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.
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
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
88
Certified beds
Average residents
81
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
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,063
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.41% · Performance 22.89% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.14
Baseline 6.29% · Performance 7.50% · Measure score 1.14 · Achievement 1.14 · Improvement 0
Total nurse turnover
2.66
Baseline 50.58% · Performance 52.81% · Measure score 2.66 · Achievement 2.66 · Improvement 0
Adjusted total nurse staffing
4.82
Baseline 4.65 hours · Performance 4.45 hours · Measure score 4.82 · Achievement 4.82 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 7.41% · Lower 95% interval 6.54% |
| Discharge to community | 57.06% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 50.83% · Lower 95% interval 46.67% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 109 · Denominator 109 |
| Falls with major injury | 1.83% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 109 |
| Discharge self-care score | 70.37% |
53.69%
16.7 pts better
|
Numerator 38 · Denominator 54 |
| Discharge mobility score | 55.56% |
50.94%
4.6 pts better
|
Numerator 30 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.83% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 109 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 7.29% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 8.22% |
42%
33.8 pts worse
|
Numerator 12 · Denominator 146 |
| Discharge function score | 62.96% |
56.45%
6.5 pts better
|
Numerator 34 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 78 · Denominator 78 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10.91% |
25.2%
14.3 pts worse
|
Numerator 6 · Denominator 55 |
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 · Adjusted 3.7 · Observed 3.4 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 3.1 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 90.9% |
| 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 · Q1 6.9% · Q2 5.7% · Q3 0.0% · Q4 2.9% · 4Q avg 3.9% · Used in QM five-star |
| 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 · Q1 6.2% · Q2 4.9% · Q3 6.5% · Q4 1.6% · 4Q avg 4.8% |
| 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 · Q1 10.4% · Q2 11.9% · Q3 6.2% · Q4 9.7% · 4Q avg 9.5% |
| 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 · Q1 33.3% · Q2 30.2% · Q3 23.1% · Q4 23.1% · 4Q avg 27.5% |
| 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 · Q1 29.8% · Q2 34.0% · Q3 35.7% · Q4 35.7% · 4Q avg 33.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 26.7% · Q2 31.8% · Q3 24.6% · Q4 28.6% · 4Q avg 27.8% · Used in QM five-star |
| 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 · Q1 19.0% · Q2 38.3% · Q3 34.9% · Q4 30.0% · 4Q avg 30.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.2% · Q3 2.5% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 33.3% · Q2 27.1% · Q3 26.6% · Q4 46.8% · 4Q avg 33.5% |
| 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 · Q1 9.1% · Q2 6.5% · Q3 12.0% · Q4 9.5% · 4Q avg 9.3% · Used in QM five-star |
| 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 · Q1 98.8% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 · Adjusted 19.6% · Observed 18.6% · Expected 10.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 4.1% · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 96.7% |
| 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 · Adjusted 25.3% · Observed 21.6% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Rotolo, Robert
5% Or Greater Direct Ownership Interest · Individual
Philippe, Lynn
5% Or Greater Direct Ownership Interest · Individual
Briar Hill Management, LLC
Operational/Managerial Control · Organization
Burlison, Sandy
Operational/Managerial Control · Individual
Burns, Sharon
Operational/Managerial Control · Individual
Cooper, Sheila
Operational/Managerial Control · Individual
Green, Donna
Operational/Managerial Control · Individual
King, Curtis
Operational/Managerial Control · Individual
Muha, Ashley
Operational/Managerial Control · Individual
Rotolo, David
Operational/Managerial Control · Individual
Rotolo, Robert
Operational/Managerial Control · Individual
Walters, Johnnie
Operational/Managerial Control · Individual
White, Deborah
Operational/Managerial Control · Individual
Whitlow, Carrie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Edgewood Health & Rehabilitation
Byram, MS
1-star overall rating with 1-star inspections with $130,008 in total fines with 17 recent health deficiencies
#2
Pleasant Hills Com Liv Center
Jackson, MS
2-star overall rating with 2-star inspections with abuse icon flag with $68,630 in total fines with 12 recent health deficiencies
#3
Chadwick Community Care Center
Jackson, MS
1-star overall rating with 2-star inspections with $8,281 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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