Inspection Reports for
Willow Creek Retirement Center

Complaint survey conducted 6/01/26 through 6/04/26; the facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 7/09/26.

Complaint survey conducted 6/01/26 through 6/04/26; the facility was found in compliance and no deficiencies were cited.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 7/09/26.

Complaint 3043869 was investigated related to Residents’ Rights. The SA determined the facility was in compliance with no deficiencies cited.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint 3043869 and Complaint 3043868 were investigated; the facility was found in compliance with no deficiencies cited.

During the survey, SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Seven complaint investigations were conducted (CI MS #3031377, #3016147, #2997156, #2991628, #2974630, #2972270, and #2970187) related to resident neglect, abuse, misappropriation of medication, and quality of care. Deficiencies were cited for abuse (F0600) associated with CI MS #3031377 and misappropriation (F0602) associated with CI MS #2991628.

Two deficiencies were cited: the facility failed to protect a resident from physical abuse by a Resident Representative who struck the resident's face, and failed to prevent misappropriation of medication by a licensed nurse who took resident medication offsite.

CI MS #3031377 was investigated related to Resident Abuse and deficiencies were cited. The facility was found not in compliance with Minimum Standards and state licensure requirements.

The facility failed to protect a resident from physical abuse when the Resident Representative struck the resident in the face twice during assistance with dressing. The resident was assessed with no injuries, but the incident was reported to authorities and investigated by the facility and State Agency.

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 04/06/26.

The facility was found to be in compliance with the Life Safety Code requirements as of 04/06/26. No deficiencies were cited during the emergency preparedness survey conducted on 03/03/26.

The facility was found not in compliance with multiple deficiencies including failure to ensure reasonable accommodations for communication needs, failure to maintain a safe and homelike environment, failure to implement comprehensive care plans, improper catheter care, medication storage issues, and infection prevention and control failures.

The facility was found not in compliance with state licensure requirements due to failures in ensuring residents' rights, proper urinary catheter care, secure medication storage, and infection control practices.

The facility was found to have a deficiency related to the electrical equipment; specifically, the annunciator panel for the generator was inoperable and failed to meet NFPA 99 requirements. The Emergency Preparedness survey found the facility met all applicable requirements with no deficiencies cited.

Complaint survey completed on 01/06/26; the facility was found to be in compliance after corrective measures were confirmed.

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 02/05/26.

Two complaint investigations (CI MS #2704690 and CI MS #2703004) related to dementia care were conducted. Deficiency F0740 was cited, indicating the complaints were substantiated.

The facility failed to provide necessary behavioral health services by qualified staff to ensure residents’ dignity, privacy, and safety and failed to promote mental and psychosocial well-being for five residents with dementia. Multiple incidents involving Resident #1 wandering into other residents’ rooms, aggressive behaviors, and inadequate supervision were documented.

The complaint investigation was substantiated, focusing on Resident #1's repeated wandering into other residents' rooms, aggressive behaviors, and inadequate supervision. The complainant and family representatives expressed concerns about safety and supervision, particularly during evening and night shifts.

The facility failed to provide necessary behavioral health care and supervision to ensure residents' dignity, privacy, and safety, resulting in repeated incidents of wandering, aggression, and unsafe interactions among residents with dementia. The interdisciplinary team reviewed incidents and attempted interventions, but adequate supervision and individualized non-pharmacological interventions were not fully implemented.

Complaint investigations MS #487081, MS #487099, MS #487098, and MS #2564771 were conducted regarding resident care concerns including improper transition, incontinence care, injury from a lift, and delayed medical attention. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

Complaint Investigations MS #487081, MS #487099, MS #487098, and MS #2564771 were investigated regarding resident care concerns including inappropriate transitions, incontinence care, injury from falls, and delayed medical attention. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

CI MS#28407 investigated nursing services; the complaint was not substantiated and no deficiencies were cited.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint number CI MS#28407 was investigated related to nursing services. The complaint was not substantiated as no deficiencies were cited.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint numbers MS #27585 and MS #27775 were investigated regarding Responsible Party notification, Quality of Life, Assess and Monitor, Resident death, and Inappropriate feeding assistance. The complaints were not substantiated as no deficiencies were cited.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint numbers MS #27585 and MS #27775 were investigated regarding Responsible Party notification, Quality of Life, Assess and Monitor, Resident death, and Inappropriate feeding assistance. The complaints were not substantiated as no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.

The State Agency is recommending that the facility be placed back in compliance effective 12/04/24. No deficiencies were cited in this desk review.

