medication Orders
Penalty
Summary
The facility failed to ensure pharmacy recommendations were completed accurately for two residents reviewed for pharmacy recommendations. For one resident with diagnoses including metabolic encephalopathy, depression, cognitive communication deficit, anxiety, and psychotic disorder with hallucinations, the chart showed repeated trazodone orders written as 1.5 tablets of 100 mg at bedtime for insomnia even after the pharmacist recommended changing the order to match what was actually being administered. The pharmacist first noted that the supplier was sending separate 50 mg and 100 mg tablets for a total dose of 150 mg, then later noted the supplier was sending a single 150 mg tablet, but the physician order was not updated to reflect the actual 150 mg tablet until later. The Director of Nursing confirmed the order should have been changed when the pharmacy recommendation was first made and again when it was repeated, but it was not accurately changed until the later order. For another resident with diagnoses including cerebral infarction, diabetes mellitus, hypertension, dementia, anxiety, major depressive disorder, and heart failure, the physician orders included multiple ophthalmic medications for both eyes. The pharmacist recommended adding instructions to allow 5 minutes between administration of different eye drops to all eye drop orders. Review of the physician orders showed that this instruction was not added to any of the applicable orders. The Director of Nursing confirmed the instructions had not been added and stated that nursing staff had been educated about allowing five minutes between eye drop administrations.
Unsecured insulin left in resident room
Penalty
Summary
Medication storage was not kept secure for Resident #60, whose record showed an admission date of 05/22/26 and diagnoses including hemiplegia and hemiparesis, type 2 diabetes mellitus, diffuse traumatic brain injury, seizures, chronic kidney disease, chronic systolic heart failure, and anxiety. The quarterly MDS identified the resident as moderately cognitively impaired. A physician order dated 07/25/25 directed Tresiba FlexTouch insulin 54 units subcutaneously at bedtime for diabetes mellitus, with a dose decrease to 48 units if blood sugar was less than 80 and blood sugar checks before administration. During observation on 05/26/26 at 11:40 A.M., surveyors found a Tresiba long-acting insulin pen with an expiration date of 07/21/26 and no open date documented sitting on a small dining room table in Resident #60's room. Resident #60 could not confirm whether the medication had been given that morning or left by night shift. An LPN later confirmed the insulin was unattended on the dining table and stated she believed it had been returned to the room by the resident's daughter after the resident left for a leave of absence the night before. The DON confirmed the facility did not have a medication storage policy and acknowledged that insulin should not be left out unsecured.
Delayed Urine Specimen Processing and Lab Submission
Penalty
Summary
The facility failed to ensure a urine specimen was collected, processed, and submitted to the laboratory in a timely manner for one resident reviewed for urinary tract infections. The resident had diagnoses including type 2 diabetes mellitus, thrombocytopenia, urinary retention, transient ischemic attack, and anxiety, and was cognitively intact, dependent on toileting hygiene, and always incontinent of urine. A physician ordered a urine culture and urinalysis, and when the laboratory could not perform sensitivity testing on the initial specimen because of abnormal leukocytes, the nurse practitioner ordered recollection. The resident refused urine collection multiple times on 05/21/26 and 05/22/26, though urine was eventually collected by an RN on 05/22/26 and placed in the refrigerator. The RN stated the laboratory needed to be contacted for pickup, but the record contained no documentation that the lab was contacted for specimen pickup from 05/22/26 through 05/26/26. The urinalysis report later showed three or more isolates, suggesting contamination. A subsequent urine specimen collected on 05/27/26 was also contaminated and results could not be obtained, and the nurse practitioner discontinued the urinalysis order.
