Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Creek Retirement Center during CMS and state inspections, most recent first.
Infection prevention and control practices were not followed during resident care. A CNA performed incontinent care without hand hygiene before glove use or between glove changes, two CNAs provided catheter care to a resident requiring Enhanced Barrier Precautions without donning a gown, and an LPN used contaminated gloves from wound care to handle a dressing from the floor and touch the bed remote control. The DON confirmed the expected hand hygiene, gown use, and glove removal practices.
A resident with Alzheimer’s disease and severely impaired cognition had a bedside telephone that was present but not functioning, despite the wife’s repeated attempts over several months to get an incoming-call-only phone set up. The wife said she spoke with the SW, purchased the phone, and brought it to the facility, but the phone remained non-operational. The SW did not follow up to confirm it worked, the Maintenance Director was unaware it needed setup, and the DON acknowledged the facility failed to ensure the phone was operational.
A resident’s room air conditioning vent was observed to have visible dust and debris, and it remained dirty on a later observation. The resident’s wife said she had told an LPN about the issue about a month earlier and was told maintenance had been notified, but it was not addressed. The LPN said she spoke with maintenance staff but did not submit a maintenance request ticket, and the Maintenance Director confirmed no request had been logged.
A resident with an indwelling Foley catheter had a care plan intervention for Enhanced Barrier Precautions, but CNA staff provided catheter care without wearing a gown as required. One CNA said she forgot the gown, and another confirmed the intervention was not followed. The DON and care plan nurse stated staff are expected to follow the care plan during direct care.
Failure to secure a Foley catheter with a leg strap occurred for one resident during catheter care. CNA staff provided care, but the tubing was left unsecured even though the resident had an order for catheter care and a leg strap every shift. CNA #2 said she forgot to get a leg strap, and the DON stated all nursing staff were responsible for ensuring the strap was in place. The resident had retention of urine and severely impaired cognition.
Unsecured Medications Left at Resident Bedside: An LPN left a medication cup with six pills unattended at a resident’s bedside during a med pass, and the resident said she wanted to eat first. The resident later received the meds after the LPN returned. The DON stated nurses should not leave meds at the bedside, and the facility policy required drugs and biologicals to be stored securely and accessible only to authorized staff.
QAPI failed to sustain oversight after a prior F880 infection control citation, and the same issue recurred during the current survey. Surveyors observed failures in hand hygiene during incontinent care, failure to implement EBP during catheter care, and contamination of environmental surfaces during wound care. The DON stated hand hygiene had remained a recurring issue since the last survey and had not been monitored or tracked, and the Administrator said monthly QAPI meetings had not identified continued monitoring of hand hygiene since the prior POC.
The facility failed to provide adequate behavioral health services and supervision on a dementia unit, allowing a severely cognitively impaired, ambulatory resident with dementia and anxiety to repeatedly wander into other residents’ rooms, lie in their beds, remove their belongings, urinate in inappropriate locations, and display aggression toward staff and other residents. Multiple residents with dementia, severe cognitive impairment, hemiplegia, depression, and histories of falls were directly affected, including one who fell during an intrusion and others who became frightened or refused to enter their own rooms. Staff and leadership acknowledged that this resident required close monitoring and that staff were responsible for intervening when residents entered others’ rooms, yet intrusive and aggressive behaviors continued. The DON also acknowledged that certain individualized, non-pharmacologic interventions identified for this resident, such as ensuring access to personal entertainment devices and visual cues to help him identify his own room and bathroom, had not been implemented, contributing to ongoing violations of residents’ dignity, privacy, and psychosocial well-being.
An LPN in a long-term care facility failed to follow infection control protocols during wound care for a resident with a pressure ulcer and PEG tube site care for another resident with dysphagia. The LPN did not use barriers or change gloves during wound care and neglected hand hygiene during PEG tube care, risking cross-contamination.
A facility failed to implement a care plan for a resident with a PEG tube. The care plan required the head of the bed to remain elevated and the PEG site to be cleaned and dried. An LPN lowered the bed while feeding continued and did not dry the site before dressing. Interviews confirmed the care plan was not followed. The resident had severely impaired cognition and required PEG tube care.
A facility failed to follow physician orders for a resident with a PEG tube. An LPN lowered the bed while the feeding pump was infusing, against orders to keep the bed elevated. The LPN also did not dry the PEG site after cleaning, increasing infection risk. The resident had severe cognitive impairment and required specific care instructions.
A medication error occurred when an LPN prepared and intended to administer the wrong medication to a resident. The resident, with a history of anxiety, depression, and insomnia, was prescribed Lorazepam but was mistakenly given Alprazolam. The error was identified and corrected before administration. The DON expressed concern over the potential adverse outcomes of such errors.
