Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Billdora Senior Care during CMS and state inspections, most recent first.
A resident with a stage 3 sacral pressure ulcer moaned, yelled out, and showed facial grimacing during wound care, but pain medication was not provided in a timely manner before treatment. Record review showed repeated pain scores over several months with no documented pain medication administration, and staff interviews confirmed the resident had ongoing pain during wound care and that stronger pain control was needed than acetaminophen alone.
Staff failed to follow hand hygiene and EBP during wound care and peri care for a resident with a stage 3 sacral pressure ulcer. An RN and the IP nurse were observed missing hand hygiene before glove use, leaving and re-entering the room while handling supplies, and performing peri care without a gown. The RN, IP nurse, and DON all confirmed the hand hygiene and gown use lapses during direct care.
A resident with severe cognitive impairment, dementia with psychosis, and a known history of wandering was admitted with orders for monitoring of wandering and elopement, and could ambulate independently. The next morning, the resident was last seen in the room and hallway by an LPN, then could not be found by a CNA when lunch was being served, prompting a missing resident code and search. Security footage and staff interviews showed that a dietary aide, who did not recognize the resident or verify with nursing, entered the numeric code on the front entrance keypad and allowed the resident to exit unaccompanied and unsupervised. The facility’s elopement policy required adequate supervision and use of door locks/alarms and systematic monitoring for at-risk residents, but the facility relied on staff-held door codes and did not have a two-part safe wandering system; the resident was later found by maintenance staff about half a mile away and returned without injury.
The facility failed to provide residents with mail on Saturdays, as one resident reported not receiving mail on weekends. The facility's policy requires residents to receive mail, but interviews revealed a lack of clarity and execution regarding weekend mail distribution. The Activities Director handles mail during weekdays, but there is no clear protocol for weekends, leading to mail being stored until Monday. Staff interviews indicated confusion and inconsistency in the process, with many unaware of any responsibility for weekend mail distribution.
A resident reported a missing Saints jersey, but the facility failed to resolve the grievance promptly. Social Services did not follow up on the status of the replacement, and the Nursing Home Administrator did not verify the correct size before ordering. The resident's representative confirmed the jersey was missing, and the facility's actions reflect a deficiency in addressing grievances effectively.
A facility failed to provide a written reason for a resident's hospital discharge to the resident and/or their representative. The resident, admitted with Acute Respiratory Failure and Congestive Heart Failure, was discharged to the hospital without the required reason in the transfer letter. The Social Service Director and Administrator were unaware of the requirement, with the latter mistakenly believing it would violate HIPAA.
A facility did not place an 'Oxygen in Use' sign on the door of a resident receiving oxygen therapy, as required by policy. This was confirmed by an LPN and the DON, who stated the sign should have been posted upon the resident's admission to alert staff and visitors. The resident had diagnoses of dysphagia and shortness of breath and was unable to complete a mental status interview.
Failure to Provide Pain Medication Before Wound Care
Penalty
Summary
The facility failed to provide sufficient pain medication prior to wound care for a resident with a stage 3 sacral pressure ulcer. During wound care, the resident moaned, yelled out, and displayed facial grimacing throughout the procedure while the RN cleaned the wound. The resident had been given acetaminophen about 10 minutes before wound care began, and the record showed no pain medication had been ordered prior to that date despite repeated documentation of pain over several months. The resident was admitted with a stage 3 sacral pressure ulcer and had wound care orders for daily cleansing, collagen, calcium alginate, betadine to the peri-wound skin, and a silicone border dressing. The record review showed multiple pain assessments and vital sign summaries documenting pain levels ranging from 3 to 6 on several dates, with no documentation that pain medication was administered for those episodes. The EMAR from admission through the day before the observation showed no pain medications given, and the resident’s MDS indicated pain medication was not received. During interviews, the RN stated the resident always moaned and hollered during wound care and acknowledged she had not obtained an order for pain medication during the prior months. The LPN, IP nurse, CNA, DON, and physician all confirmed the resident showed signs of pain during wound care and that pain medication should have been provided before treatment. The physician stated the wound was painful and worsening and that the resident required more medication than acetaminophen, and later changed the pain medication so the resident would not be in pain during wound care.
