Inspection Reports for
Willow Creek Retirement Center
49 Willow Creek Lane, Byram, MS, 39272
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 6, 2026
Visit Reason
The inspection was conducted following a complaint investigation related to behavioral health care and supervision concerns for residents with dementia, specifically focusing on incidents involving Resident #1 and interactions with other residents.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0740: The facility failed to provide necessary behavioral health care and 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.
Report Facts
Residents affected: 5
BIMS score: 3
BIMS score: 6
BIMS score: 3
BIMS score: 13
BIMS score: 3
One-on-one supervision hours: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Nurse Practitioner | Involved in assessment and treatment planning for Resident #1 after emergency room transfer |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Provided direct care and attempted redirection of Resident #1 during night shift |
| Social Services Director | Social Services Director | Confirmed interdisciplinary team discussions on residents' behaviors and interventions |
| Administrator | Administrator | Confirmed review of incidents and responsibility for staff supervision on dementia unit |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for in-service training and confirmed environmental accommodations and staffing |
| Director of Nurses | Director of Nurses | Confirmed staff training, supervision expectations, and awareness of Resident #1's behaviors |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care plan implementation, feeding tube care, medication administration, infection prevention, and control practices at Willow Creek Retirement Center.
Findings
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.
Deficiencies (4)
F 0656: The facility failed to implement comprehensive care plan interventions during PEG tube care for Resident #30, including keeping the head of bed elevated and drying the PEG site before dressing.
F 0693: The facility failed to follow physician orders for PEG tube care for Resident #30, including stopping the feeding pump before positioning the bed flat and drying the PEG site before applying dressing.
F 0760: The facility failed to prevent significant medication errors for Resident #9 when an incorrect medication (Alprazolam) was pulled instead of the prescribed Lorazepam.
F 0880: The facility failed to ensure proper infection control during wound and PEG tube care for Residents #14 and #30, including failure to perform hand hygiene, use barriers for soiled dressings, and change gloves appropriately.
Report Facts
Residents sampled for care plans: 19
Residents observed for medication administration: 6
Feeding pump infusion rate: 50
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Named in findings for failure to follow care plan and infection control during PEG tube and wound care | |
| Licensed Practical Nurse (LPN) #3 | Named in medication error observation for Resident #9 | |
| Director of Nursing (DON) | Provided statements on expectations for care plan adherence, medication administration, and infection control | |
| Infection Preventionist | Provided statements on infection control expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted following a complaint and incident investigation regarding a burn injury sustained by Resident #1 from a spilled coffee in the nursing home.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent an accidental coffee burn for Resident #1, resulting in a partial thickness burn requiring hospital treatment and surgery.
Report Facts
Burn size: 20
Burn size: 16
Coffee temperature limit: 140
Date of incident: Sep 3, 2024
Date of final report: Sep 6, 2024
Date of surgery: Sep 4, 2024
Date of discharge: Sep 5, 2024
BIMS score: 3
In-Service Training attendance: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Notified local vendor and implemented removal of commercial coffee maker and temperature monitoring |
| Director of Nurses | Director of Nurses | Assessed Resident #1's injury and confirmed hot liquids evaluations and staff training |
| Administrator | Administrator | Oversaw facility investigation, reviewed security footage, coordinated corrective actions and staff training |
| Registered Nurse #1 | Registered Nurse | Conducted initial Hot Liquids Evaluation for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 24, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to provide appropriate wound care and prevent infection for a resident with a pressure ulcer.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #2. The resident had open sacral wounds without dressings for nearly two hours, despite physician orders for daily dressing changes to prevent infection.
Report Facts
Residents affected: 1
Residents reviewed for wound care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Performed wound care for Resident #2 after 5:30 PM on 5/23/24 |
| Assistant Director of Nurses | Assistant Director of Nurses | Assigned to Resident #2 on 5/23/24 and delayed wound care during meal delivery |
| MD #1 | Medical Doctor | Provided medical opinion on importance of dressing changes to prevent infection |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care standards related to pressure ulcer treatment and urinary catheter care at Willow Creek Retirement Center.
Findings
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.
Deficiencies (2)
F 0686: The facility staff failed to perform hand hygiene properly and applied a calcium alginate dressing overlapping the wound margins for a resident with a Stage 2 pressure ulcer.
F 0690: The facility failed to keep the catheter drainage bag and tubing off the floor, increasing the risk of urinary tract infection for a resident with an indwelling urinary catheter.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Named in wound care and hand hygiene deficiency | |
| Director of Nurses (DON) | Confirmed facility policies on hand hygiene and catheter care | |
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding catheter drainage bag placement | |
| Medical Doctor (MD) #1 | Interviewed regarding catheter drainage bag infection risk |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to investigate complaints of abuse and neglect involving two residents at Willow Creek Retirement Center.
Complaint Details
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.
Findings
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.
Deficiencies (2)
F 0600: The facility failed to protect residents from abuse and neglect. CNA #1 yelled and used derogatory language toward Resident #1 during care, and CNA #2 neglected Resident #2 by not providing incontinence care or repositioning during a shift.
F 0656: The facility failed to develop and implement complete care plans meeting residents' needs. Care plans for Residents #1 and #2 were not followed, resulting in inadequate assistance with dressing, hygiene, incontinence care, and repositioning.
