Inspection Reports for
Billdora Senior Care

The facility remained out of compliance due to deficiencies cited on the Health Annual Recertification survey conducted on 04/07/26. The Emergency Preparedness survey conducted on 04/07/26 found the facility met all applicable requirements with no deficiencies cited.

The State Agency found the facility to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and recommends the facility be placed back in compliance effective 5/12/26.

The facility was found not in compliance due to failure to provide adequate pain management prior to wound care and failure to follow proper infection prevention and control practices including hand hygiene and use of enhanced barrier precautions during wound and peri care.

The facility failed to ensure staff followed proper hand hygiene and Enhanced Barrier Precautions during wound care and peri care for one sampled resident, placing the resident at higher risk of infection.

One deficiency was cited related to the smoke barrier wall failing to provide the required half-hour fire resistance rating, with unsealed holes observed that compromised smoke containment.

CI MS #2722686 for Accidents/Elopement. The complaint was substantiated with Immediate Jeopardy and Substandard Quality of Care cited for failure to provide adequate supervision resulting in Resident #1 eloping from the facility. The Immediate Jeopardy was removed prior to the survey and the deficiency was determined to be past noncompliance.

The facility was found out of compliance due to failure to provide adequate supervision to prevent elopement of Resident #1, a newly admitted cognitively impaired resident, who exited the facility unsupervised on 1/20/26 and was found approximately 0.5 miles away. The Immediate Jeopardy was removed prior to the survey and the deficiency was determined to be past noncompliance.

Complaint Investigation CI MS #2722686 involved allegations of Accidents/Elopement. The facility was found to have Immediate Jeopardy and Substandard Quality of Care that was removed prior to the survey. The deficiency was substantiated as Past Noncompliance with citation of M640.

The facility failed to provide adequate supervision for Resident #1, resulting in the resident eloping unnoticed and unsupervised on 1/20/26. The facility identified Immediate Jeopardy and Substandard Quality of Care, which was removed prior to the survey, and the deficiency was determined to be Past Noncompliance.

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 04/06/25.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in residents' communication rights, grievance resolution, transfer/discharge notice, and respiratory care.

The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights and special needs care. Specifically, the facility failed to provide mail delivery on weekends and failed to promptly resolve a grievance regarding missing property, and also failed to ensure oxygen in use signage was placed on a resident's door.

The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 12/11/23.

The facility failed to keep garbage in water-tight suitable containers with tight fitting covers for three garbage receptacles. The city-provided garbage bins lacked lids or had ill-fitting lids, and the facility had no policy related to dumpsters.

The facility failed to collaborate with hospice services related to a resident's continuous plan of care for one of two hospice residents reviewed, specifically Resident #30. Hospice documentation was incomplete and not consistently communicated to facility staff, impacting coordination of care.

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

CI MS# 21045 investigated an elopement incident where Resident #1 exited the facility unsupervised through a window and was missing for approximately two hours and 37 minutes. The complaint was substantiated with deficiencies cited.

The facility failed to provide adequate supervision to prevent the elopement of Resident #1, who had severe cognitive impairment and exited through a window unnoticed. This placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. The facility implemented corrective actions including one-on-one monitoring, staff in-service training, securing windows, and updating care plans and risk assessments.

CI MS# 21045 related to an elopement. The complaint was substantiated with deficiencies cited.

The facility failed to provide adequate supervision to prevent Resident #1, who had severe cognitive impairment, from eloping through a window and being unsupervised for approximately two hours and 37 minutes. This placed Resident #1 and other residents at risk for serious injury or death.

Complaint number CI MS#19381 involved an allegation of elopement. The complaint was not substantiated and no deficiencies were cited.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The complaint for elopement was not substantiated and no deficiencies were cited.

Complaint number CI MS #19381 was investigated regarding elopement. The complaint was not substantiated and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements. The complaint for elopement was not substantiated and no deficiencies were cited.

The State Agency is recommending that the facility be placed back in compliance effective 04/29/22. No deficiencies were cited in this desk review.

The facility was found not in compliance with state licensure requirements, citing deficiencies related to residents' rights, specifically the failure to ensure residents had reasonable access to their personal funds seven days a week.

The facility was found not in compliance with Medicare and Medicaid Requirements, citing deficiencies in protection/management of personal funds, accuracy of assessments, and bowel/bladder incontinence care.

There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.

Complaint numbers MS #17575 and MS #17181 were investigated; the complaints were not substantiated and no deficiencies were cited.

The State Agency did not substantiate the complaint for injury of unknown origin and neglect related to medication. The facility was found in compliance with no deficiencies cited.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The survey identified deficiencies related to resident self-administration of medications, transfer/discharge notice requirements, PASARR screening, comprehensive care planning, meal/snack timing, and infection prevention and control. The facility failed to assess and care plan for self-administered eye drops, notify family and ombudsman timely for hospital transfers, complete PASARR Level II screening accurately, and maintain infection control practices during ice delivery.