A resident with severe cognitive impairment suffered a burn injury after spilling hot coffee on himself. The resident was initially assessed as capable of managing hot liquids independently, but the incident occurred when he placed the coffee cup on his stomach, causing it to spill. The facility failed to supervise the resident adequately and ensure the coffee was served at a safe temperature, leading to the burn injury.
A resident with a stage 2 pressure ulcer did not receive timely wound care, as observed when the resident was found with a wet incontinence brief and open sacral wounds without a bandage. The ADON delayed care due to meal delivery duties, leaving the resident without a dressing for over an hour, contrary to physician orders. Interviews confirmed the importance of following wound care protocols to prevent infection, which were not adhered to in this instance.
Infection Prevention and Control Failures During Resident Care
Penalty
Summary
The facility failed to follow infection prevention and control practices during resident care in three observed situations. The report states that during incontinent care for a resident admitted with chronic kidney disease and assessed as cognitively intact, a CNA donned gloves and began peri-care without performing hand hygiene first. During the same care, the CNA removed and replaced gloves multiple times but did not perform hand hygiene between glove changes while cleaning fecal material. The facility also failed to implement Enhanced Barrier Precautions during Foley catheter care for a resident admitted with urinary retention and assessed as severely cognitively impaired. During the observation, two CNAs provided catheter care after hand hygiene and glove use, but they did not don a gown while providing direct care to the resident who had an indwelling urinary catheter. The DON stated staff should wear gowns when providing direct care to residents who require Enhanced Barrier Precautions. In a third observation, an LPN performed wound care to a resident with dementia and a pressure ulcer on the left great toe. While wearing the same gloves used during wound care, the LPN picked up a dressing from the floor to discard and then used the same gloves to touch the bed remote control to lower the bed. The LPN confirmed touching the wound site, the floor, and the bed remote control with the same gloves and acknowledged she should have removed her gloves and performed hand hygiene before touching environmental surfaces.
Failure to Ensure a Working Bedside Phone
Penalty
Summary
The facility failed to ensure reasonable accommodation of a resident’s communication needs when a functioning bedside telephone was not provided for Resident #9. Resident #9 was admitted on 6/3/25 with diagnoses including Alzheimer’s Disease, and his MDS dated 12/17/25 showed a BIMS score of 3, indicating severely impaired cognition. During observation on 3/2/26, a telephone was present at the bedside but was not functioning, and the resident’s wife stated she had been trying for about three months to get an incoming-call-only phone set up because the resident had forgotten how to use his cell phone due to dementia. The wife reported she had spoken with the Social Worker, purchased the phone, and brought it to the facility, but the phone remained non-operational. Follow-up observations on 3/3/26 and 3/4/26 showed the phone was still in the room and not working. The Social Worker stated she told the wife to contact the phone company and did not follow up to confirm the phone was working or request a demonstration. The Maintenance Director stated he was not notified that the phone had been brought in, and the Administrator stated it was not the facility’s responsibility to follow up with the family regarding setup. The DON stated the facility should have followed up and acknowledged the phone was not operational for Resident #9.
Dirty Air Vent in Resident Room
Penalty
Summary
The facility failed to ensure Resident #9 had a safe, clean, comfortable, and homelike environment when the air conditioning vent in the resident’s room was visibly dirty with excessive dust and debris. Resident #9 was admitted on 6/3/25 with diagnoses including Alzheimer’s Disease, and the MDS dated 12/17/25 showed a BIMS score of 3, indicating severely impaired cognition. On 3/2/26, the air conditioning vent in Resident #9’s room was observed to contain visible dust and debris, and it remained visibly dirty during a later observation on 3/3/26. The resident’s wife stated she had told LPN #1 about the dusty vent about one month earlier when the resident moved into the room, and she was told maintenance had been notified and the vent would be cleaned, but it had not been addressed. LPN #1 stated she had spoken with maintenance staff about the vent but did not submit a maintenance request ticket. The Maintenance Director stated no maintenance request had been received or logged for the vent, and the DON stated nursing staff should document maintenance issues using a maintenance request form or the facility’s maintenance request process.