Report Facts
Residents reviewed for abuse and neglect: 4
Dates of incidents: Jun 16, 2023
Dates of incidents: Jun 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Named in verbal abuse finding toward Resident #1 | |
| Certified Nurse Aide (CNA) #2 | Named in neglect finding for Resident #2 | |
| Licensed Practical Nurse (LPN) #1 | Provided testimony regarding Resident #2 care | |
| Director of Nurses (DON) | Confirmed care plan implementation expectations and investigation findings |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, grievance handling, medication management, catheter care, and food safety at Willow Creek Retirement Center.
Findings
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.
Deficiencies (6)
F 0561: The facility failed to honor residents' right to self-determination by not allowing residents #15 and #24 to go back to bed during mealtimes despite their requests.
F 0565: The facility failed to document and act promptly to resolve grievances from Resident Council Meetings for six months, as complaints were not recorded or followed up.
F 0677: The facility failed to shave Resident #48 who required assistance with shaving, despite policy and observations confirming the need.
F 0690: The facility failed to provide appropriate catheter care for Resident #29 by keeping the nephrostomy bag at the head of the bed instead of below the kidneys, risking backflow and infection.
F 0758: The facility failed to discontinue PRN psychotropic medication (Lorazepam) for Resident #9 after 14 days as required, with continuous use for 10 months without reassessment or stop date.
F 0812: The facility failed to maintain a clean ice machine, with white, red, and black residue buildup observed inside and outside, risking contamination and resident illness.
Report Facts
PRN medication administrations: 7
PRN medication administrations: 20
PRN medication administrations: 16
PRN medication administrations: 10
PRN medication administrations: 4
PRN medication administrations: 3
PRN medication administrations: 2
PRN medication administrations: 2
PRN medication administrations: 4
PRN medication administrations: 10
PRN medication administrations: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed about mealtime bed policy and resident rights |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about mealtime bed policy and catheter care |
| Registered Nurse/Wound Care Nurse | Registered Nurse/Wound Care Nurse | Interviewed about mealtime bed policy and catheter care |
| Director of Nursing | Director of Nursing | Interviewed about mealtime bed policy, shaving care, catheter care, and psychotropic medication stop dates |
| Administrator | Administrator | Interviewed about mealtime bed policy, grievance process, psychotropic medication risks, and ice machine cleanliness |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about shaving care for Resident #48 |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Interviewed about catheter care for Resident #29 |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Interviewed about catheter care for Resident #29 |
| Certified Nurse Assistant #5 | Certified Nurse Assistant | Interviewed about shower schedule and shaving care |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed about psychotropic medication stop date requirements |
| Dietary Cook | Dietary Cook | Interviewed about ice machine cleanliness |
| Dietary Manager | Dietary Manager | Interviewed about ice machine cleaning responsibilities and observations |
| Assistant Activities Director | Assistant Activities Director | Interviewed about Resident Council Meetings and grievance documentation |
| Social Services Director | Social Services Director | Interviewed about grievance monitoring and Resident Council Meetings |
Inspection Report
Routine
Census: 85
Deficiencies: 7
Date: Oct 3, 2019
Visit Reason
Routine inspection of Willow Creek Retirement Center to assess compliance with regulatory requirements including PASARR screening, care plan implementation, accident prevention, RN staffing, and infection control.
Findings
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.
Deficiencies (7)
F0645 PASARR screening for Mental disorders or Intellectual Disabilities was inaccurately completed for Resident #78, who had diagnoses requiring Level II referral.
F0646 The facility failed to refer Resident #78 for a Level II review after a significant change in condition.
F0656 The facility failed to follow care plans for Resident #9's use of a full body lift and Resident #3's catheter care.
F0689 The facility failed to provide adequate supervision and assistance related to mechanical lifts, resulting in a fall with shoulder dislocation for Resident #9.
F0690 The facility failed to prevent possible infection spread during catheter care for Resident #3 due to improper technique.
F0727 The facility failed to provide a Registered Nurse Supervisor for eight of seventeen days despite a census of 85 residents.
F0880 The facility failed to implement proper infection prevention and control practices during wound, stoma, and catheter care for multiple residents, including improper hand hygiene and placement of biohazard bags on floors.
Report Facts
Residents present: 85
Days RN Supervisor not provided: 8
Residents reviewed for PASARR screening: 4
Residents reviewed for accidents: 4
Resident care plans reviewed: 23
Residents affected by deficiencies: 1
Residents affected by lift incident: 1
Residents affected by catheter care deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Worker #1 | Verified admission diagnosis and confirmed failure to refer Resident #78 for Level II review | |
| Registered Nurse (RN) #1 | Registered Nurse | Interviewed regarding Level II referral and care plan adherence |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Documented incident and assisted Resident #9 after fall |
| Certified Nurse Aide (CNA) #2 | Certified Nurse Aide | Used incorrect lift causing Resident #9 fall; terminated |
| Certified Nurse Aide (CNA) #3 | Certified Nurse Aide | Performed improper catheter care for Resident #3 |
| Director of Nursing | Director of Nursing | Provided statements on staffing and infection control issues |
| Administrator | Administrator | Interviewed about RN Supervisor staffing |
| Registered Nurse (RN) #2 | Infection Control Nurse | Confirmed infection control issues related to catheter care |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Observed performing wound and stoma care with infection control lapses |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Observed performing stoma care with infection control lapses |
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