01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-05 | 10 | 2026-03-05 | 1 |
| Cycle 2 | 2024-11-07 | 5 | 2024-11-07 | 0 |
| Cycle 3 | 2023-02-23 | 11 | 2023-02-23 | 1 |
CMS CCN 2553002026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willow Creek Retirement Center
49 Willow Creek Lane · Byram, MS 39272 · Hinds County
Certified beds88CMS provider file
Recent citation rows28current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
28 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-04 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2026-07-09 · complaint2026-06-04 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Deficient, Provider has date of correction · 2026-07-09 · complaint2026-03-05 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · HEALTHF0867Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-05 · FIREK0919Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-01-06 · HEALTHF0740Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2026-02-05 · complaint2024-11-07 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-12-042024-11-07 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-12-042024-11-07 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-12-042024-11-07 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-12-042024-09-12 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2024-09-05 · complaint2024-05-24 · HEALTHF0686Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-07-04 · complaint2024-03-13 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2024-03-13 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-04-15 · complaint2023-08-11 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2023-09-23 · complaint2023-08-11 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-09-23 · complaint2023-02-23 · FIREE0039Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-03-292023-02-23 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2023-03-292023-02-23 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2023-03-2903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-09-12 | Fine | $8,018 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PHILIPPE, LYNNIndividual · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/28/2008
- ROTOLO, DAVIDIndividual · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/28/2008
- ROTOLO, ROBERTIndividual · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 01/28/2008
- BRIAR HILL MANAGEMENT, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/03/2003
- BURLISON, SANDYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/25/2019
- BURNS, SHARONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/28/2008
- GREEN, DONNAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/04/2010
- KING, CURTISIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2016
- MUHA, ASHLEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/04/2010
- ROTOLO, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/28/2008
- ROTOLO, ROBERTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/28/2008
- WALTERS, JOHNNIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/12/2026
- WHITE, DEBORAHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/12/2014
- WHITLOW, CARRIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/05/2022
- BRIAR HILL MANAGEMENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2025
- OMNICARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2017
- WCR LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/28/2008
- BURLISON, SANDYIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/25/2019
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.05per resident day
RN hours0.55per resident day
Weekend nurse hours3.64per resident day
Staff turnover52.9%CMS reported field
06 / LOCAL RECORDS
Open the Byram ledger →