Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Country Club Center V, Inc during CMS and state inspections, most recent first.
Unsecured Medication and Treatment Carts: Surveyors observed the medication cart and treatment cart near the nurses' station unlocked and unattended, and later found a bottle of Gabapentin left on top of a medication cart in the hallway. An RN confirmed the medication was left unsecured while he assisted another resident, and the treatment cart was left unlocked while he was in a resident's room. The DON stated that medication and treatment carts must remain locked when not in use.
Failure to timely report an abuse allegation: A cognitively intact resident who needed substantial assistance with toileting reported that a night shift aide was rough during care, continued despite the resident yelling in pain, and brought a hand near the resident’s face. The concern was documented by hospice, but the Administrator and DON stated they were not notified when it was first reported, and the allegation was not reported to the state within the required timeframe.
Failure to monitor weekly weights led to a missed significant weight loss for a resident with severe cognitive impairment and multiple complex diagnoses, including chronic respiratory failure, Type II DM, CKD, and morbid obesity. The resident’s care plan identified malnutrition risk, and the physician ordered weekly weights, but there was a gap between recorded weights that showed a 9.4% loss. The DON confirmed there should have been at least one additional weight, and the dietitian stated there were no weight changes noted during the facility visit because the weights had not been obtained.
Failure to identify PTSD triggers and personalize behavioral health plan: A resident with multiple medical and psychiatric diagnoses, including PTSD, had a care plan and LEC-5 form that noted traumatic events but did not identify the specific incidents causing the trauma. The behavior logs were general and not resident-specific, and the DON confirmed staff could not find documentation of the specific trauma or a plan addressing potential triggers.
Two residents with complex medical needs experienced significant delays in call light response, with one waiting 49 minutes for incontinence care and another waiting 45 minutes for respiratory therapy. Staff interviews revealed a lack of clear expectations for response times, and facility audits showed multiple instances of delayed responses.
A resident with multiple neurological diagnoses and a history of family conflict was transferred to another facility without documented evidence that she participated in or agreed to her discharge plan. Despite indications of intact cognition and requests for a court-appointed guardian, staff did not document any conversations with the resident about her involvement in the discharge process, resulting in a failure to support resident self-determination.
A resident with atrial fibrillation and hypertension did not have their blood pressure and heart rate monitored twice daily as ordered while receiving Amiodarone, and the cardiologist was not notified when the medication was held due to low heart rates. Staff interviews confirmed the monitoring orders were not properly entered, resulting in incomplete vital sign checks and lack of required physician notification.
Two residents did not receive meals consistent with their prescribed diets and meal tickets. One resident on a mechanical diet was served the wrong vegetable, while another on a pureed diet received only part of the required meal, with several pureed items missing at the time of service. Staff confirmed the discrepancies and were unable to provide reasons for the omissions, despite facility policy requiring adherence to the menu and meal tickets.
A resident with Alzheimer's disease, dementia, and dysphagia who required a pureed diet was served food that was not fully pureed, with visible chunks of brussels sprouts, bacon, and ham present in the meal. Staff and dietary management confirmed that the food did not meet the required smooth consistency, and facility policy for pureed food preparation was not followed.
A CNA failed to perform required hand hygiene after removing soiled gloves and before donning new gloves while providing incontinence care to a resident with neurogenic bladder and impaired mobility. The CNA handled personal items and continued care without changing gloves or sanitizing hands, despite visible fecal contamination, in violation of facility infection control policies.
A resident in a long-term care facility was subjected to verbal abuse on social media by a CNA, who posted racially insensitive and aggressive messages on Facebook. The resident, who was cognitively intact and had a history of significant medical conditions, saw the posts and was distressed. The facility's policies prohibited such conduct, and the CNA was suspended and later terminated after an investigation.
A resident with intact cognition experienced multiple falls and a transfer to the emergency department without their representative being notified, despite the facility's policy requiring such notifications. Interviews confirmed the resident's desire for notification and staff acknowledged the failure to follow protocol.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure medications, the medication cart, and the treatment cart were secured properly. During observation on 04/20/26 at 10:41 A.M., the medication cart and treatment cart near the main nurses' station were unlocked and unattended. LPN #115 confirmed at 10:42 A.M. that both carts were unlocked and unattended. On 04/21/26 at 6:12 A.M., surveyors observed a bottle of Gabapentin 300 mg/6 mL solution sitting on top of the medication cart in the 200 hallway while both the medication and treatment carts were locked. The Gabapentin remained unsecured on top of the cart through 6:19 A.M. RN #142 then emerged from a resident's room, unlocked the treatment cart, and prepared a resident's medication using the Gabapentin solution before entering the resident's room at 6:20 A.M. The treatment cart remained unlocked and unattended from 6:20 A.M. through 6:25 A.M. RN #142 confirmed the Gabapentin had been left on top of the cart while he was assisting another resident with a treatment, and that the treatment cart was left unlocked while he was in the resident's room. The DON confirmed medications must be stored securely in medication carts and that medication and treatment carts must remain locked when staff are not preparing medications and must not be left unlocked when staff are not present.
