Cycle 1
Health 2024-12-06 · Fire 2024-12-06
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Goldsboro, NC
Willow Creek Nursing and Rehabilitation Center
3-star overall rating with 3-star inspections with $6,570 in total fines with 7 recent health deficiencies
2401 Wayne Memorial Drive, Goldsboro, NC
(919) 736-2121
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1974-06-01
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
0.65
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,977
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9911
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.66
Baseline 22.12% · Performance 20.00% · Measure score 3.66 · Achievement 3.08 · Improvement 3.66
Healthcare-associated infections
7.13
Baseline 8.36% · Performance 5.79% · Measure score 7.13 · Achievement 6.83 · Improvement 7.13
Total nurse turnover
2.25
Baseline 56.44% · Performance 54.49% · Measure score 2.25 · Achievement 2.25 · Improvement 0.12
Adjusted total nurse staffing
2.12
Baseline 3.60 hours · Performance 3.68 hours · Measure score 2.12 · Achievement 2.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.2% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 261 · Observed rate 11.49% · Lower 95% interval 8.58% |
| Discharge to community | 57.42% |
50.57%
6.9 pts better
|
No Different than the National Rate · Eligible stays 284 · Observed rate 49.65% · Lower 95% interval 50.1% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.49% |
95.27%
2.8 pts worse
|
Numerator 160 · Denominator 173 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 173 |
| Discharge self-care score | 59.23% |
53.69%
5.5 pts better
|
Numerator 77 · Denominator 130 |
| Discharge mobility score | 49.23% |
50.94%
1.7 pts worse
|
Numerator 64 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 3.47% |
2.29%
1.2 pts worse
|
Numerator 6 · Denominator 173 · Adjusted rate 3.14% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 4.19% · Lower 95% interval 3.44% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 23.83% |
42%
18.2 pts worse
|
Numerator 51 · Denominator 214 |
| Discharge function score | 56.92% |
56.45%
0.5 pts better
|
Numerator 74 · Denominator 130 |
| Transfer of health information to provider | 95.77% |
95.95%
0.2 pts worse
|
Numerator 68 · Denominator 71 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 70 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 4 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 44.4% |
91.5%
47.1 pts worse
|
93.4%
49 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.9% · Q2 42.0% · Q3 46.5% · Q4 44.4% · 4Q avg 44.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 69.7% |
94.1%
24.4 pts worse
|
95.5%
25.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 69.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.6%
1.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.2% · Q3 1.6% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
4.8%
0.8 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.3% · Q3 4.3% · Q4 2.7% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 13.9% |
7.2%
6.7 pts worse
|
5.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 17.2% · Q3 11.1% · Q4 10.6% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
21.6%
3.3 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 19.7% · Q3 16.7% · Q4 12.5% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
15.0%
2.7 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.9% · Q3 10.7% · Q4 14.5% · 4Q avg 12.3% · 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 | 19.3% |
21.5%
2.2 pts better
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 25.0% · Q3 19.9% · Q4 22.1% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
16.8%
2 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 16.0% · Q3 14.0% · Q4 8.6% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
0.9%
1.9 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.5% · Q3 2.5% · Q4 4.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.6%
0.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.2% · Q3 3.9% · Q4 1.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.1% |
21.2%
14.1 pts better
|
19.8%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 3.7% · Q3 7.7% · Q4 6.2% · 4Q avg 7.1% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
6.0%
1.2 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 8.3% · Q3 8.7% · Q4 4.9% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
79.9%
1.2 pts worse
|
81.7%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.5% · Q2 79.2% · Q3 82.5% · Q4 80.9% · 4Q avg 78.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
13.2%
3.2 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 15.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.1% · Q3 0.6% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.7% |
78.1%
12.4 pts worse
|
79.7%
14 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
22.9%
7.3 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 15.9% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-24
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
2024-12-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-19
D · Potential for more than minimal harm
2024-12-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-24
F · Potential for more than minimal harm
2023-11-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-28
F · Potential for more than minimal harm
2023-11-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-28
E · Potential for more than minimal harm
2023-11-30
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 2023-12-28
E · Potential for more than minimal harm
2023-11-30
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 2023-12-28
D · Potential for more than minimal harm
2023-11-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-12-28
E · Potential for more than minimal harm
2022-11-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-11-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-11-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-11-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-11-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-11-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-11-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-22
B · Minimal harm
2022-11-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-12-22
Penalties and ownership
What sits behind the stars
$6,570
2024-12-06
Fine
Fine · fine $6,570
Fine
Ownership
Boice, Gale
Corporate Officer · Individual
Hill, Raymond
5% Or Greater Direct Ownership Interest · Individual
Hill, Robert
5% Or Greater Direct Ownership Interest · Individual
Hill, Stephen
5% Or Greater Direct Ownership Interest · Individual
Hood, Lynn
Operational/Managerial Control · Individual
Hood, Lynn
Corporate Officer · Individual
Johnson, Dianne
Corporate Officer · Individual
Principle It Services, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Principle Long Term Care, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Goldsboro Rehabilitation and Healthcare Center
Goldsboro, NC
3-star overall rating with 3-star inspections with $24,850 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
O'Berry Neuro-Medical Treatment Center
Goldsboro, NC
1-star overall rating with 1-star inspections with Special Focus status with $167,242 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Mount Olive Center
Mount Olive, NC
1-star overall rating with 1-star inspections with $172,957 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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