Failure to Follow Enhanced Barrier Precautions During Foley Catheter Care
Penalty
Summary
The facility failed to implement Resident #13’s comprehensive care plan intervention related to Enhanced Barrier Precautions. The resident’s care plan identified a focus that the resident had an indwelling Foley catheter and included Enhanced Barrier Precautions as an intervention. During an observation on 3/3/26 at 2:14 PM, CNA #1, assisted by CNA #2, provided Foley catheter care to Resident #13 without wearing a gown, despite the care plan requirement for Enhanced Barrier Precautions. During interviews on 3/4/26, CNA #2 confirmed she did not wear a gown during the catheter care and stated she forgot to put it on, noting that the purple dot by the resident’s name was a reminder to wear a gown when providing care. CNA #1 confirmed staff did not wear a gown and stated she was responsible for ensuring Enhanced Barrier Precaution supplies were stocked outside the resident’s room, acknowledging the care plan intervention requiring a gown was not followed. The DON stated staff should wear gowns when providing direct care to residents who require Enhanced Barrier Precautions and confirmed staff are expected to follow care plan interventions. RN #1, the care plan nurse, stated the care plan is intended to guide staff in providing resident care and should be followed when delivering care. Resident #13 was admitted on 2/10/21 with a diagnosis of retention of urine, and the quarterly MDS dated 2/2/26 showed a BIMS score of 6, indicating severely impaired cognition.
Failure to Secure Foley Catheter Tubing
Penalty
Summary
Failure to provide appropriate catheter care occurred for one resident with an indwelling Foley catheter when staff did not ensure the catheter tubing was secured with a leg strap. Facility policy stated that catheter tubing should be secured to the resident's leg or bed clothing to prevent pulling and irritation of the urinary meatus, and the resident's physician order required catheter care with soap and water every shift and a leg strap secured every shift. During an observation, CNA #1 and CNA #2 provided Foley catheter care to the resident, but the catheter tubing was not secured with a leg strap. CNA #2 later confirmed the resident did not have a leg strap in place and stated she forgot to obtain one. She also stated the purpose of the leg strap was to keep the Foley catheter from being pulled out and believed it was the nurse's responsibility to ensure the leg strap was in place. The DON stated the leg strap was used to keep the Foley catheter secured and maintain proper flow, and that all nursing staff were responsible for ensuring a leg strap was in place. The resident had diagnoses including retention of urine and a BIMS score of 6, indicating severely impaired cognition.
Unsecured Medications Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were stored securely when medications were left unattended at a resident’s bedside during a medication pass. During an observation, Resident #33 pointed to a medication cup sitting on the bedside table that contained six pills: three round pills, two pink pills, and one white oblong pill. The resident stated she did not know why she had to take so many medications. The facility policy reviewed stated medication supply must be accessible only to licensed nursing personnel or staff lawfully authorized to administer medications, and that all drugs, treatments, and biologicals must be stored securely. During the same observation, an LPN entered the room and stated that when she previously left the room, the resident had the pills in her hands. The resident stated she had told the nurse she wanted to eat first. The LPN then handed the medication cup to the resident, and the resident took the medications. The LPN later stated she should not have left the medications in the resident’s room and should have remained with the resident to ensure the medications were taken. The DON stated nurses should not leave medications at the bedside and that leaving medications unattended could allow another resident access to them. Resident #33 was admitted with diagnoses including essential hypertension and hyperlipidemia, had a BIMS score of 15, and had active orders for Ativan, losartan, aspirin, Mobic, cholecalciferol, and cyanocobalamin, all documented as administered during the 8:00 AM medication pass.
QAPI Failed to Sustain Infection Control Monitoring
Penalty
Summary
The facility's QAPI Committee failed to sustain corrective actions after a previously cited F880 infection control deficiency recurred on the current survey. The facility had been cited on 11/7/24 for failing to ensure proper infection control practices during PEG tube site care, and the current survey again identified failures in infection prevention and control, showing that the issue had not been effectively monitored or tracked after the prior citation. During the current recertification survey, surveyors observed the facility failing to follow infection prevention and control practices during resident care, including failing to perform hand hygiene during incontinent care for one resident, failing to implement Enhanced Barrier Precautions during catheter care for another resident, and contaminating environmental surfaces with soiled gloves during wound care for a third resident. The DON stated that lack of hand hygiene during patient care had been a recurring issue since the last survey and that the facility had not monitored the issue or implemented performance improvement plans since the prior plan of correction. The Administrator, who had been at the facility since January 2026, stated that monthly QAPI meetings were being held but did not recall identifying or addressing continued tracking or monitoring of hand hygiene during resident care since the prior plan of correction.