Failure to Timely Report an Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of abuse involving one resident who was admitted with diagnoses including Type II diabetes mellitus, muscle weakness, chronic pain syndrome, legal blindness, and low back pain, and who required substantial to maximal assistance with toileting. The resident, who was cognitively intact, reported that a night shift aide was rough while assisting her to the toilet, continued turning her despite her yelling that her leg hurt, and brought a hand up to her face during the interaction. The resident also stated that a male nurse entered the room and made the aide stop, after which the aide left the room. The resident told the hospice nurse about the concern, and the hospice documentation reflected the allegation that a staff person was mean, rough during toileting care, and may have intended to strike her face. RN #126 stated she learned of the concern from the hospice nurse and reported it to the Administrator and ADON, but the Administrator and DON later stated that neither the hospice nurse nor RN #126 notified them of the allegation when it was first documented. The facility’s abuse policy required staff to report allegations in a timely manner to the Administrator or designee and to report abuse allegations to the state no later than two hours after the allegation was made, but the allegation was not reported to the state agency timely.
Failure to Monitor Weekly Weights and Identify Significant Weight Loss
Penalty
Summary
The facility failed to monitor weights for a resident who experienced a significant weight loss. Resident #3 was admitted with multiple diagnoses including chronic respiratory failure with hypoxia, acute respiratory failure, dependence on respirator, neuromuscular dysfunction of bladder, hypertension, Type II diabetes, hyperlipidemia, chronic kidney disease, colostomy status, cerebral infarction, tracheostomy status, morbid obesity, anoxic brain damage, obstructive and reflux uropathy, and muscle weakness. His MDS assessment dated 03/13/26 showed severe cognitive impairment, and his care plan dated 03/09/26 identified him as at risk for malnutrition with a goal of no significant weight changes, including five percent or more in 30 days. Review of his weights showed documented weights of 289.1 pounds on 03/10/26, then 262 pounds on 03/27/26, and 262.7 pounds on 03/29/26, reflecting a 9.4 percent decline between the first and second recorded weights. Physician orders required weekly weights for four weeks, but the order created on 03/09/26 was not started until 03/15/26. The DON confirmed she could not explain why there were no weights between 03/10/26 and 03/27/26 and agreed there should have been at least one additional weight during that period. The dietitian also confirmed that when she and another contracted dietary staff member visited on 03/18/26, they had no recommendations because there were no weight changes, and she deferred to the facility policy and/or dietary orders for obtaining weights. The facility's Height and Weight policy stated newly admitted residents are to be weighed weekly and longer if requested per dietitian, physician, or nursing recommendation.
Failure to Identify PTSD Triggers and Personalize Behavioral Health Plan
Penalty
Summary
The facility failed to properly address and plan for a resident’s diagnosis of PTSD by identifying specific triggers and addressing the underlying causes of the traumatic experience. Resident #17 was admitted with multiple diagnoses including acute and chronic respiratory failure, CHF, muscle weakness, dependence on respirator, mild cognitive impairment, venous insufficiency, COPD, peritoneal abscess, borderline personality disorder, mood disorder, anxiety disorder, depression, insomnia, Type II diabetes, hypertension, tracheostomy status, and other conditions. Her MDS assessment dated 01/29/26 indicated she was cognitively intact. Review of the resident’s LEC-5 form dated 10/10/24 showed difficult or stressful life events of life-threatening illness or injury and sudden accidental death, but it did not identify what specific events caused the distress. The care plan dated 09/17/24 noted PTSD and/or a traumatic event related to life-threatening illness or injury or sudden accidental death, with interventions to observe for triggered events such as increased anxiety, crying, withdrawal, not eating, and anger, and to offer psychological services as needed. However, the care plan did not identify the specific traumatic incidents or actions that could trigger harm to her mental health. Behavior logs dated 02/01/26 to 04/21/26 were general and not personalized, with only one verbal behavior documented. The DON confirmed the behavior log was general and not specific to the resident, and staff could not find documentation identifying the specific incidents that caused the trauma or a plan to address potential triggers.
