Willow Creek Retirement Center
49 Willow Creek Lane · Byram, MS · 39272 · 6018634201
88 certified beds For profit - Limited Liability company Chain: Briar Hill Management
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 4.04 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.52 | 0.55–0.75 |
| Weekend hours / resident-day | 3.72 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | 1 · $8,018 |
Inspection citations (24 in the current record)
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Potential for harm · D March 5, 2026
Reasonably accommodate the needs and preferences of each resident.
Corrected April 6, 2026 · Resident Rights
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Potential for harm · D March 5, 2026
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.
Corrected April 6, 2026 · Resident Rights
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Potential for harm · D March 5, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 6, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 5, 2026
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 April 6, 2026 · Quality of Life and Care
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Potential for harm · D March 5, 2026
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected April 6, 2026 · Pharmacy Service
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Potential for harm · D March 5, 2026
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected April 6, 2026 · Administration
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Potential for harm · F March 5, 2026
Provide and implement an infection prevention and control program.
Corrected April 6, 2026 · Infection Control
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Potential for harm · E January 6, 2026 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected February 5, 2026 · Quality of Life and Care
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Potential for harm · D November 7, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 4, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 7, 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.
Corrected December 4, 2024 · Quality of Life and Care
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Potential for harm · D November 7, 2024
Ensure that residents are free from significant medication errors.
Corrected December 4, 2024 · Pharmacy Service
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Potential for harm · E November 7, 2024
Provide and implement an infection prevention and control program.
Corrected December 4, 2024 · Infection Control
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Actual harm · G September 12, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 5, 2024 · Quality of Life and Care
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Potential for harm · E May 24, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 4, 2024 · Quality of Life and Care
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Potential for harm · D March 13, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 15, 2024 · Quality of Life and Care
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Potential for harm · D March 13, 2024 · found via complaint
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 April 15, 2024 · Quality of Life and Care
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Potential for harm · E August 11, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 23, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 11, 2023 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 23, 2023 · Resident Assessment and Care Planning
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Potential for harm · D February 23, 2023
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected March 29, 2023 · Resident Rights
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Potential for harm · E February 23, 2023
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected March 29, 2023 · Resident Rights
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Potential for harm · D February 23, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 29, 2023 · Quality of Life and Care
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Potential for harm · D February 23, 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.
Corrected March 29, 2023 · Quality of Life and Care
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Potential for harm · D February 23, 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.
Corrected March 29, 2023 · Pharmacy Service
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Potential for harm · F February 23, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 29, 2023 · Nutrition and Dietary
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 12, 2024 | Fine | $8,018 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 255300 · certified since August 1, 2003. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.