Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jacob's Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and aggressive behavior was observed with his arm around another resident's neck, causing distress and physical harm. Both residents had psychiatric conditions and were on psychotropic medications. Staff intervened to separate them and assess their conditions, but the facility failed to prevent the altercation, resulting in a deficiency.
The facility failed to post required 'Oxygen in Use' signage outside the rooms of residents receiving supplemental oxygen therapy. Despite the presence of oxygen concentrators and nasal cannulas, no signage was observed during multiple checks. Interviews revealed confusion among staff about who was responsible for posting the signage, and the DON reported that the facility had been informed that such signage was no longer required.
The facility failed to label and date food in nourishment room refrigerators and freezers, including opened smoothie mix bags and nutritional supplements. The Dietary Manager and DON confirmed that all food should be labeled and dated, and the nursing staff were responsible for labeling food brought in by residents' families. The manufacturer's guidelines for nutritional supplements were not followed, as they were not labeled with open dates.
A resident with severe cognitive impairment and dementia did not receive necessary foot care and podiatry services, despite a care plan indicating the need for assistance with activities of daily living. Observations showed severely overgrown toenails, and interviews revealed that requests for podiatry consultations were made but not fulfilled. The facility failed to ensure timely podiatry care and proper documentation, leading to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #123, who was severely cognitively impaired and had a history of aggressive behavior, was observed with his arm around Resident #100's neck, causing her distress and physical harm. Resident #100, also severely cognitively impaired, was found crying with a blue face and petechiae on her neck after the incident. Both residents were known to have psychiatric conditions and were on psychotropic medications. The incident occurred in an empty resident room where Resident #123 was sitting on a container and had his arms around Resident #100, who was leaning forward and crying. Staff members intervened by separating the residents and assessing their conditions. Resident #100 showed signs of physical distress, while Resident #123 was confused and claimed he was trying to retrieve his motorcycle. The staff reported the incident to the administration and initiated immediate monitoring and assessment of both residents. Interviews with staff and review of records indicated that both residents had a history of behavioral issues and were receiving psychiatric care. Despite this, the facility failed to prevent the altercation, which resulted in physical harm to Resident #100. The facility's high-risk population and the residents' psychiatric conditions contributed to the difficulty in managing behaviors, leading to this deficiency.
Removal Plan
- Resident #123 was placed on 1:1 monitoring.
- Resident #100 was assessed and placed on 15-minute checks.
- The Assistant Director of Nursing and Unit Manager notified the physician and resident representatives.
- Resident #100 remained on every 15-minute checks with no negative findings observed.
- The Social Worker completed a wellness visit with Resident #100 with no negative findings.
- Resident #100 was seen by the psych Nurse Practitioner with no new orders.
- The interdisciplinary team decided to decrease Resident #123's supervision to 15-minute checks every 1st and 3rd shifts and remain on 1:1 on 2nd shift.
- Resident #123 was seen by psych services with no new orders.
- The interdisciplinary team decided to decrease Resident #123's supervision to every 15-minute checks on all shifts.
- Resident #123 was admitted to a behavior health treatment center and his psych medications were adjusted.
- Upon return to the facility, the every 15-minute checks for Resident #123 were removed.
- Skin assessments were completed on all residents in the memory care unit for signs and symptoms of abuse with no negative findings.
- 100% of resident's progress notes and behavior alerts were audited to ensure interventions were in place to prevent escalation of behaviors.
- Incident reports related to resident to resident altercations were reviewed to identify patterns and trends.
- An in-service was initiated with all facility staff regarding recognizing and de-escalating resident behaviors.
- All newly hired staff will be educated during orientation regarding de-escalating resident behaviors/prevention of resident to resident altercation/abuse.
- A Performance Improvement Plan was developed for prevention of resident to resident altercations/abuse.
- Unit Managers will review progress notes and behavior alerts.
- The Director of Nursing or Assistant Director of Nursing will review the Behavior Audit Tool.
