Billdora Senior Care: Immediate Jeopardy Safety - MS
The resident, identified in inspection records only as Resident #1, left the building without staff authorization. A maintenance technician found the resident and brought them back. The inspection report does not say how long the resident was outside, where they were found, or what the weather was.
Federal inspectors classified the incident as immediate jeopardy, the most serious level of harm designation available under Medicare oversight, meaning the situation placed the resident at risk of serious injury or death.
The dietary aide was suspended the same day and then terminated.
The facility's own root cause analysis was blunt: the aide entered the door code and allowed the resident to walk out without following resident-identification protocols. Those protocols exist specifically to prevent staff from inadvertently helping a wandering resident escape. The aide did not follow them. The resident left.
Within two hours of the resident's return, the response at Billdora moved fast. A physician assessed Resident #1 at 11:58 a.m. and found no injury. A licensed practical nurse performed a full body audit. A registered nurse completed a pain assessment. By noon, the resident was placed on one-to-one monitoring, meaning a staff member assigned to that resident alone.
At 12:01 p.m., the same registered nurse reassessed Resident #1 for wandering and elopement risk and scored the resident as moderate risk. The care plan was updated fourteen minutes later.
Four other residents at the facility were also identified as being at continued risk for wandering and elopement during an audit of 43 residents conducted that afternoon by the director of nurses, the MDS coordinator, and the quality assurance nurse.
The administrator reported the incident to the Mississippi State Department of Health hotline at 1:00 p.m. and filed a report on the Attorney General Medicaid Fraud site. At 1:15 p.m., the dietary manager updated colored signage at the doors instructing staff to check with nursing before allowing anyone to exit.
An emergency quality assurance meeting convened the same afternoon with twelve staff members present, including the administrator, medical director, director of nursing, and activity director. The facility began retraining all staff on elopement and wandering policies starting January 20, the day of the incident, and finished the following day. Elopement drills were conducted on each shift. Staff were educated before beginning their shifts.
The monitoring plan the facility put in place was detailed. Beginning January 22, the staff development coordinator and director of nursing would test three staff members five days a week for two weeks on wandering and elopement safety, then taper down to monthly checks over three months. The social services director was assigned to check the elopement binder, which contains photographs and risk assessments for at-risk residents, five times a week. Alert bands on residents identified as elopement risks would be checked on the same schedule until a safe wandering system with electronic bracelets could be installed.
The facility told inspectors all corrective action was completed on January 20, the day of the incident.
State surveyors validated the corrective action plan on January 29 and determined that the immediate jeopardy had been removed on January 21, before surveyors arrived on January 28. The violation was classified as past noncompliance.
What the inspection record does not contain is any account of what Resident #1 experienced between the moment the door closed behind them and the moment the maintenance technician brought them back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Billdora Senior Care from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
BILLDORA SENIOR CARE in TYLERTOWN, MS was cited for immediate jeopardy violations during a health inspection on January 29, 2026.
The resident, identified in inspection records only as Resident #1, left the building without staff authorization.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.