Billdora Senior Care

In the surveyor’s words

From the most serious findings on record at Billdora Senior Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 29, 2026

  Based on observation, interview, record review and facility policy review, the facility failed to ensure adequate supervision was provided to prevent an elopement from the facility for one (1) of four (4) sampled residents reviewed. Resident #1The facility's failure to provide adequate supervision resulted in Resident #1 leaving the facility unnoticed and unsupervised on 1/20/26. This placed Resident #1 and all other residents who are at risk for wandering in a situation that is likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 1/20/26 when Resident #1 eloped from the facility. […]

• Immediate jeopardy, isolatedF689Mar 23, 2023

  Based on observations, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1, who had severe cognitive impairment, from exiting the facility through a window on 3/14/23 at approximately 8:00 PM. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised for approximately two (2) hours and 37 minutes, until facility staff located the resident approximately 500 hundred feet away from the facility at a local business. This concern was identified for one (1) of four (4) residents reviewed for wandering behavior and risk for elopement. The State Agency (SA) conducted a Complaint Investigation (CI) at the facility from 3/21/23 through 3/23/23. […]

• Actual harm, isolatedF697Apr 9, 2026

  Based on observation, interview, record review and facility policy review the facility failed to provide sufficient pain medication prior to wound care for a resident who moaned and yelled out during wound care for one (1) of two (2) wound care observations. Resident #1Findings Include:Policy review of facility's policy Pain Management dated 2025 revealed the facility should provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based on observation, interview, and record review, and facility policy review the facility failed to ensure staff followed proper hand hygiene and Enhanced Barrier Precautions (EBP) during wound care and peri care for one (1) of two (2) sampled residents reviewed for pressure ulcers. Resident #1. Findings Include:Record review of the facility policy Hand Hygiene Policy dated 2025 revealed, Policy: Staff involved direct contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors.Record review of the facility policy Enhanced Barrier Precautions undated, revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.4. […]

• No harm, potential for more than minimal, isolatedF576Mar 6, 2025

  Based on facility policy review, interviews, and record review, the facility failed to provide residents with mail on Saturdays for one (1) of (17) sampled residents, Resident #25. Findings included: A record review of the facility policy Communications Within and External to the Facility revised in August 2024, revealed, The facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility. The facility will ensure the resident has the ability to .receive mail, letters, packages, and other materials delivered to the facility . On 03/04/2025 at 10:10 AM, during a resident council meeting, members stated that residents in the facility does not receive mail on weekends. […]