Inspection Reports for
Sunshine Health Care
1677 Highway 9 North, Pontotoc, MS, 38863
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Inspection Report — Jul 24, 2025
CMS
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to assess the accuracy of the Minimum Data Set (MDS) assessments for residents, specifically regarding coding for serious mental illness and anticoagulant medication use.
Findings
The facility failed to ensure accurate coding on the MDS assessments for six of 32 sampled residents. Specifically, anticoagulant medications were incorrectly coded for residents who were actually on antiplatelet medications, and a resident with serious mental illness was incorrectly coded as not having the condition.
Deficiencies (2)
F 0641: The facility failed to ensure that the MDS assessment was coded accurately for anticoagulant medication use for Residents #1, #3, #7, #21, and #33, who were on antiplatelet medications but coded as receiving anticoagulants.
F 0641: The facility failed to ensure that the MDS assessment was coded accurately for serious mental illness for Resident #10, who was incorrectly coded as not having a serious mental illness.
Report Facts
Sampled residents: 32
Residents with inaccurate MDS coding: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) MDS Coordinator | Interviewed and confirmed inaccurate coding of Plavix as anticoagulant | |
| Director of Nursing (DON) | Interviewed and confirmed expectation for accurate MDS coding and acknowledged facility failure |
Inspection Report — Mar 6, 2024
Plan of Correction CMS
Date: Mar 6, 2024
Visit Reason
The inspection was conducted to review the accuracy of the Minimum Data Set (MDS) assessments, specifically focusing on discharge coding accuracy for residents.
Findings
The facility failed to accurately code the MDS discharge assessment for one of 17 resident assessments reviewed. Resident #56 was incorrectly coded as discharged to an acute care hospital when she was discharged home.
Deficiencies (1)
F 0641: Ensure each resident receives an accurate assessment. The facility failed to accurately code the Minimum Data Set discharge assessment for Resident #56, incorrectly indicating discharge to an acute care hospital instead of home.
Report Facts
Resident assessments reviewed: 17
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident #56's discharge status | |
| MDS Licensed Practical Nurse | Interviewed and acknowledged coding error for Resident #56 | |
| MDS Coordinator | Interviewed and verified expectation for accurate MDS coding |
Inspection Report — Nov 3, 2022
CMS
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to assess compliance with respiratory care standards, specifically regarding the posting of Oxygen In Use signage for residents utilizing oxygen therapy.
Findings
The facility failed to post Oxygen In Use signage for two residents using oxygen therapy, which is a safety concern. Observations and interviews confirmed the absence of required signage on the room entrance shared by Resident #15 and Resident #25.
Deficiencies (1)
F 0695: The facility failed to post Oxygen In Use signage for residents using oxygen therapy in the room shared by Resident #15 and Resident #25. This signage absence poses a safety risk by not alerting visitors and staff to the presence of oxygen use.
Report Facts
Residents affected: 2
Oxygen flow rate: 2
Brief Interview for Mental Status (BIMS) score: 11
Brief Interview for Mental Status (BIMS) score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Confirmed absence of Oxygen In Use signage and stated it should have been posted | |
| Licensed Practical Nurse (LPN) #2 | Confirmed absence of Oxygen In Use signage and noted it would be a safety alert | |
| Director of Nursing (DON) #1 | Confirmed absence of Oxygen In Use signage and acknowledged its safety importance |
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