Failure to Follow Hand Hygiene and EBP During Wound and Peri Care
Penalty
Summary
The facility failed to ensure staff followed proper hand hygiene and Enhanced Barrier Precautions (EBP) during wound care and peri care for one resident with a stage 3 pressure ulcer of the sacral region. During an observed wound care treatment, RN #2 donned a gown but did not don gloves before touching the feeding pump and did not perform hand hygiene before applying gloves. RN #1 also removed gloves, left the room to retrieve supplies, returned and donned gloves without performing hand hygiene, and later forgot to bring hand sanitizer into the room. After removing gloves again, RN #1 went to the cart for hand sanitizer, then continued wound care after handling saline and gauze in a manner corrected by RN #2. RN #1 did not sanitize hands after removing gloves before returning to the room to continue care. After wound care, RN #1 removed the gown and gloves and left the room to gather peri care supplies, then returned and began peri care to the buttocks area without putting on a gown. In interview, RN #1 confirmed she had to leave the room several times because she did not have all supplies needed, acknowledged she did not have a gown during peri care, and stated she should have had one on. RN #2 confirmed she did not realize RN #1 had not washed her hands a couple of times and stated the resident had a higher risk of infection from RN #1 not wearing a gown during peri care. The DON confirmed RN #2 should have washed her hands before applying gloves and that RN #1 should have worn a gown for EBP during direct care, including peri care.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision at Secured Exit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who was newly admitted with dementia, delusional disorder, hallucinations, and a documented history of wandering. The resident’s admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and identified a history of wandering, while functional assessment documented that the resident could ambulate independently for 150 feet. The admission history and physical from the community setting described dementia with agitation and psychosis, aggressive behaviors and irritability related to attempts to cross the street, and agitation when unable to perform desired activities such as going across the road. The physician had previously discussed safety issues with the family and recommended additional door locks at home to prevent wandering and leaving the house. Upon admission, the facility had a physician order to monitor wandering and elopement for 14 days and an active order to monitor behavior each shift for anxiety, restlessness, and pacing. On the morning following admission, the resident was observed by an LPN at approximately 10:35–10:40 a.m. sitting on the side of the bed and had been seen walking in the hallway and to the nurse’s station earlier in the day. Around 11:30–11:40 a.m., when staff were preparing lunch, a CNA was unable to locate the resident in the room, dining room, or therapy area and notified nursing staff that the resident might be missing. A brief search inside the facility was conducted before the DON was notified and a missing resident code was called overhead. Staff then initiated a broader search of the building and surrounding outside areas after learning the identity of the missing resident. The Administrator later reviewed security camera footage and determined that a dietary aide had assisted the resident with the front entrance door. The dietary aide reported that she had seen the resident at the front door, did not know who he was, and entered the numeric code into the keypad to disengage the lock, allowing the resident to exit the building unaccompanied and unsupervised. The facility’s elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision, that interventions were to be added to the care plan and communicated to staff, and that door locks/alarms and a systematic approach to monitoring and managing residents at risk were to be used. At the time of the incident, the facility relied on staff-held numeric codes for exit doors and did not have a two-part safe wandering system with resident-worn monitors and corresponding door monitors. The resident was ultimately located by the maintenance technician approximately 0.5 miles from the facility, sitting on the steps of a local business, and was returned to the facility. Interviews with staff confirmed the sequence of events and the lack of recognition of the resident’s identity and risk status at the exit door. The Administrator confirmed that the dietary aide had not checked with nursing staff before entering the door code and allowing the resident to leave. The maintenance technician stated that, regardless of the route taken, the resident would have had to cross two of the busiest streets in town to reach the location where he was found. At the time he was located, the resident’s clothing and shoes were clean and dry, and staff assessments upon return noted no injuries or pain. The facility’s failure to ensure that a resident with known severe cognitive impairment and a history of wandering was adequately supervised, and to prevent an untrained staff member from facilitating his exit through a secured door, resulted in the resident leaving the facility unnoticed and unsupervised.
Removal Plan
- Initiated Code [NAME] (missing resident) and began facility-wide search when Resident #1 could not be located.
- Notified the Administrator immediately via Code [NAME].
- Notified the physician.
- Notified the resident representative.
- Completed a head count to ensure all other residents were accounted for.
- Expanded the search throughout the facility.
- Expanded the search outside the facility and assigned maintenance staff to search by vehicle.
- Located Resident #1 off-site and returned the resident safely to the facility.
- Physician assessed and evaluated Resident #1 upon return; no injury noted.
- LPN performed a full body audit upon return; no injury noted.
- RN performed a pain assessment upon return; no pain verbalized.
- Placed Resident #1 on one-on-one (1:1) monitoring upon return.
- Reassessed Resident #1 for wander and elopement risk (moderate risk).
- Updated Resident #1 care plan to include one-on-one (1:1) monitoring.
- Verified all doors were functioning properly.
- Audited residents to identify risk for wandering and elopement and identified additional residents at risk who continued to be monitored.
- Reported the event to the Mississippi State Department of Health Hotline.
- Reported the event on the Attorney General Medicaid Fraud Site.
