Cycle 1
Health 2025-12-18 · Fire 2024-09-18
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Madison, NC
Jacob's Creek Nursing and Rehabilitation Center
5-star overall rating with 4-star inspections with $16,801 in total fines with 4 fire-safety deficiencies in the latest cycle
1721 Bald Hill Loop, Madison, NC
(336) 548-9658
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
170
Certified beds
Average residents
148
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1968-05-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 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
0.28
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.35
Baseline 53.85% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.83
Adjusted total nurse staffing
2.27
Baseline 4.32 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 11.76% · Lower 95% interval 7.35% |
| Discharge to community | 29.99% |
50.57%
20.6 pts worse
|
Worse than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 16.87% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 213 |
| Staff flu vaccination coverage | 23.21% |
42%
18.8 pts worse
|
Numerator 55 · Denominator 237 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.5%
8.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.7% · Q3 5.4% · Q4 6.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.8%
2.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.7% · Q3 0.0% · Q4 5.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
7.2%
0.4 pts better
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.4% · Q3 8.8% · Q4 8.1% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.7% |
21.6%
11.1 pts worse
|
19.6%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 33.8% · Q3 32.8% · Q4 33.1% · 4Q avg 32.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
15.0%
9 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.3% · Q3 5.3% · Q4 8.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 11.3% |
21.5%
10.2 pts better
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 10.6% · Q3 7.2% · Q4 15.0% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
16.8%
10.2 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 2.6% · Q3 5.2% · Q4 8.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 3.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.7% |
21.2%
12.5 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 15.1% · Q3 6.0% · Q4 4.7% · 4Q avg 8.7% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
6.0%
3.2 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.6% · Q3 2.4% · Q4 2.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
79.9%
1.7 pts better
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.9% · Q3 85.7% · Q4 86.1% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
13.2%
8.9 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 5.0% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 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 | 80.0% |
78.1%
1.9 pts better
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
22.9%
2.9 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.0% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-18 · Fire 2023-04-27
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-27 · Fire 2022-01-11
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-09-18
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 2025-01-20
D · Potential for more than minimal harm
2024-09-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-09-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-20
D · Potential for more than minimal harm
2023-04-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-05
D · Potential for more than minimal harm
2022-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-10
Inspection history
Recent health citations
J · Immediate jeopardy
2024-09-18
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 2024-08-05
E · Potential for more than minimal harm
2024-09-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-18
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-10-11
D · Potential for more than minimal harm
2023-04-27
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 2023-05-25
D · Potential for more than minimal harm
2023-04-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-27
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
$4,017
2024-09-18
Fine
Fine · fine $4,017
Fine
$12,784
2024-09-18
Fine
Fine · fine $12,784
Fine
$0
2024-09-18
Payment Denial
Payment Denial · denial start 2024-10-09 · 2 days
2 day denial
Ownership
Principle It Services, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Hill, Robert
5% Or Greater Indirect Ownership Interest · Individual
Hill, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Hill, Raymond
5% Or Greater Indirect Ownership Interest · Individual
Boice, Gale
Corporate Officer · Individual
Johnson, Dianne
Corporate Officer · Individual
Principle Long Term Care, Inc.
Operational/Managerial Control · Organization
Wilson, Kathleen
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Countryside
Stokesdale, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Eden Rehabilitation and Healthcare Center
Eden, NC
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
UNC Rockingham Rehab & Nursing Care Center
Eden, NC
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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