C77

WILLOW CREEK RETIREMENT CENTER

Grade C 77/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
3/5
Health Insp.
3/5
Quality
2/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

88

Ownership

For profit - Limited Liability company

Total Fines

$8,018

Last Survey

N/A

49 WILLOW CREEK LANE, BYRAM, MS 39272
6018634201

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.65h
LPN
1.53h
CNA
2.71h
Total
4.90h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

PHILIPPE, LYNN

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2008

20%

ROTOLO, DAVID

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2008

40%

ROTOLO, ROBERT

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2008

40%

BRIAR HILL MANAGEMENT, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Sep 2003

BURLISON, SANDY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2019

BURNS, SHARON

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2008

CLAYTON, JOSHUA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2024

COOPER, SHEILA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Nov 2024

GREEN, DONNA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2010

KING, CURTIS

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2016

MUHA, ASHLEY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2010

ROTOLO, DAVID

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2008

ROTOLO, ROBERT

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2008

WHITE, DEBORAH

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2014

WHITLOW, CARRIE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2022

Penalties & Fines (1)

$8,018total fines
DateTypeDescriptionAmount
Sep 12, 2024Fine$8,018

Health Inspection Deficiencies (21)

November 7, 2024Health4 deficiencies
0656DMinimal harm, Isolated

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

Corrected Dec 4, 2024
0693DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Dec 4, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Dec 4, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 4, 2024
September 12, 2024Health1 deficiency1 severe
0689GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Sep 5, 2024
May 24, 2024Health1 deficiency
0686EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Jul 4, 2024
March 13, 2024Health2 deficiencies
0686DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 15, 2024
0690DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 15, 2024
February 23, 2023Health6 deficiencies
0561DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Mar 29, 2023
0565EMinimal harm, Pattern

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

Resident Rights Deficiencies

Corrected Mar 29, 2023
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 29, 2023
0690DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 29, 2023
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Mar 29, 2023
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Mar 29, 2023
October 3, 2019Health7 deficiencies
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Nov 1, 2019
0646DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Nov 1, 2019
0656DMinimal harm, Isolated

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

Corrected Nov 1, 2019
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 1, 2019
0690DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 1, 2019
0727DMinimal harm, Isolated

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.

Nursing and Physician Services Deficiencies

Corrected Nov 1, 2019
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 1, 2019

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Frequently Asked Questions

What is the CareGrader rating for WILLOW CREEK RETIREMENT CENTER?

WILLOW CREEK RETIREMENT CENTER in BYRAM, Mississippi has a CareGrader grade of C (Average), with a composite score of 77.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WILLOW CREEK RETIREMENT CENTER?

WILLOW CREEK RETIREMENT CENTER has an overall CMS star rating of 3 out of 5, a health inspection rating of 3/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WILLOW CREEK RETIREMENT CENTER have?

WILLOW CREEK RETIREMENT CENTER has 21 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has WILLOW CREEK RETIREMENT CENTER been fined?

Yes. WILLOW CREEK RETIREMENT CENTER has $8,018 in total fines from CMS enforcement actions across 1 penalty.

How many beds does WILLOW CREEK RETIREMENT CENTER have?

WILLOW CREEK RETIREMENT CENTER has 88 certified beds with approximately 80 current residents (91% occupancy). The facility is located at 49 WILLOW CREEK LANE, BYRAM, Mississippi 39272. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.