Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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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 | — | 2 | 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 | — | 0 | 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 August 2026) and official state health department websites.