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

Chain footprint

7 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.06

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.07

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.19

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.32

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

2.13

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.94

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.49

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.75

CMS adjusted RN staffing hours

Adjusted total hours

3.04

CMS adjusted total nurse staffing hours

Case-mix index

1.94

Higher values indicate more complex resident acuity

RN turnover

10%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,699

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29

Composite VBP score used to determine payment impact.

Payment multiplier

0.9852

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.50

Baseline 21.99% · Performance 20.01% · Measure score 3.50 · Achievement 3.08 · Improvement 3.50

Healthcare-associated infections

0

Baseline 7.26% · Performance 8.77% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

8.10

Baseline 42.50% · Performance 30.56% · Measure score 8.10 · Achievement 8.10 · Improvement 6.27

Adjusted total nurse staffing

0

Baseline 3.13 hours · Performance 2.88 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.02%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 11.11% · Lower 95% interval 7.14%
Discharge to community	57.81%	50.57% 7.2 pts better	No Different than the National Rate · Eligible stays 65 · Observed rate 58.46% · Lower 95% interval 50.37%
Medicare spending per beneficiary	1.11	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 32 · Denominator 32
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 32
Discharge self-care score	52.38%	53.69% 1.3 pts worse	Numerator 11 · Denominator 21
Discharge mobility score	47.62%	50.94% 3.3 pts worse	Numerator 10 · Denominator 21
Pressure ulcers or injuries, new or worsened	3.13%	2.29% 0.8 pts worse	Numerator 1 · Denominator 32 · Adjusted rate 2.35%
Healthcare-associated infections requiring hospitalization	8.77%	7.12% 1.6 pts worse	No Different than the National Rate · Eligible stays 34 · Observed rate 14.71% · Lower 95% interval 4.43%
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Staff flu vaccination coverage	15.22%	42% 26.8 pts worse	Numerator 14 · Denominator 92
Discharge function score	52.38%	56.45% 4.1 pts worse	Numerator 11 · Denominator 21
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 21 · Denominator 21
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.

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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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 · 4Q avg 97.9%
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 · Q1 2.4% · Q2 0.0% · Q3 2.3% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star
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 · Q1 0.0% · Q2 7.7% · Q3 5.0% · Q4 0.0% · 4Q avg 3.4%
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 · Q1 10.8% · Q2 10.0% · Q3 5.4% · Q4 2.7% · 4Q avg 7.3%
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 · Q1 29.7% · Q2 27.5% · Q3 28.9% · Q4 27.0% · 4Q avg 28.3%
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 · Q1 7.7% · Q2 3.3% · Q3 5.9% · Q4 3.7% · 4Q avg 5.1% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 3.2% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 33.8% · Q2 16.1% · Q3 21.1% · Q4 13.2% · 4Q avg 20.5%
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 · Q1 5.6% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
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 · Q1 92.6% · Q2 97.6% · Q3 96.8% · Q4 94.6% · 4Q avg 95.1%
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 · Adjusted 5.4% · Observed 5.0% · Expected 10.4% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 85.0%
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 · Adjusted 21.5% · Observed 20.0% · Expected 22.2% · Used in QM five-star

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