Willow Creek Retirement Center
Willow Creek Retirement Center is a for profit - limited liability company facility in Byram, MS with 88 certified beds and a 3-star overall CMS rating. The inspection file holds 23 deficiency records. Total penalties: $8K.
49 Willow Creek Lane, Byram, MS 39272
Phone: 6018634201
Overall CMS Rating
vs 3.0 national avg
The verdict
Willow Creek Retirement Center holds a 3-star CMS overall rating — right around the 3.0-star national average, with nurse staffing above the national norm. 1 inspection finding reached the actual-harm or immediate-jeopardy level.
- 3 / 5
- CMS overall rating (nat'l avg 3.0)
- 3.92
- Nursing hrs/resident-day (nat'l 3.89)
- 23
- Inspection findings on file · 1 serious
- $8K
- Federal penalties (1)
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.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 255300
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 88
- Residents
- 81
- In Hospital
- No
- County
- Hinds
- Last Inspection
- Nov 7, 2024
Staffing Data
- RN Hours
- 0.52 (nat'l avg: 0.68)
- LPN Hours
- 1.22
- CNA Hours
- 2.17
- Total Nursing Hours
- 3.92 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 49.5%
- RN Turnover
- 40.0%
What the CMS Record Reveals About Willow Creek Retirement Center
Willow Creek Retirement Center operates 88 certified beds in Byram, MS with approximately 81 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (4★), and quality measures (2★). 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.
The inspection file contains 23 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $8K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.92 total nursing hours per resident day (national average 3.89), with RN coverage at 0.52 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Willow Creek Retirement Center falls into a category where comparative context matters. 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. Reported nursing turnover at this facility is 49.5%, within a range generally associated with stable care teams. 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 (23 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 4, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Dec 4, 2024
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 4, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 4, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 5, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 4, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 23, 2023
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: Sep 23, 2023
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: Mar 29, 2023
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: Mar 29, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 29, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 29, 2023
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Mar 29, 2023
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: Mar 29, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 1, 2019
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 1, 2019
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 1, 2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 1, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 1, 2019
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 1, 2019
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 1, 2019
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 30.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 9.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.4% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.4% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 27.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 27.5% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 90.9% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 96.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 9.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 33.5% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 33.8% | Yes |
Penalty History 1 penalties totaling $8K
| Date | Type | Amount |
|---|---|---|
| Sep 12, 2024 | Fine | $8K |
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Understanding Nursing Home Data
Frequently Asked Questions
What is the overall CMS rating for Willow Creek Retirement Center?
What are the staffing levels at Willow Creek Retirement Center?
How many beds does Willow Creek Retirement Center have?
Does Willow Creek Retirement Center have any deficiencies on record?
Has Willow Creek Retirement Center received any fines or penalties?
Who owns Willow Creek Retirement Center?
When was Willow Creek Retirement Center last inspected?
What quality measures are tracked for Willow Creek Retirement Center?
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.