| Willow Creek Retirement Center | |
| 49 Willow Creek Lane, Byram, Mississippi 39272 | |
| (601) 863-4201 | |
| Name | Willow Creek Retirement Center |
|---|---|
| Location | 49 Willow Creek Lane, Byram, Mississippi |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 88 |
| Occupancy Rate | 90.11% |
| Medicare ID (CCN) | 255300 |
| Legal Business Name | Wcrl, LLC |
| Ownership Type | For Profit - Limited Liability Company |
| Chain | Briar Hill Management (6 nursing homes) |
| Chain Average Overall Rating | 3.2 out of 5 |
| NPI Number | 1780758904 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Wcrl, LLC |
| Doing Business As | Willow Creek Retirement Center |
| Address | 49 Willow Creek Ln, Jackson, MS 39272 |
| Phone Number | 601-863-4201 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 4.05 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.55 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.09 | 0.86 |
| Nurse aide hours per resident per day | 2.41 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.64 | 3.42 |
| RN hours per resident per day on the weekend | 0.33 | 0.48 |
| Physical therapist hours per resident per day | 0.01 | 0.07 |
| Total nursing staff turnover | 52.9% | 45.8% |
| Registered nurse turnover | 57.1% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 1 |
| Total Amount of Fines in Dollars | $8,018 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 1 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Jun 4, 2026 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Jul 9, 2026 |
| Jun 4, 2026 | Protect each resident from the wrongful use of the resident's belongings or money. F0602, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Jul 9, 2026 |
| Mar 5, 2026 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, widespread | Corrected by Apr 6, 2026 |
| Mar 5, 2026 | Reasonably accommodate the needs and preferences of each resident. F0558, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Apr 6, 2026 |
| Mar 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. F0584, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Apr 6, 2026 |
| Mar 5, 2026 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Apr 6, 2026 |
| Mar 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. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 6, 2026 |
| Mar 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Apr 6, 2026 |
| Mar 5, 2026 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867, Administration, Standard inspection | Potential for harm, isolated | Corrected by Apr 6, 2026 |
| Jan 6, 2026 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. F0740, Quality of Life and Care, Complaint inspection | Potential for harm, pattern | Corrected by Feb 5, 2026 |
| Nov 7, 2024 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Dec 4, 2024 |
| Nov 7, 2024 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Dec 4, 2024 |
| Nov 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. F0693, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 4, 2024 |
| Nov 7, 2024 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 4, 2024 |
| Sep 12, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Actual harm, isolated | Past non-compliance (already corrected) |
| May 24, 2024 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Complaint inspection | Potential for harm, pattern | Corrected by Jul 4, 2024 |
| Mar 13, 2024 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Apr 15, 2024 |
| Mar 13, 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. F0690, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Apr 15, 2024 |
| Aug 11, 2023 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, pattern | Corrected by Sep 23, 2023 |
| Aug 11, 2023 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Complaint inspection | Potential for harm, pattern | Corrected by Sep 23, 2023 |
| Feb 23, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Mar 29, 2023 |
| Feb 23, 2023 | Honor the resident's right to organize and participate in resident/family groups in the facility. F0565, Resident Rights, Standard inspection | Potential for harm, pattern | Corrected by Mar 29, 2023 |
| Feb 23, 2023 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. F0561, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Mar 29, 2023 |
| Feb 23, 2023 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 29, 2023 |
| Feb 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. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 29, 2023 |
| Feb 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Mar 29, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.68 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 5.45 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.19 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0.36 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 1.92 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.45 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.66 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.75 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.26 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.91 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.67 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 11.73 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.84 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 31.74 | 15.38 |
Edgewood Health & Rehabilitation Location: 205 Byram Parkway, Byram, Mississippi 39272 Phone: (601) 362-5394 |