The facility failed to ensure proper implementation of care plans during PEG tube care, adherence to physician orders for feeding tube care, prevention of medication errors, and proper infection control practices during wound and PEG tube care for sampled residents.

The facility was found not in compliance with state licensure requirements due to failures in gastric feeding care and infection control practices related to PEG tube site care and wound care for two residents.

The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in comprehensive care plan implementation, tube feeding management, medication administration, and infection prevention and control.

No deficiencies were cited during this survey.

Complaint Investigation (CI), MS #26369 and CI MS #26411, related to a Facility Reported Accident and resident neglect and safety involving the accident. The facility was found in compliance with the requirements based on corrective actions completed prior to the survey.

F0689 - The facility failed to provide adequate supervision to prevent an accidental coffee burn for one of four sampled residents, resulting in a partial thickness burn requiring hospital treatment and surgery. Corrective actions were completed prior to the survey entrance, and the facility was found in compliance with the complaint requirements.

The complaint investigation was substantiated. Resident #1 sustained a burn injury from hot coffee spilled when the resident rested a covered coffee cup on his stomach, which fell and spilled unobserved by staff. The injury was reported to the State Agency and appropriate corrective actions were implemented prior to the survey.

The facility failed to provide adequate supervision to prevent an accidental coffee burn for one resident. The resident suffered a partial thickness burn requiring hospital treatment and surgery. The facility implemented corrective actions including removal of the commercial coffee maker, temperature monitoring of coffee, staff training, and policy revisions.

Complaint survey completed on 05/24/24; the facility was found in compliance after corrective measures were confirmed.

The State Agency found the facility in compliance based on the desk review and recommended the facility be placed back in compliance effective 07/04/24.

Complaint number CI MS# 25683 was investigated as a Life Safety Code complaint survey. The facility was found in compliance and no deficiencies were cited.

This survey found the facility to be in compliance with the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No deficiencies were cited.

CI MS #25783 was investigated related to physical environment and resident safety. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this complaint investigation. However, the facility remains out of compliance due to deficiencies cited on the 5/24/2024 survey.

CI MS #25783 was investigated related to physical environment and resident safety. The complaint was not substantiated as no deficiencies were cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited during this investigation.

The investigation was complaint-driven, focusing on wound care neglect for Resident #2. The complaint was substantiated based on observations, interviews, and record reviews confirming delayed wound care and lack of dressing.

The facility failed to provide timely wound care and dressing changes for Resident #2, who had a stage 2 pressure ulcer on the sacral area. The Assistant Director of Nurses delayed wound care during meal delivery, resulting in the resident having no dressing in place for an extended period, increasing risk of infection.

CI MS #24849 was investigated related to resident neglect and quality of care related to client services not provided per care plan and physician orders and for responsible party not notified of resident change of condition. Deficiency F0686 was cited.

The facility was found not in compliance with Medicare and Medicaid requirements and cited for failure to provide care and services to promote healing and prevent infection for one resident with a pressure ulcer.

Complaint survey completed on 03/13/24. The facility was found to have corrected the deficient practice and sustained compliance. No deficiencies cited.

The State Agency is recommending that the facility be placed back in compliance effective 04/15/24. No deficiencies were cited in this desk review.

Four complaints were investigated: CI MS #24189 for Resident Neglect related to Pressure Sores; CI MS #23825 for Quality of Care regarding residents left wet and no pressure sore precautions; CI MS #23818 for Accidents related to Falls; and CI MS #23449 for Resident Neglect regarding Pressure Sores and Quality of Care/Treatment regarding residents left wet and inappropriate feeding assistance. Deficiencies were cited related to CI MS #24189 and CI MS #23449.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with deficiencies cited at M615 related to pressure sores and M620 related to urinary incontinence and catheter care.

The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident. Additionally, the facility failed to prevent the potential for urinary tract infections by improper catheter drainage bag and tubing placement for another resident.

Four complaint investigations were conducted: CI MS #24189 for Resident Neglect related to Pressure Sores, CI MS #23825 for Quality of Care regarding residents left wet and no pressure sore precautions, CI MS #23818 for Accidents related to Falls, and CI MS #23449 for Resident Neglect and Quality of Care/Treatment issues. Deficiencies were cited related to CI MS #24189 and CI MS #23449; the facility was found not in compliance.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies included failure to provide proper treatment and services to promote healing and prevent complications of pressure ulcers, and failure to prevent urinary tract infections related to indwelling urinary catheter care.

