Country Club Center: Forced Discharge Against Wishes - OH
The case at Country Club Center V involved Resident #51, an 81-year-old woman with cognitive impairment who had been battling her daughters over financial decisions since her May admission. On July 15, she told staff "I don't want those two here," referring to two of her daughters, and requested a court-appointed guardian.
The next day, one of those daughters called the facility requesting a transfer to Capri Gardens, where she worked.
Within 10 days, the resident was moved there.
Federal inspectors found the facility violated the resident's right to self-determination by failing to ensure she had any say in her discharge planning. The August inspection was triggered by a complaint.
The resident had suffered a stroke in May, leaving her with aphasia, difficulty swallowing, and memory problems. Despite these challenges, a mental status assessment showed intact cognition with a score of 14 out of 15. She required maximum assistance for mobility but could make her own healthcare decisions.
Her 2017 power of attorney documents named three daughters as healthcare decision-makers. But by July, the family was fracturing over money.
A physician's letter dated July 7 mentioned "possible financial abuse." Progress notes from the same day revealed the resident had consulted an elder care attorney and was trying to change her power of attorney paperwork.
The next day, she requested facility staff be present whenever her daughter visited.
When staff informed the daughter of this request on July 9, the daughter explained the resident was angry because they had stopped the resident's sister from accessing her money. The daughter said they were considering moving the resident to Tennessee "to get her away from her sister and closer to her two daughters."
Facility staff told the daughter they would follow both the power of attorney paperwork and the resident's wishes.
But six days later, the resident's frustration boiled over.
"They did this to her," she told staff on July 15, implying her daughters had caused her sister's suicide attempt. She explicitly stated she didn't want two of her daughters visiting and requested a court-appointed guardian to make decisions for her.
Staff immediately called the daughter to report what the resident had said.
The daughter's response was swift. She called the facility the next morning requesting a referral to Capri Gardens.
The timing troubled facility staff. Social Services worker #150 later told inspectors the request was "suspicious" and came at an "odd timing" - the day after the resident asked for a different decision-maker.
The physician's letter also raised red flags. Social Services #150 called it "odd" that the letter included information about financial concerns between family members without any cognitive assessment being completed to support the transfer.
Despite these concerns, the facility processed the discharge. On July 25, the resident was transferred to Capri Gardens with specific instructions that the facility was not to tell the resident's sister where she had gone.
When inspectors interviewed the Director of Nursing and Social Services worker #150 in August, both acknowledged the facility had failed the resident.
They confirmed they had no documented evidence that Resident #51 participated in her discharge planning or agreed to the transfer. They admitted concern about the pattern of the resident requesting different decision-makers, only to have her daughters "put barriers in place" each time.
No conversations were documented with the resident about whether she wanted to participate in the discharge process or whether she was agreeable to leaving Country Club Center.
The facility's own staff recognized the troubling sequence: a resident with intact cognition explicitly requests a court-appointed guardian to escape her daughters' control, and within 24 hours, those same daughters arrange her transfer to a facility where one of them works.
Social Services #150 acknowledged to inspectors that the timing raised serious questions about whether the resident's right to self-determination had been honored.
The case illustrates how family conflicts over finances can override a nursing home resident's expressed wishes, even when that resident has the cognitive ability to make her own decisions. Federal regulations require facilities to promote and facilitate resident self-determination through support of resident choice.
Instead, Country Club Center allowed the resident to be moved against her stated preferences, with no documentation that she agreed to or participated in the discharge planning process.
The resident's request for a court-appointed guardian - a clear expression of her desire to escape her daughters' control over her healthcare decisions - was effectively ignored. Within days, she found herself at a facility where one of those daughters worked, with instructions that her sister not be told her location.
The inspection was part of complaint investigation #2575389. The facility's census at the time was 44 residents, with this violation affecting one of three residents reviewed for resident rights compliance.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for Resident #51, the impact was profound - her explicit request for independence from family members who she believed had wronged her was overruled by those same family members within 24 hours.
The case raises questions about how nursing homes handle situations where residents with cognitive capacity conflict with their appointed healthcare decision-makers, particularly when financial abuse allegations surface. The resident's consultation with an elder care attorney and attempt to change her power of attorney documents suggested she was actively trying to regain control over her life.
Instead, she found herself moved to a facility chosen by the daughters she no longer trusted, with no documented evidence she agreed to the plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Club Center V, Inc from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COUNTRY CLUB CENTER V, INC in DELAWARE, OH was cited for violations during a health inspection on August 28, 2025.
On July 15, she told staff "I don't want those two here," referring to two of her daughters, and requested a court-appointed guardian.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.