Your report for Jacob's Creek Nursing and Rehabilitation Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- North CarolinaAbove only 44% of peers417 rated homes · average 2.9★
- Rockingham CountyAbove only 25% of peers5 rated homes · average 3.8★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.9 vs NC avg
- StaffingCan add or remove a star3★+0.3 vs NC avg
- Quality measuresCan add or remove a star5★+1.8 vs NC avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 17% of peersNC avg2.9★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 46% of peersNC avg2.7★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 84% of peersNC avg3.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.31hrsAbove only 25% of peersNC avg3.78Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.28hrsAbove only 7% of peersNC avg0.59Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better40%Above 74% of peersNC avg50%RN turnover27%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$16,801Above only 40% of peersNC avg$45,050Fines · denials2 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJan 2022 – Sep 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 18, 2024Cycle 1worst J · immediate jeopardy$4,017, $12,784, payment denial
- F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Oct 11, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Oct 11, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 11, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Aug 5, 2024
Apr 27, 2023Cycle 2worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 25, 2023
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected May 25, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 25, 2023
- F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected May 25, 2023
Jan 11, 2022Cycle 3worst K · immediate jeopardy
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Feb 11, 2022
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Feb 11, 2022
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Feb 11, 2022
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Feb 11, 2022
- F584Honor 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.Resident RightsB · patternCorrected Feb 11, 2022
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Feb 11, 2022
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationK · patternCorrected Feb 11, 2022
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalK · patternCorrected Feb 11, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.31hrs
- Registered nursesRN hours only0.28hrs
- Licensed practical nursesLPN hours0.81hrs
- Nurse aidesCNA hours2.23hrs
- Weekend nursingAll staff on Saturdays and Sundays3.05hrs
- North Carolina average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better40%Above 74% of peersNC avg 50%
- RN turnoverRegistered nurses only27%Not ranked by CMS
- Administrators who leftIn the past year3Leadership changed
- Occupancy170 certified beds · ~148 residents a day87%Above 52% of peersNC avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $16,801In fines
- 2Fines
- 1Payment denial
- $45,050NC avg in fines
Actions on record
- Sep 18, 2024Civil money penalty$4,017
- Sep 18, 2024Civil money penalty$12,784
- Sep 18, 2024Denial of payment for new admissionsfrom Oct 9, 2024
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Principle Long Term Care44 facilities in the chain3.0★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Principle It Services, INC.
- Principle Long Term Care, INC.
- Raymond Hill
- Robert Hill
- Stephen Hill
- Principle Long Term Care, INC.
- Raymond Hill
- Robert Hill
- Roger Hill
- Stephen Hill
- Roger Hill
- Gale Boice
- Dianne Johnson
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 345050 · 1721 Bald Hill Loop, Madison, NC, 27025.
- Percentiles compare this facility with every rated nursing home in North Carolina and Rockingham County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