Complaint Investigation MS #23016 involved a resident-on-resident allegation of sexual abuse and MS #22989 involved low staffing levels interfering with quality care. Both complaints were investigated and found to be unsubstantiated with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint Investigation MS #23016 involved a resident-on-resident allegation of abuse and MS #22989 involved low staffing levels interfering with quality care. Both complaints were investigated and found to be unsubstantiated with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for Medicare and Medicaid, and there were no deficiencies cited.

CI MS#26995 - The complaint survey was reviewed and the facility was found to have corrected the deficient practice; the facility was placed back in compliance.

The State Agency found the facility in compliance and is recommending it be placed back in compliance effective 09/23/23. No deficiencies were cited in this document.

Complaint Investigation (CI) MS #21937 for Resident Abuse was substantiated with citation F600. CI MS #21963 for Quality of Care related to resident left wet, soiled and not turned for extended periods was substantiated with citations F600 and F656.

The facility was found to have failed to ensure residents were free from abuse and neglect for two residents reviewed. The facility also failed to implement comprehensive person-centered care plans for these residents.

The complaint investigation substantiated verbal abuse by CNA #1 toward Resident #1 on 6/16/23 and neglect by CNA #2 toward Resident #2 on 6/24/23. Investigations included interviews, record reviews, and security camera footage.

The facility failed to ensure residents were free from abuse and neglect, substantiating verbal abuse by a CNA toward Resident #1 and neglect of Resident #2 due to lack of care. Additionally, the facility failed to implement comprehensive person-centered care plans for both residents.

The SA investigated MS #21195 for Quality of care related to incontinent care, feeding assistance and staffing and MS #21413 related to Misappropriation of property and Residents Rights and cited no deficiencies.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited related to the complaints investigated.

Complaint CI MS #21195 involved Quality of care related to incontinent care, feeding assistance and staffing. Complaint CI MS #21413 involved Misappropriation of property and Residents Rights. Both complaints were investigated and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited related to the complaints investigated.

The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.

The State Agency is recommending that the facility be placed back in compliance effective 03/29/23. No deficiencies were cited in this desk review.

The State Agency is recommending that the facility be placed back in compliance effective 03/29/23. No deficiencies were cited in this review.

The facility failed to provide documentation and after-action report for the full-scale community-based exercise of the emergency preparedness plan as required by 42 CFR §483.70(a).

The facility was found deficient in honoring residents' rights to self-determination during mealtimes, documenting and resolving grievances from Resident Council Meetings, providing adequate personal care such as shaving, maintaining appropriate catheter care, ensuring psychotropic medications had proper stop dates, and maintaining a clean ice machine.

The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights, activities of daily living, and safe food handling procedures. Specific issues included failure to honor residents' right to make choices about going to bed during mealtimes, failure to assist a resident with shaving, and failure to maintain a clean ice machine.

The facility was found not in compliance with multiple requirements including resident self-determination, grievance handling, ADL care, catheter care, psychotropic medication management, and food safety related to ice machine cleanliness.

The facility was found in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and no deficiencies were cited.

CI MS#26995 complaint investigation was reviewed and the facility was found in compliance with no deficiencies cited.

The facility was found to have put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency is recommending the facility be placed back in compliance effective 11/23/22.

Complaint Investigations (CI), MS #19676, MS #19365, and MS #18825 were conducted. MS #19365 for Verbal Abuse and MS #18825 for Resident Neglect were not substantiated. MS #19676 for Misappropriation of Property was substantiated with deficiencies cited.

The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm due to misappropriation of personal funds for one resident. The investigation revealed CNA #4 cashed three checks totaling $180 from Resident #2's account without proper authorization.

Complaint survey conducted on 3/24/22; the facility was found to have corrected the deficient practice and was placed back in compliance effective 04/29/22.

The State Agency is recommending that the facility be placed back in compliance effective 04/29/22. No deficiencies were cited in this desk review.

Complaint Investigation MS #18600 was substantiated for failure to notify the Resident Representative of a change of condition; complaints MS #18598 and MS #18232 were not substantiated.

The facility failed to notify the Responsible Representative for a resident with cognitive impairment of an abnormal lab result, new infection, and new diagnosis related to COVID-19 for one of four residents reviewed. The Responsible Representative was not notified of the resident's positive COVID-19 test on 1/18/22 until visiting the facility on 1/19/22, despite facility policy requiring prompt notification.

Complaint investigation CI MS#26995 was reviewed and found to be in compliance with no deficiencies cited.

