Byram, MS

Willow Creek Retirement Center

3-star overall rating with 3-star inspections with $8,018 in total fines with 5 recent health deficiencies

49 Willow Creek Lane, Byram, MS

(601) 863-4201

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Briar Hill Management

Operator or chain grouping

Approved since

2003-08-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing

LPN hours / resident day

1.22

Licensed practical nurse staffing

Aide hours / resident day

2.17

Nurse aide staffing

Weekend hours

3.61

Weekend nurse staffing

RN turnover

40%

Annual RN turnover

Total nurse turnover

50%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.7	2.4 1.3 pts worse	1.9 1.8 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	3.1	2.9 0.2 pts worse	1.8 1.3 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.7% 4.3 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.9%	97.0% 6.1 pts worse	95.5% 4.6 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.9%	3.2% 0.7 pts worse	3.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	4.8%	1.6% 3.2 pts worse	11.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	9.5%	6.1% 3.4 pts worse	5.4% 4.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	27.5%	24.4% 3.1 pts worse	19.6% 7.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	33.8%	23.4% 10.4 pts worse	16.7% 17.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	27.8%	22.8% 5 pts worse	16.3% 11.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	30.5%	20.6% 9.9 pts worse	14.9% 15.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.4%	1.5% 0.1 pts better	1.0% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.7%	2.5% 1.8 pts better	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.5%	21.4% 12.1 pts worse	19.8% 13.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	9.3%	6.9% 2.4 pts worse	5.1% 4.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	87.9% 11.5 pts better	81.7% 17.7 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	19.6%	15.3% 4.3 pts worse	12.0% 7.6 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	2.6% 1.2 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.7%	84.6% 12.1 pts better	79.7% 17 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.3%	27.9% 2.6 pts better	23.9% 1.4 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-07 · Fire 2024-11-07

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-02-23 · Fire 2023-02-23

10 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2019-10-03 · Fire 2019-10-03

9 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2023-02-23

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-03-29

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-06

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2026-02-05

E · Potential for more than minimal harm 2024-11-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-04

D · Potential for more than minimal harm 2024-11-07

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-12-04

D · Potential for more than minimal harm 2024-11-07

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-12-04

D · Potential for more than minimal harm 2024-11-07

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-12-04

G · Actual harm 2024-09-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-05

E · Potential for more than minimal harm 2024-05-24

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-04

D · Potential for more than minimal harm 2024-03-13

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-04-15

D · Potential for more than minimal harm 2024-03-13

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-04-15

E · Potential for more than minimal harm 2023-08-11

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-23

E · Potential for more than minimal harm 2023-08-11

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-09-23

F · Potential for more than minimal harm 2023-02-23

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-03-29

E · Potential for more than minimal harm 2023-02-23

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-23

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-23

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-23

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-03-29

D · Potential for more than minimal harm 2023-02-23

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-03-29

E · Potential for more than minimal harm 2019-10-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-11-01

D · Potential for more than minimal harm 2019-10-03

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2019-11-01

D · Potential for more than minimal harm 2019-10-03

F646 · Resident Assessment and Care Planning Deficiencies

Health

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Corrected 2019-11-01

D · Potential for more than minimal harm 2019-10-03

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2019-11-01

D · Potential for more than minimal harm 2019-10-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-11-01

D · Potential for more than minimal harm 2019-10-03

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2019-11-01

D · Potential for more than minimal harm 2019-10-03

F727 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2019-11-01

Penalties and ownership

What sits behind the stars

$8,018 2024-09-12

Fine

Fine · fine $8,018

Fine

Ownership

Rotolo, David

5% Or Greater Direct Ownership Interest · Individual

40% 6 facilities 2008-01-28

Rotolo, Robert

5% Or Greater Direct Ownership Interest · Individual

40% 6 facilities 2008-01-28

Philippe, Lynn

5% Or Greater Direct Ownership Interest · Individual

20% 6 facilities 2008-01-28

Briar Hill Management, LLC

Operational/Managerial Control · Organization

0% 6 facilities 2003-09-03

Burlison, Sandy