- The Administrator or Director of Nursing will present the findings of the Behaviors Audit Tools to the QAPI committee.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to post cautionary signage outside the rooms of residents who were using supplemental oxygen, as required by their policy on Oxygen Therapy. This deficiency was observed in seven residents who were receiving continuous oxygen therapy to maintain oxygen levels greater than 90%. Despite the presence of oxygen concentrators and nasal cannulas in use, no signage indicating 'Oxygen in Use' was found near the entrances of these residents' rooms during multiple observations over several days. The residents involved had various medical conditions requiring oxygen therapy, including chronic obstructive pulmonary disease, respiratory failure, and congestive heart failure. Some residents were cognitively impaired, while others were cognitively intact. Observations consistently showed that these residents were receiving oxygen therapy, yet the required signage was absent, which was confirmed through interviews with nursing staff who were unaware of the responsibility for placing such signage. Interviews with nursing staff and management revealed a lack of clarity regarding the responsibility for posting oxygen signage. Some staff believed it was the Unit Manager's responsibility, while others thought it was the Assistant Director of Nursing or the admitting nurse. The Director of Nursing reported that the facility had been informed that the signage was no longer required, leading to its removal and non-use since the last annual recertification.
Failure to Label and Date Food in Nourishment Rooms
Penalty
Summary
The facility failed to properly label and date food items stored in nourishment room refrigerators and freezers, which could potentially affect the quality of food served to residents. During an observation, it was found that two opened bags of frozen smoothie mix in the nourishment room freezer were not labeled or dated. The Dietary Manager was unaware of who placed the bags there, but later identified that the activity staff had done so for a resident activity. The Director of Nursing (DON) confirmed that all food should be labeled and dated before being stored in the nourishment areas. Additionally, in another nourishment room refrigerator, there were several items, including insulated lunch bags, a brown paper lunch bag, an opened soda bottle, an opened energy drink, and opened nutritional supplements, none of which were labeled with dates. The manufacturer's guidelines for the nutritional supplements specified that they should be labeled and refrigerated, with opened containers discarded after four days if kept refrigerated. The DON stated that the nursing staff were responsible for labeling food brought in by residents' families and for labeling nutritional supplements when opened. The DON also mentioned that the refrigerators were cleaned daily, and food brought in by families was discarded the following morning.
Failure to Provide Adequate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide adequate foot care and arrange necessary podiatry services for a resident with severe cognitive impairment and dementia. The resident was admitted with a care plan that highlighted the risk for skin breakdown and the need for assistance with activities of daily living. Despite a podiatry order being placed shortly after admission, there was no record of the resident being seen by a podiatrist, and the condition of the resident's toenails was not documented in the skin assessments conducted by nursing staff over several months. Observations revealed that the resident's toenails were severely overgrown, curling, and in contact with adjacent toes, with visible dirt and thick layers of skin between the toes. Interviews with family members and staff indicated that requests for podiatry consultations were made at the time of admission and again in July, but no action was taken. Staff members, including nurse aides and nurses, reported the condition of the toenails to nursing, but the resident was not scheduled for a podiatry visit, and the toenails remained unaddressed. The Director of Nursing and other staff confirmed that the resident's toenails were in poor condition upon transfer to a different unit, and attempts to address the issue were made but not completed. The social work department was not aware of the initial podiatry order, and the resident was not added to the podiatry schedule due to a full list. The facility's failure to ensure timely podiatry care and proper documentation of the resident's foot condition led to the deficiency identified in the report.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Countryside | 9.4 mi | ★★★★★ | 0 | 0 |
| Eden Rehabilitation And Healthcare Center | 12.3 mi | ★★★★★ | 4 | 1 |
| Unc Rockingham Rehab & Nursing Care Center | 13 mi | ★★★★★ | 0 | 0 |
| Cypress Valley Center For Nursing And Rehabilitati | 13.1 mi | ★★★★★ | 0 | 0 |
| Penn Nursing Center | 13.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.