Incomplete and Inaccurate Resident Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For one resident with metabolic encephalopathy, type 2 diabetes mellitus, GERD, anxiety, and psychotic disorder with hallucinations, the record showed weekly weights were ordered because of significant weight loss, but a documented refusal of a scheduled weight was not entered in the electronic medical record, and there was no documentation that staff reattempted the weight or used an alternate method. A later weekly weight was also not documented as completed, refused, or attempted, and the MAR showed an N/A entry without supporting documentation in the record. The same resident was readmitted from the hospital and ordered to receive Accu-Checks twice daily, but the electronic medical record did not contain the blood glucose results from two days of monitoring. Handwritten nursing report sheets contained the missing glucose values, yet those results were not entered into or accessible through the electronic record. The DON confirmed the MAR did not generate a documentation field for glucose results and that nursing did not enter the values into the vitals tab as required by the physician order. For another resident with cerebral infarction, chronic back pain, and fibromyalgia, the record showed orders for Hydromorphone HCl 4 mg every eight hours as needed for pain, and the narcotic count sheets documented multiple administrations across March, April, and May 2026. However, the MAR did not reflect those administrations on the corresponding dates and times. The DON confirmed that nurses were not accurately documenting hydromorphone administration on the MAR after medication administration and stated that her expectation was for medication administration to be documented immediately and accurately on the MAR.
Broken Bedside Table Within Resident Reach
Penalty
Summary
The facility failed to ensure that a bedside table was in good repair for Resident #59, who was admitted with diagnoses including cerebral infarction, schizophrenia, and acute embolism. The resident’s MDS assessment showed moderate cognitive impairment, no upper body impairment, and anticoagulant use, and the care plan identified risk for bleeding related to anticoagulant medications. During observation, the resident’s bedside table was within reach and was found to have an unfinished, broken edge with approximately three inches of exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed that the bedside table was broken with rough, exposed particle board and wood chips and was within reach of the resident.
Failure to Ensure Continuity of Care Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to ensure the continuity of care for a resident who was admitted with a primary diagnosis of acute bilateral subdural hemorrhage. Despite hospital discharge orders and recommendations to hold off on anticoagulation therapy until a follow-up with a neurosurgeon, the resident was administered Coumadin. This oversight occurred when a Certified Nurse Practitioner (CNP) ordered the medication without consulting the physician, neurosurgeon, or cardiologist, leading to the resident being sent back to the hospital with an increased subdural hemorrhage. The resident, who had a history of atrial fibrillation, was admitted to the facility with specific instructions from the hospital to discontinue anticoagulation therapy. However, the CNP ordered Coumadin for the resident, citing a cardiology note and family discussions, despite not having access to the complete hospital discharge summary at the time. The facility's documentation did not reflect any consultation with the necessary specialists or a review of the hospital's after-visit summary, which clearly stated to hold off on anticoagulants. Interviews with the involved medical staff revealed a lack of communication and verification of hospital discharge orders. The physician and CNP both stated they would not have started the resident on Coumadin if they had seen the hospital's discharge orders. The facility's process for reviewing and implementing hospital discharge orders was not followed, leading to the resident's readmission to the hospital for a craniotomy due to the increased hemorrhage.
Removal Plan
- The DON and designee reviewed all residents receiving Coumadin with Physician #200. One resident (#37) was identified to be currently on Coumadin and no new orders received. The DON or designee performed a head-to-toe assessment on Resident #37 and no adverse findings were noted. The appropriate dose was ordered, there was indication for use, and the facility implemented the physician's orders accurately.
- The DON and designee completed an initial audit to ensure the hospital after visit summaries were available, accurate, and implemented for all residents residing in the facility. No negative findings were noted.
- The DON re-educated all 24 licensed nurses on Coumadin best practices, new admission procedures, thoroughly reviewing the hospital after-visit summary to ensure continuity of care, order clarification and indications for use.
- The facility's Quality Assurance (QA) Committee, including Medical Director #200, held an impromptu QA Committee meeting to review the facility's Immediate Jeopardy, investigation, corrective actions, and audits.
- CNP #205 was re-educated by Medical Director #200 on ensuring residents receive the continuity of care upon admission to the facility, including following physician orders and recommendations following a hospital stay.
- The DON will audit all new hospital after visit summaries to ensure accurate review and implementation; and all new orders, including new admission and Coumadin orders, to ensure accurate order transcription, indication for use, and implementation per the physician's order.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lewis Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Brook Christian Home | 3.6 mi | ★★★★★ | 8 | 0 |
| Highbanks Care Center | 3.7 mi | ★★★★★ | 8 | 0 |
| Worthington Christian Village | 3.9 mi | ★★★★★ | 10 | 0 |
| Landings Of Westerville Health And Rehab The | 5.5 mi | ★★★★★ | 2 | 0 |
| Laurels Of Norworth The | 5.9 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.