- Reviewed the Wander and Elopement Binder to ensure updated risk assessments and current photos for residents at risk.
- Updated colored signage instructing staff to check with nursing before allowing anyone out the door.
- Suspended the Dietary Aide pending investigation and terminated employment.
- Held an emergency QAPI meeting.
- Completed facility-wide education/in-services on the Elopement and Wandering Residents Policy, Code [NAME] Policy, identifying residents at risk for elopement, and resident identification protocols.
- Conducted elopement drills on each shift.
- Implemented ongoing monitoring of staff competency/knowledge regarding wandering risk and safety awareness using scheduled knowledge testing.
- Implemented monitoring of the Elopement Binder to ensure each at-risk resident has a current photograph and up-to-date risk assessment.
- Implemented monitoring of residents at risk for wandering/elopement to ensure alert band placement, with planned replacement by safe wandering system bracelet placement upon installation.
Failure to Distribute Mail on Weekends
Penalty
Summary
The facility failed to provide residents with mail on Saturdays, as evidenced by the experience of one resident, who reported not receiving mail on weekends. The facility's policy, revised in August 2024, mandates that residents have the right to receive mail, but interviews with staff and residents revealed a lack of clarity and execution regarding mail distribution on weekends. The Activities Director is responsible for distributing mail during weekdays, but there is no clear protocol for weekend mail distribution, leading to mail being stored until Monday. Interviews with various staff members, including the Administrator, front desk receptionist, LPN, CNA, Social Services Director, and RN, indicated confusion and inconsistency in the process of mail distribution on weekends. The Administrator believed that mail was distributed by nurses or CNAs on weekends, but staff interviews contradicted this, with many stating they were unaware of any such responsibility. The Director of Nursing assumed social services or activities staff handled weekend mail, but this was not confirmed by the staff involved. The resident in question, who is cognitively intact, confirmed that mail received on weekends is not delivered until the following Monday.
Failure to Resolve Grievance for Missing Property
Penalty
Summary
The facility failed to promptly resolve a grievance related to a resident's missing property, specifically a Saints jersey, for one of the sampled residents. The resident reported the missing jersey to Social Services (SS) late in 2024, during football season. SS initially informed the resident that a replacement jersey would be ordered, but later stated in January 2025 that it needed to be reordered. Despite these assurances, SS did not follow up with the resident regarding the status of the jersey. Additionally, there was no record of the grievance in the grievance book, indicating a lack of proper documentation and follow-up. The Nursing Home Administrator (NHA) was informed of the issue by SS but had not contacted the resident's family to verify ownership of the jersey or the correct size before attempting to order a replacement. The resident's representative confirmed the jersey was missing and that a 2XL jersey, which the NHA planned to order, would not fit the resident. The resident's inventory sheet from November 2024 documented the presence of the jersey, and the resident was cognitively intact with a BIMS score of 15. The facility's failure to resolve the grievance promptly and accurately reflects a deficiency in safeguarding the resident's property and addressing grievances effectively.
Failure to Provide Reason for Hospital Discharge
Penalty
Summary
The facility failed to provide written notification of the reason for a resident's hospital discharge to the resident and/or Resident Representative (RR). This deficiency was identified for a resident who was admitted with diagnoses including Acute Respiratory Failure with Hypoxia and Acute Systolic Congestive Heart Failure. The resident was discharged to the hospital, but the transfer/discharge letter did not include the reason for the transfer. The Social Service Director, responsible for mailing these letters, was unaware of the requirement to include the reason for the transfer/discharge. The Administrator also expressed a lack of awareness regarding the regulation, mistakenly believing that including such information would violate HIPAA.
Failure to Display Oxygen in Use Sign for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding oxygen therapy for a resident requiring such care. During a survey observation, it was noted that a resident receiving oxygen therapy at a flow rate of 3 milliliters per hour did not have an 'Oxygen in Use' sign on the door of their room. This omission was confirmed by both an LPN and the Director of Nursing, who acknowledged that the signage should have been placed upon the resident's admission to alert staff and visitors to the presence of oxygen and prevent fire hazards. The resident, who was admitted with diagnoses including dysphagia and shortness of breath, was unable to complete a mental status interview as indicated by their Minimum Data Set assessment.
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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 Tylertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Tylertown | 0.9 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Living Center | 17.8 mi | ★★★★★ | 5 | 0 |
| Fair City Health And Rehab | 19.3 mi | ★★★★★ | 5 | 0 |
| Courtyard Health And Rehabilitation | 19.6 mi | ★★★★★ | 3 | 3 |
| Columbia Rehabilitation And Healthcare Center | 20.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.