The State Agency is recommending the facility be placed back in compliance effective 7/20/21. No deficiencies were cited in this desk review.

CI MS #17844 for alleged neglect of pain, failure to notify the family of falls, and poor quality of care was unsubstantiated and no deficiencies were cited.

The SA determined that CI MS #17844 was unsubstantiated and no deficiencies were cited on 07/26/2021. The facility was in substantial compliance with the standards of participation in Medicare and Medicaid.

CI #17790 for Abuse (Certified Nurse Assistant (CNA) #1 applied liquid soap in Resident #1 eyes and face was substantiated. The facility was not in compliance and cited M500, Level II for physical abuse for Resident #1.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged and Infirm due to physical abuse of Resident #1 by a staff member who poured liquid soap on the resident's body, face, and eyes causing distress. The staff member was terminated and corrective actions were implemented.

CI #17146 was not substantiated for Resident Neglect and Nursing Services. CI #17245 was not substantiated for Resident Abuse and Quality of Care/Treatment.

The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

Complaint investigations CI #17146 and #17245 were not substantiated for Resident Neglect, Nursing Services, Resident Abuse, and Quality of Care/Treatment.

The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Complaint investigations CI #17146 and #17245 were not substantiated.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

Complaint investigation CI MS #16536 was substantiated with no deficiencies cited.

The SA substantiated the facility's self-reported compliant #16536, and no facility deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid requirements.

Complaint MS #16115 was investigated. The SA substantiated the facility failed to prevent a resident from falling related to use of a mechanical lift and cited deficiencies at F656 and F689. Alleged abuse for MS #16027 and MS #15907 was not substantiated.

The facility was found not in compliance with Medicare and Medicaid requirements. Deficiencies were cited for failure to accurately complete PASARR screenings, failure to notify state authorities of significant changes, failure to develop and implement comprehensive care plans, failure to provide adequate supervision to prevent accidents, failure to provide proper catheter care, failure to maintain adequate RN supervision, and multiple infection control issues. No Life Safety Code deficiencies were cited. The Emergency Preparedness survey found the facility in compliance.

Complaint #MS #16115 involved failure to provide adequate supervision and assistance with mechanical lifts, resulting in a fall and minor injury to Resident #9. Deficiency was cited.

M640 - Accidents. The facility failed to provide adequate supervision and assistance related to mechanical lifts, causing Resident #9 to fall and sustain a shoulder dislocation due to use of the wrong lift by a Certified Nurse Aide.

The facility failed to accurately complete PASARR Level I screening and failed to refer a resident for Level II review after a significant change. Care plans were not consistently followed, resulting in a resident fall with injury and improper catheter care. The facility lacked a consistent RN Supervisor for required days. Infection control practices were inadequate during wound, stoma, and catheter care, increasing risk of infection.

Complaint number CI MS #15274 was investigated and found unsubstantiated with no deficiencies cited.

The facility was found to be in compliance with requirements for participation in Medicare and Medicaid. Four areas of concern were unsubstantiated with no deficiencies cited.

Complaint number CI MS #15256. The allegation was that the facility was not in compliance with resident rights and care plan requirements. The complaint was substantiated with deficiencies cited.

The facility was cited for deficiencies related to resident rights and failure to follow the care plan for a resident with dementia. Two areas of concern were substantiated, and one was unsubstantiated.

Complaint survey MS 15096 was conducted from 3/26/18 through 3/27/18. The complaint was substantiated with deficiencies cited related to neglect and failure to follow care plans.

The facility was found to have failed to follow the care plan for Resident #1, who required a two-person sit to stand lift transfer. CNA #1 attempted a pivot transfer without using the lift or assistance, causing Resident #1 to fall and hit her head on the wheelchair armrest. The facility terminated CNA #1 and implemented staff education and audits to prevent recurrence.

CI MS#15057: A complaint investigation was conducted and was unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited.

CI MS#15022: A complaint investigation was conducted and was unsubstantiated with no deficiencies cited.

The result of the investigation was unsubstantiated with no deficiencies cited.

The facility was found not in compliance due to failure to prevent cross contamination during medication administration and accucheck procedures, and failure to provide complete sprinkler system coverage in one smoke compartment.

The facility failed to provide incontinent and indwelling urinary catheter care in a manner to prevent infection for two of five observations, including failure to secure the catheter strap properly and improper cleaning techniques. Licensed Practical Nurse and Certified Nursing Assistants did not follow proper procedures, increasing infection risk.