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
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing
LPN hours / resident day
0.81
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing
Weekend hours
3.05
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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