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Willow Creek Nursing and Rehabilitation Center
2401 Wayne Memorial Drive, Goldsboro, NC 27534 · CMS Certification Number (CCN) 345113
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 24 in the last 3 inspection cycles (0 immediate jeopardy, 2 actual harm, 14 from complaints)
- Fire safety citations
- 1
- Fines (last 3 years)
- 3 fines, total $15,696
- Payment denials
- 0
- Most recent standard inspection
- March 19, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.9 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.9 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 2.7 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | March 19, 2026 | 9 | 2 | 7 |
| Cycle 2 | December 6, 2024 | 11 | 7 | 7 |
CMS weighted health inspection score: 72 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
24 health citations across 6 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 11, 2026: 5 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/30/2026 |
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/30/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/30/2026 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/30/2026 |
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/30/2026 |
March 19, 2026: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/07/2026 |
| B | F-0584 | 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. Resident Rights Deficiencies | Standard | No revisit needed Corrected 04/07/2026 |
February 13, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| G | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance |
| G | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance |
January 24, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/29/2025 |
December 6, 2024: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/24/2025 |
| D | F-0726 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/24/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/24/2025 |
| D | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/24/2025 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/24/2025 |
| D | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Past Non-Compliance Corrected 05/19/2024 |
| D | F-0584 | 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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/24/2025 |
November 30, 2023: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0688 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| D | F-0584 | 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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/28/2023 |
| F | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/28/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
1 fire safety citations across 1 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 03/19/2026 | F | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 04/07/2026 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| February 13, 2026 | Fine | $4,563 | — |
| February 13, 2026 | Fine | $4,563 | — |
| December 6, 2024 | Fine | $6,570 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.58 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.51 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 1.1 | Not published | Not published |
| Nurse aide hours per resident per day | 1.97 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.32 | Not published | Not published |
| RN hours per resident per day, weekends | 0.39 | Not published | Not published |
| Total nursing staff turnover (%) | 59.2 | 49 | 45.8 |
| Registered nurse turnover (%) | 46.4 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Birch Ltc Group, LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Principle Long Term Care (40 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 200
- Average residents per day
- 165.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- June 1, 1974
- County/parish
- Wayne
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
17 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| PRINCIPLE IT SERVICES, INC. | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| PRINCIPLE LONG TERM CARE, INC. | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| KRISHNARAJ, RAMESH | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STROUD, WENDY | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BOICE, GALE | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HOOD, LYNN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JOHNSON, DIANNE | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PRINCIPLE LONG TERM CARE, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HOOD, LYNN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PRINCIPLE IT SERVICES, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| PRINCIPLE LONG TERM CARE, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BOICE, GALE | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HILL, RAYMOND | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HILL, ROBERT | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HILL, STEPHEN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KRISHNARAJ, RAMESH | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STROUD, WENDY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Willow Creek Nursing and Rehabilitation Center. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.