Failure to Ensure Timely Call Light Response for Dependent Residents
Penalty
Summary
The facility failed to ensure timely response to call lights for two residents who required significant assistance with care. One resident, admitted with respiratory failure, vent dependence, dysphagia, muscle weakness, and diabetes, was observed to have activated her call light for incontinence care and waited 49 minutes before care was provided. During this period, staff entered the room only to deliver a meal tray, and the CNA responsible was unaware of the request, stating she did not hear the call light or radio due to assisting elsewhere. The Assistant Director of Nursing acknowledged the delay and stated there was no specific expectation for call light response time. The Director of Nursing also confirmed the facility policy was vague and agreed the wait time was excessive. Another resident, dependent on staff for eating and with diagnoses including acute chronic respiratory failure and vent dependence, activated her call light to request respiratory therapy and waited 45 minutes before being seen. The resident expressed uncertainty about when care would be provided. Review of call light audits over a two-month period showed multiple instances where response times exceeded 10 minutes, with the longest being 20 minutes. Staff interviews revealed inconsistent understanding of expected response times, and the facility's policy only stated that staff should strive to answer call lights promptly, without specifying a timeframe.
Failure to Ensure Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was provided with choice and self-determination regarding discharge planning. The resident, who had diagnoses including cerebral infarction, non-traumatic intracerebral hemorrhage, aphasia, dysphagia, and memory deficit, was admitted with three daughters named as healthcare POAs. Despite a Brief Interview of Mental Status (BIMS) score indicating intact cognition, a physician letter later stated the resident had cognitive impairment and required assistance with decision making, also mentioning possible financial abuse. Progress notes documented the resident's attempts to change POA paperwork, her request for facility representation during family visits, and her expressed desire for a court-appointed guardian. The resident also stated she did not want two of her daughters involved, citing family conflict. Facility staff reported they would follow POA paperwork and the resident's wishes, but interviews with the DON and Social Services confirmed there was no documented evidence that the resident participated in or agreed to her discharge plan. The timing of the physician letter and the family's request for transfer was noted as suspicious, especially as it followed the resident's request for a court-appointed guardian. Social Services acknowledged that no conversations with the resident regarding her involvement in the discharge process or her agreement to the plan were documented, resulting in a failure to honor the resident's right to self-determination in discharge planning.
Failure to Follow Physician Orders for Medication and Vital Sign Monitoring
Penalty
Summary
Staff failed to implement physician orders and monitor vital signs as required for a resident with multiple diagnoses, including paroxysmal atrial fibrillation and hypertension. The resident was prescribed Amiodarone with specific instructions to monitor blood pressure and heart rate twice daily and to hold the medication if the heart rate fell below a certain threshold, with notification to the cardiologist if the medication was held. However, review of the medical and medication administration records showed that vital signs were only monitored once daily instead of twice as ordered, and there was no documentation that the cardiologist was notified when the medication was held due to low heart rates on two occasions. Further review and staff interviews confirmed that the orders for vital sign monitoring were not properly entered into the medication or treatment administration records, resulting in the required monitoring not being completed. The Director of Nursing and an LPN both acknowledged that the medical record lacked evidence of physician notification and that the vital sign checks were not performed as ordered. The resident was severely cognitively impaired at the time, and the failure to follow physician orders and document required actions constituted the deficiency.
Failure to Provide Prescribed and Complete Meals per Menu and Meal Tickets
Penalty
Summary
The facility failed to provide residents with meals that met their prescribed dietary needs and preferences as outlined in their meal tickets and the facility menu. For one resident with hemiplegia, vascular dementia, and other conditions, the meal ticket specified a mechanical diet including glazed ham, green beans, rice pudding, au gratin potatoes, and a wheat dinner roll. However, the resident was served brussels sprouts instead of green beans, and the green beans were not prepared at all. Staff confirmed the discrepancy and were unable to explain why the correct vegetable was not provided, despite the meal ticket indicating otherwise. Another resident, with Alzheimer's disease, dementia, and dysphagia, was ordered a regular diet with puree texture. The meal ticket and menu called for pureed glazed ham, brussels sprouts, au gratin potatoes, rice pudding, and bread. At the time of service, only pureed ham and brussels sprouts were available and served; the other pureed items were not prepared. The kitchen manager acknowledged the missing items and stated that the equipment needed to prepare them was unavailable at the time. The diet technician confirmed that all items on the meal ticket should have been served. Facility policy requires that menus be followed as written unless changed for preference or unavailability, but no such changes were documented.