Failure to Provide Adequate Behavioral Health Services and Supervision on Dementia Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services by qualified staff to support dignity, privacy, safety, and psychosocial well-being for multiple residents on a dementia unit. Facility policy on dementia care required person-centered care, individualized non-pharmacological approaches, and services that maximize dignity, autonomy, privacy, socialization, independence, choice, and safety. Despite this, one resident with severe cognitive impairment, Pick’s disease, Alzheimer’s disease, anxiety, and a history of falls repeatedly wandered into other residents’ rooms, lay in their beds, removed their belongings, and displayed aggressive behaviors such as yelling, hitting, and growling at staff and residents. Progress notes and incident reports documented numerous episodes over several months, including entering rooms uninvited, sleeping in other residents’ beds, urinating in other residents’ rooms and in the hallway, attempting to take other residents’ food, and physically attacking another resident. The records show that several other residents with dementia or cognitive impairment were directly affected by these behaviors. One resident with severe cognitive impairment and a history of falls was involved in an incident in which another resident entered her room and got into her bed; another resident with severe cognitive impairment and hemiplegia fell during an intrusion by the same wandering resident, as reported in a progress note. A cognitively intact resident with dementia and depression experienced an incident in her room when the wandering resident exited her bathroom and moved toward her, resulting in physical contact between their hands. Another severely cognitively impaired resident with Alzheimer’s disease and a history of falls was also identified as having her room and bed entered by the same resident, including an episode where he got into her bed while she was out of the room. Interviews with staff, the administrator, the DON, the ADON, the SSD, a complainant, and a resident representative confirmed that wandering into other residents’ rooms was common on the dementia unit and that the specific resident’s behaviors were recurrent and known to the facility. Staff acknowledged that care instructions for this resident included supervision and monitoring for safe wandering, and leadership stated that residents with wandering behaviors required close monitoring and that staff were trained to intervene when a resident attempted to enter another resident’s room or invade their privacy. The complainant and the resident representative expressed concern about the adequacy of supervision, particularly during evening and night shifts, and described episodes where residents appeared frightened or refused to enter their own rooms due to the intruding resident’s presence. The DON further acknowledged that individualized, non-pharmacological interventions specific to this resident, such as ensuring access to personal entertainment devices and visual cues to help him identify his own room and bathroom, had not been incorporated, despite awareness of his repeated intrusive and aggressive behaviors toward other residents. Overall, the documented incidents, resident records, and interviews demonstrate that the facility did not effectively implement its dementia care policy or provide sufficient behavioral health services and supervision to prevent repeated intrusions, aggression, and privacy violations affecting multiple residents. The failure to consistently monitor and redirect the wandering resident, to prevent him from entering other residents’ rooms and using their belongings, and to implement identified individualized non-pharmacological interventions contributed to ongoing episodes that compromised the dignity, privacy, and psychosocial well-being of at least five residents on the dementia unit.
Infection Control Lapses During Wound and PEG Tube Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound care and PEG tube site care for two residents. For Resident #14, an LPN conducted a dressing change on the resident's right elbow without using a barrier for the soiled dressing, placing it directly on the bedside table, and did not dispose of it in a red biohazard bag. The LPN also failed to change her gloves after handling the soiled dressing before applying a new dressing. The resident had been admitted with diagnoses including dementia and a stage 3 pressure ulcer on the right elbow. For Resident #30, the same LPN provided PEG tube site care without performing hand hygiene upon entering the room or before donning gloves. She lowered the bed with bare hands, applied gloves, and proceeded with the care without changing gloves or performing hand hygiene at any stage. The resident had been admitted with diagnoses including dysphagia and required attention to a gastrostomy. Both the Infection Preventionist and the DON confirmed that the LPN's actions did not adhere to the facility's infection control protocols, which could lead to the spread of infection.
Failure to Implement PEG Tube Care Plan
Penalty
Summary
The facility failed to implement comprehensive care plan interventions during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The care plan for the resident, who was admitted with diagnoses including Dysphagia and required attention to a gastrostomy, specified that the head of the bed should remain elevated at all times and that the PEG site should be cleaned with normal saline and dried with gauze. However, during an observation, an LPN was noted to lower the head of the bed to a flat position while the feeding pump continued to infuse, and did not dry the PEG site before applying the split gauze dressing. Interviews with the LPN involved and the Director of Nursing confirmed that the care plan was not followed. The LPN acknowledged the failure to adhere to the care plan, and the Director of Nursing stated that staff are expected to follow the care plan when providing care. The resident involved had a severely impaired cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 99, and the Minimum Data Set (MDS) was coded for PEG tube usage.
