B

Jacob's Creek Nursing and Rehabilitation Center

1721 Bald Hill Loop, Madison, NC 27025
Score: 76 / 100

With a score of 76/100 and a B grade, Jacob'S Creek Nursing And Rehabilitation Center is a well-regarded option in Madison, North Carolina. The facility performs above average in most CMS categories, placing it in the 80th percentile statewide.

Staffing levels are a potential concern at Jacob'S Creek Nursing And Rehabilitation Center, with 3.31 total nursing hours per resident per day — below the national average of 3.8 hours. Lower staffing can impact care quality and staff responsiveness.

Recent CMS inspections identified 8 deficiencies at Jacob'S Creek Nursing And Rehabilitation Center, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody..

Score Breakdown

Overall CMS Rating 40 / 40 pts
5 ★ CMS rating
Health Inspections 20 / 25 pts
4 ★ inspection rating
Staffing 12 / 20 pts
3 ★ staffing rating
Quality Measures 15 / 15 pts
5 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.31 3.8 Below Average
Registered Nurses (RN) 0.28 0.7 Below Average
Licensed Practical Nurses (LPN) 0.81 0.7 Above Average
Certified Nursing Assistants (CNA) 2.23 2.4 Average
Weekend Total Nursing 3.05 3.8 Below Average
Weekend RN Hours 0.12 0.7 Below Average

🔍 Inspection & Deficiency History

8
Total Deficiencies
Sep 17, 2024
Most Recent Inspection
🟠 7 Moderate 🔴 1 Serious
View recent deficiencies (5 shown)
  • Tag 0600 Severity J
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Sep 17, 2024 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0695 Severity E
    Provide safe and appropriate respiratory care for a resident when needed.
    Sep 17, 2024 · Quality of Life and Care Deficiencies
  • Tag 0812 Severity E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Sep 17, 2024 · Nutrition and Dietary Deficiencies
  • Tag 0687 Severity D
    Provide appropriate foot care.
    Sep 17, 2024 · Quality of Life and Care Deficiencies
  • Tag 0609 Severity D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Apr 26, 2023 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 2.8% 4.5% Better
Falls with major injury 5.0% 3.0% Worse
On antipsychotic medication 6.0% 14.5% Better
Urinary tract infections 1.9% 2.5% Better
ADL decline (daily activities) 6.6% 14.0% Better
Excessive weight loss 6.8% 7.5% Average
New/worsened incontinence 8.7% 45.0% Better

⚠️ Penalties & Fines

2 penalties recorded by CMS

Total fines: $16,801

How This Grade Was Calculated

This facility's grade of B is based on a score of 76 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 5★ → 40 pts (max 40)
  • Health Inspection Rating: 4★ → 20 pts (max 25)
  • Staffing Rating: 3★ → 12 pts (max 20)
  • Quality Measures Rating: 5★ → 15 pts (max 15)
  • Penalty deductions: -10 pts
  • Fine deductions: -1 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
170
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Dec 17, 2025
Deficiencies (Cycle 1)
0