Failure to Provide Properly Pureed Food for Resident on Modified Diet
Penalty
Summary
Staff failed to provide food in a form that met the individual needs of a resident who required a pureed diet due to diagnoses including Alzheimer's disease, dementia, and dysphagia. The resident's diet order specified a regular diet with pureed texture, and the facility's meal spreadsheet indicated that pureed versions of certain foods, such as brussels sprouts and ham, should be provided. However, during meal preparation, staff were observed blending brussels sprouts with bacon, but not all pieces were fully pureed, leaving visible chunks of brussels sprout leaves and bacon in the container. The blended mixture was then served with these unpureed pieces still present. Further observations and interviews with the Kitchen Manager and Diet Tech confirmed that the pureed foods, including ham and au gratin potatoes, were not of the required smooth, pudding-like consistency, and contained chunks that should not have been present. The facility's own policy required pureed foods to be processed until smooth, but this was not followed, as evidenced by the presence of unpureed bacon and vegetable pieces in the meals prepared for the resident on a pureed diet.
Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
During an observation of incontinence care, a certified nurse assistant (CNA) failed to follow proper infection control procedures while providing personal care to a resident with multiple diagnoses, including neurogenic bladder, urinary retention, and impaired mobility. The CNA performed hand hygiene before entering the room and donned gloves, but after removing soiled gloves, she handled a walkie-talkie and donned new gloves from her pocket without performing hand hygiene. The CNA continued to provide care, including cleaning the resident and repositioning, without changing gloves or performing hand hygiene between tasks, even when visible fecal matter was present on the gloves. The resident involved was cognitively intact but dependent on staff for toileting and was frequently incontinent of bowel and bladder. Facility policies required hand hygiene after removing gloves and after handling potentially contaminated objects, but these procedures were not followed during the observed care. Both the CNA and the Director of Nursing confirmed that hand hygiene should have been performed after doffing soiled gloves and before donning new ones, which did not occur during the incident.
Resident Subjected to Verbal Abuse on Social Media by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse on social media, which was perpetrated by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact and had a history of paraplegia, chronic respiratory failure, dysphagia, tracheostomy, anxiety, and depression. The resident was subjected to inappropriate and aggressive messages posted by the CNA on Facebook, which were racially insensitive and referenced the resident's personal tragedies, including the death of her child. The posts were seen by the resident, who was friends with the CNA on Facebook, and caused distress among the resident and her friends. The incident was reported to the Licensed Nursing Home Administrator (LNHA) by the Director of Nursing (DON) after the inappropriate posts were discovered. The facility's policies prohibited employees from sharing any information about residents on social media, and the CNA had acknowledged these policies upon hiring. Despite the CNA's claim that her Facebook profile was cloned, she was unable to provide evidence to support this. The CNA admitted to having a verbal altercation with the resident prior to the posts, during which she expressed irritation towards the resident. The facility's abuse policy defined abuse as including verbal and mental abuse facilitated through technology. The LNHA initially did not consider the posts as abuse since the resident and facility were not named, but the posts were shared widely, leading to community concern. The facility's employee handbook prohibited making malicious or misleading statements about residents, and the CNA's actions were in violation of this policy. The incident was investigated, and the CNA was suspended and subsequently terminated for her conduct.
Failure to Notify Resident's Representative of Incidents
Penalty
Summary
The facility failed to notify the representative of Resident #23 of several incidents, including falls and a transfer to the emergency department. Resident #23, who was admitted with multiple diagnoses including acute pulmonary insufficiency and anxiety disorder, had a documented intact cognition. Despite this, there was no evidence in the medical record that the resident's representative was informed of a fall on April 13, 2024, a transfer to the emergency department on May 8, 2024, and subsequent falls on June 22, August 19, and September 25, 2024. Interviews with Resident #23 confirmed her desire for her representative to be contacted in case of falls, incidents, changes in condition, and new medication or treatment orders. Staff interviews, including those with a registered nurse, a licensed practical nurse, and the Director of Nursing, revealed that the facility's protocol required notifying the provider and the resident's representative following a fall or change in condition. However, the Director of Nursing confirmed that the notifications were not made as required. The facility's policy, revised in January 2020, also stipulated that the physician and responsible party should be notified in the event of a fall, which was not adhered to in these instances.
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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 Delaware
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherith Care Center At Willow Brook | 1 mi | ★★★★★ | 0 | 0 |
| Ohio Living Sarah Moore | 1.1 mi | ★★★★★ | 12 | 0 |
| Delaware Court Health Care Center | 1.9 mi | ★★★★★ | 18 | 0 |
| Arbors At Delaware | 3 mi | ★★★★★ | 35 | 0 |
| Capri Gardens | 7 mi | ★★★★★ | 8 | 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.