Inspection Reports for
Sunshine Health Care
1677 Highway 9 North, Pontotoc, MS, 38863
Back to Facility Profile33 Reports
Inspection Report — Aug 6, 2026
Annual Inspection
Date: Aug 6, 2026
Visit Reason
On 08/06/26 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual recertification survey that was completed from 06/22/26-06/25/26.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending your facility be placed back in compliance effective 08/04/26.
Inspection Report — Jun 25, 2026
Annual Inspection
Date: Jun 25, 2026
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 6/22/26 through 6/25/26. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation and cited F584, F677, and F925.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to deficiencies in maintaining a clean and home-like environment, providing adequate personal hygiene and grooming care, and maintaining an effective pest control program.
Deficiencies (3)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to maintain a clean and home-like environment by allowing a bedside fan used by a resident to accumulate dust, posing a risk to the resident's environment.
F0677 - ADL care provided for dependent residents. The facility failed to provide necessary care to maintain personal hygiene and grooming, including physician-ordered nail care and daily clothing changes, for one resident whose fingernails were long with brown substance underneath and who wore the same clothing for multiple days.
F0925 - Maintains effective pest control program. The facility failed to maintain effective pest control in one resident's room where a continuous line of ants was observed, and the resident had ant bites on her arm.
Report Facts
Deficiencies cited: 3
Inspection Report — Jun 22, 2026
Life Safety
Date: Jun 22, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Apr 8, 2026
Complaint Investigation
Date: Apr 8, 2026
Visit Reason
The State Agency conducted a complaint investigation (CI MS #2969644) at the facility on 04/08/26.
Complaint Details
CI MS #2969644: The complaint investigation was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements with no deficiencies cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Sep 2, 2025
Annual Inspection
Date: Sep 2, 2025
Visit Reason
On 09/02/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 07/24/25. 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.
Findings
The SA is recommending that your facility be placed back in compliance effective 08/29/25.
Inspection Report — Jul 24, 2025
Annual Inspection
Date: Jul 24, 2025
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 7/21/25 through 7/24/25. During the survey, the SA determined that the facility was not in compliance with the requirements for participation in Medicare and Medicaid and cited F641 for failure to accurately code Minimum Data Set Assessments.
Findings
F0641 - The facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for serious mental illness and the use of anticoagulant medications for six of 32 sampled residents. The MDS Coordinator and Director of Nursing confirmed the inaccurate coding and the facility's failure to complete the assessments correctly.
Deficiencies (1)
F0641 - The facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for serious mental illness and anticoagulant medication use for six of 32 sampled residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 24, 2025
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 — Jul 23, 2025
Life Safety
Date: Jul 23, 2025
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Apr 16, 2024
Date: Apr 16, 2024
Visit Reason
On 04/16/24 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 03/06/24. 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.
Findings
The SA is recommending that the facility be placed back in compliance effective 04/09/24.
Inspection Report — Mar 6, 2024
Annual Inspection
Date: Mar 6, 2024
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 3/4/2024-3/6/2024. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
F0641 - The facility failed to accurately code the Minimum Data Set (MDS) discharge assessment for one resident, coding a discharge to an acute care hospital incorrectly when the resident was discharged home.
Deficiencies (1)
F0641 - The facility failed to accurately code the Minimum Data Set (MDS) discharge assessment for one resident, coding a discharge to an acute care hospital incorrectly when the resident was discharged home.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 6, 2024
Plan of Correction
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 — Mar 5, 2024
Life Safety
Date: Mar 5, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
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.
Inspection Report — Apr 17, 2023
Complaint Investigation
Date: Apr 17, 2023
Visit Reason
The State Agency conducted an on site complaint investigation, CI MS #21199, that alleged the cognitively impaired residents were not appropriately supervised during transport to outside appointments and that the facility was not providing the residents with the necessary services for transportation.
Complaint Details
CI MS #21199 alleged that cognitively impaired residents were not appropriately supervised during transport and that necessary transportation services were not provided. The complaint was substantiated as the facility was found in substantial compliance with no deficiencies cited.