Failure to Follow Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to adhere to physician orders regarding the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. During an observation, an LPN was seen lowering the head of the bed to a flat position while the resident's feeding pump was infusing Glucerna 1.2 at 50 cc per hour. The LPN did not place the feeding pump on hold before adjusting the bed, which was against the physician's order to keep the head of the bed elevated between 30-90 degrees during tube feeding. Additionally, the LPN cleaned the PEG site with gauze in a circular motion but failed to dry the site before applying a split gauze, contrary to the order to pat dry the site with gauze. The resident involved had been admitted to the facility with diagnoses including Dysphagia, Oropharyngeal Phase, and Encounter for Attention to Gastrostomy. The resident's Minimum Data Set (MDS) indicated severely impaired cognition. The Director of Nursing confirmed that the LPN should have stopped the pump to prevent the risk of aspiration and noted that not drying the site could increase the risk of infection. These actions and inactions led to the deficiency identified during the survey.
Medication Error Involving Incorrect Administration
Penalty
Summary
The facility failed to prevent a significant medication error for one of the residents observed for medication administration. During an observation, an LPN incorrectly prepared a medication for a resident by pulling Alprazolam 1 mg, 1.5 tablets, instead of the prescribed Lorazepam 0.5 mg. The error was identified when the LPN was questioned by the State Agency, and it was confirmed that the Alprazolam was not due at that time and was the incorrect medication for that administration. The LPN, along with another LPN, subsequently wasted the incorrect medication. The resident involved had been admitted to the facility with diagnoses including Anxiety Disorder, Depression, and Insomnia. The resident had active orders for Lorazepam to be given once daily for anxiety and Alprazolam to be given at bedtime. The Director of Nursing expressed concern over the error, emphasizing the importance of administering the correct medications as prescribed, particularly highlighting the potential adverse outcomes of administering incorrect medications, such as narcotics.
Resident Burned by Hot Coffee Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accidental coffee burn for a resident. The incident occurred when the resident, who was assessed as capable of managing hot liquids independently, was served coffee and subsequently spilled it on himself, resulting in a burn injury. The resident was observed drinking coffee without assistance, but later placed the cup on his stomach, causing it to fall and spill onto his left thigh. This incident was not observed by facility staff at the time it happened. The resident suffered a partial thickness burn on his left thigh, which required hospital treatment, including surgery for debridement and application of a skin substitute. The resident had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, and required supervision for eating. Despite this, the resident was assessed as able to manage hot liquids independently prior to the incident. The facility's investigation revealed that the coffee was served at a temperature that could cause burns, and the resident's ability to handle hot liquids was reassessed following the incident. The facility's failure to adequately supervise the resident and ensure the coffee was served at a safe temperature contributed to the occurrence of the burn injury.
Removal Plan
- The commercial coffee maker was removed from service.
- Non-commercial coffee makers were obtained to provide coffee for residents until a new machine could be delivered.
- The temperature of coffee was measured before being served to residents and cooled to one hundred forty (140) degrees Fahrenheit or below.
- The facility's Hot Liquids Policy was revised to prevent further injury.
- In-Service Training on hot liquid services and the proposed changes to the Hot Liquid Policy were provided to all dietary and nursing staff.
- Hot Liquid Evaluations were conducted for all residents with care plans updated as needed.
- A case conference with QAPI committee members was held to review and update the facility's Hot Liquids Policy.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide adequate wound care and services to promote healing and prevent infection for a resident with a stage 2 pressure ulcer on the sacral region. Observations revealed that the resident was lying on her back with a wet incontinence brief containing fecal matter, and two small open areas on her sacral area without a bandage. The Assistant Director of Nurses (ADON) admitted to not providing wound care to the resident, as she was occupied with meal deliveries. The resident remained without a dressing from 3:50 PM until after 5:30 PM, despite being incontinent of bowel and bladder, which increased the risk of infection. Interviews with the ADON, a Registered Nurse (RN), and a Medical Doctor (MD) confirmed the importance of following physician orders for wound care to prevent exposure to urine and fecal matter, which could lead to infection. The facility's policy on dressing changes emphasized promoting wound healing and preventing infection, yet the resident's care did not align with these guidelines. The facility administrator acknowledged the expectation for physician orders to be followed and stated there was no policy preventing care during meal times. The resident had been admitted with diagnoses including chronic kidney disease, venous insufficiency, and a stage 2 pressure ulcer, with specific orders for daily dressing changes that were not adhered to on the day in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Byram
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Health & Rehabilitation | 2.2 mi | ★★★★★ | 9 | 4 |
| Pleasant Hills Community Living Center | 4.5 mi | ★★★★★ | 2 | 1 |
| Chadwick Community Care Center | 4.9 mi | ★★★★★ | 11 | 0 |
| Methodist Sepcialty Care Center | 7.2 mi | ★★★★★ | 1 | 0 |
| Woodlands Rehabilitation And Healthcare Center | 7.7 mi | ★★★★★ | 12 | 0 |
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