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Public Record

Willow Creek Retirement Center

Nursing HomeByram, MSCMS 255300
33 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
88

*CMS

Avg. residents per day
83.1

*CMS

Inspection record

On record from CMS

Citations on record
33

*CMS

Inspections on file
11

*CMS

Last inspection
2026-03-05

*CMS

Citations

33 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0919Generalpotential for harm

    Meet requirements for the use of electrical equipment.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0867Generalpotential for harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0761Generalpotential for harm

    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.

  • 0690Generalpotential for harm

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

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0584Generalpotential for harm

    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.

  • 0740Generalpotential for harm

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0693Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0689Seriousactual harm

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

  • 0686Generalpotential for harm

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

  • 0686Generalpotential for harm

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

  • 0690Generalpotential for harm

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

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0561Generalpotential for harm

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

  • 0565Generalpotential for harm

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

  • 0677Generalpotential for harm

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

  • 0690Generalpotential for harm

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

  • 0758Generalpotential for harm

    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.

  • 0812Generalpotential for harm

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

  • 0646Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0727Generalpotential for harm

    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.

  • 0690Generalpotential for harm

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

  • 0689Generalpotential for harm

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

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

Showing the 10 most recent inspections. 1 earlier inspection is also on record.

FAQ

Questions and answers

What is Willow Creek Retirement Center?
Willow Creek Retirement Center is a Medicare- and Medicaid-certified nursing home in Byram, MS, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 255300.
What is the CMS rating for Willow Creek Retirement Center?
Willow Creek Retirement Center has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Willow Creek Retirement Center have?
Willow Creek Retirement Center is certified for 88 beds. It serves an average of 83.1 residents per day.
How many citations does Willow Creek Retirement Center have?
Willow Creek Retirement Center has 33 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Willow Creek Retirement Center last inspected?
Willow Creek Retirement Center was last inspected on March 5, 2026. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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