Jacob's Creek Nursing and Rehabilitation Center
1721 Bald Hill Loop, Madison, NC 27025
Jacob's Creek Nursing and Rehabilitation Center, a 170-bed for profit - limited liability company nursing facility in Madison, NC, holds a 5-star CMS overall rating - well above the 3.0-star national average, with nurse staffing below the national norm. 3 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 3365489658
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- 5 / 5
- Much above average · CMS overall · nat'l 3.0
- 3.31
- Below average · nurse hrs/day · nat'l 3.89
- 16
- Inspection findings · 3 serious
- $17K
- Federal penalties (2)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 345050
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 170
- Residents
- 148
- In Hospital
- No
- County
- Rockingham
- Last Inspection
- Dec 18, 2025
Staffing Data
How the 3.31 total nursing hours per resident-day are staffed:
- RN Hours
- 0.28 (nat'l avg: 0.68)
- LPN Hours
- 0.81
- CNA Hours
- 2.23
- Total Nursing Hours
- 3.31 (nat'l avg: 3.89)
- PT Hours
- 0.04
- Nursing Turnover
- 39.7%
- RN Turnover
- 27.3%
What the CMS Record Reveals About Jacob's Creek Nursing and Rehabilitation Center
Jacob's Creek Nursing and Rehabilitation Center operates 170 certified beds in Madison, NC with approximately 148 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars (health inspection 4★ · staffing 3★ · quality 5★).
The inspection file contains 16 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $17K against this provider. Reported nurse staffing runs 3.31 total hours per resident day (national average 3.89); RN hours specifically are 0.28 per resident day.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Jacob's Creek Nursing and Rehabilitation Center falls into a category where comparative context matters. Reported nursing turnover at this facility is 39.7%, within a range generally associated with stable care teams.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (16 most recent)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 5, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 11, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 11, 2024
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 11, 2024
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Category: Resident Rights Deficiencies
Corrected: May 25, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: May 25, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: May 25, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 25, 2023
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Feb 11, 2022
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Feb 11, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 11, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Feb 11, 2022
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Feb 11, 2022
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Feb 11, 2022
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Feb 11, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Feb 11, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 6.6% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 11.3% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 6.0% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.8% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.8% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 32.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 8.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 81.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 80.0% | No |
Penalty History 2 penalties totaling $17K
| Date | Type | Amount |
|---|---|---|
| Sep 18, 2024 | Fine | $4K |
| Sep 18, 2024 | Fine | $13K |
| Sep 18, 2024 | Payment Denial | - |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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