Willow Creek Retirement Center is an average performer in CMS ratings, earning a C grade with a score of 56/100. Located in Byram, Mississippi, the facility meets baseline standards across most quality metrics.
Staffing at Willow Creek Retirement Center is near the national average, with 3.92 total nursing hours per resident per day (national average: 3.8 hours).
Recent inspections identified 24 deficiencies at Willow Creek Retirement Center. While none were classified as the most serious level, families should review the detailed inspection history below.
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.92 | 3.8 | Average |
| Registered Nurses (RN) | 0.52 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 1.22 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 2.17 | 2.4 | Average |
| Weekend Total Nursing | 3.61 | 3.8 | Average |
| Weekend RN Hours | 0.31 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0740 Severity EEnsure each resident must receive and the facility must provide necessary behavioral health care and services.Jan 5, 2026 · Quality of Life and Care Deficiencies
- Tag 0880 Severity EProvide and implement an infection prevention and control program.Nov 6, 2024 · Infection Control Deficiencies
- Tag 0656 Severity DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Nov 6, 2024 · Resident Assessment and Care Planning Deficiencies
- Tag 0693 Severity DEnsure 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 fNov 6, 2024 · Quality of Life and Care Deficiencies
- Tag 0760 Severity DEnsure that residents are free from significant medication errors.Nov 6, 2024 · Pharmacy Service Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 9.3% | 4.5% | Worse |
| Falls with major injury | 3.9% | 3.0% | Worse |
| On antipsychotic medication | 33.8% | 14.5% | Worse |
| Urinary tract infections | 0.7% | 2.5% | Better |
| ADL decline (daily activities) | 30.5% | 14.0% | Worse |
| Excessive weight loss | 9.5% | 7.5% | Worse |
| New/worsened incontinence | 33.5% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $8,018
How This Grade Was Calculated
This facility's grade of C is based on a score of 56 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 3★ → 24 pts (max 40)
- Health Inspection Rating: 3★ → 15 pts (max 25)
- Staffing Rating: 4★ → 16 pts (max 20)
- Quality Measures Rating: 2★ → 6 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -0 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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