Delaware, OH

Country Club Center V, Inc

5-star overall rating with 4-star inspections with 7 recent health deficiencies

478 S Sandusky St, Delaware, OH

(740) 369-8741

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

47

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Country Club Rehabilitation Campus

Operator or chain grouping

Approved since

1995-09-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.06

Registered nurse staffing

LPN hours / resident day

1.07

Licensed practical nurse staffing

Aide hours / resident day

2.19

Nurse aide staffing

Weekend hours

3.94

Weekend nurse staffing

RN turnover

10%

Annual RN turnover

Total nurse turnover

41%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.4% 7.6 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.9%	94.5% 3.4 pts better	95.5% 2.4 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	1.7%	3.3% 1.6 pts better	3.3% 1.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	3.4%	26.1% 22.7 pts better	11.4% 8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	7.3%	6.2% 1.1 pts worse	5.4% 1.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.3%	25.4% 2.9 pts worse	19.6% 8.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	5.1%	11.5% 6.4 pts better	16.7% 11.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	3.2%	7.7% 4.5 pts better	16.3% 13.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	0.8%	6.2% 5.4 pts better	14.9% 14.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.0%	0.5% 0.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.5%	21.7% 1.2 pts better	19.8% 0.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	2.2%	3.7% 1.5 pts better	5.1% 2.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.1%	78.1% 17 pts better	81.7% 13.4 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	5.4%	12.5% 7.1 pts better	12.0% 6.6 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.0%	75.6% 9.4 pts better	79.7% 5.3 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.5%	25.1% 3.6 pts better	23.9% 2.4 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-16 · Fire 2025-01-16

7 health deficiencies

Top issue: Resident Rights (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-05-12 · Fire 2022-05-12

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-08-15 · Fire 2019-08-15

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2022-05-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-05-27

E · Potential for more than minimal harm 2022-05-12

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-05-27

E · Potential for more than minimal harm 2022-05-12

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-05-27

E · Potential for more than minimal harm 2022-05-12

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-05-27

E · Potential for more than minimal harm 2019-08-15

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2019-10-03

E · Potential for more than minimal harm 2019-08-15

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2019-10-03

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-28

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-28

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-28

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-28

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-28

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-02-28

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-01-31

D · Potential for more than minimal harm 2025-01-16

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-01-29

D · Potential for more than minimal harm 2023-05-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-05-26

D · Potential for more than minimal harm 2022-05-12

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-05-27

D · Potential for more than minimal harm 2022-05-12

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-05-27

D · Potential for more than minimal harm 2019-08-15

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-10-03

D · Potential for more than minimal harm 2019-08-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-10-03

D · Potential for more than minimal harm 2019-08-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-10-03

C · Minimal harm 2019-08-15

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2019-09-06

Penalties and ownership

What sits behind the stars

Ownership

Holland Group Ii, Ltd

5% Or Greater Direct Ownership Interest · Organization

70% 4 facilities 2013-10-01

Harris, Janet

5% Or Greater Direct Ownership Interest · Individual

30% 7 facilities 2013-10-01

Gresock, Joshua