Findings
The State Agency determined that the facility was in substantial compliance with the standards for participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 20, 2022
Follow-Up
Date: Dec 20, 2022
Visit Reason
On 12/20/22 the State Agency (SA) conducted a LSC revisit survey to verify the information that was provided to our agency related to the annual survey that was conducted on 11/03/22.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 Edition of the Life Safety Code. The SA is recommending that the facility be placed back in compliance effective 12/07/22.
Inspection Report — Dec 20, 2022
Life Safety
Date: Dec 20, 2022
Visit Reason
Survey conducted on 11/03/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Dec 12, 2022
Annual Inspection
Date: Dec 12, 2022
Visit Reason
On 12/12/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/3/22. 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.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 12/7/22. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 3, 2022
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 |
Inspection Report — Nov 3, 2022
Annual Inspection
Date: Nov 3, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey and complaint investigation, CI MS# 19491, at the facility from 11/1/22 through 11/3/22.
Complaint Details
CI MS# 19491 was substantiated, but no deficiencies were cited related to the complaint.
Findings
The facility was found not in compliance due to failure to post 'Oxygen In Use' signage for residents using oxygen therapy in two rooms. The complaint investigation was substantiated but no deficiencies were cited related to the complaint.
Deficiencies (1)
F0695 - The facility failed to post 'Oxygen In Use' signage for residents using oxygen therapy in the room shared by Resident #15 and Resident #25, despite both residents actively using oxygen.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 3, 2022
Life Safety
Date: Nov 3, 2022
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association.
Findings
K0223 - The facility failed to provide self-closing doors in exit passageways, stairway enclosures, smoke barriers, or hazardous area enclosures as required by NFPA 101 section 19.2.2.2.7. This deficiency affected all smoke compartments and all residents on the day of survey.
Deficiencies (1)
K0223 - Doors in exit passageways, stairway enclosures, smoke barriers, or hazardous area enclosures were not self-closing and kept closed as required, affecting all smoke compartments and residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 8, 2022
Routine
Date: Jun 8, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/7/22 through 6/8/22.
Findings
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.
Inspection Report — Jun 8, 2022
Routine
Date: Jun 8, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 6/7/22 through 6/8/22.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Oct 12, 2021
Routine
Date: Oct 12, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 10/12/2021.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid and no deficiencies were cited.
Inspection Report — Sep 15, 2021
Routine
Date: Sep 15, 2021
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 9/14/21 to 9/15/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Sep 15, 2021
Complaint Investigation
Date: Sep 15, 2021
Visit Reason
The State Agency conducted a complaint survey, MS #18040 from 9/14/21 to 9/15/21.
Complaint Details
Complaint MS #18040 alleged Client services not performed, Resident left wet for extended periods of time, Meds not given, Facility staffing and Resident not turned/repositioned; the complaint was not substantiated and no deficiencies were cited.
Findings
The State Agency did not substantiate the complaint MS #18040 for Client services not performed, Resident left wet for extended periods of time, Meds not given, Facility staffing and Resident not turned/repositioned with no citations.
Report Facts
Complaint count: 1
Inspection Report — Sep 15, 2021
Routine
Date: Sep 15, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) along with a complaint MS #18040 on 9/14/21 to 9/15/21.
Complaint Details
Complaint MS #18040 was investigated during the survey. The SA did not substantiate complaint MS #18041 regarding client services not performed, resident left wet for extended time, medications not given according to order, facility staffing, and resident not turned or repositioned, with no deficiencies cited.
Findings
The facility was found to be in compliance with infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. The complaint MS #18041 was not substantiated and no citations were related to the complaint.
Report Facts
Complaint count: 2
Inspection Report — May 25, 2021
Complaint Investigation
Date: May 25, 2021
Visit Reason
The State Agency conducted a complaint investigation for MS00017555 and MS00017669 at the facility on 05/24/21 through 05/25/21.
Complaint Details
Complaint investigation for MS00017555 and MS00017669 found the facility in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for the Minimum Standards for the Institutions for Aged or Infirmed.
Inspection Report — May 25, 2021
Complaint Investigation
Date: May 25, 2021
Visit Reason
The State Agency conducted complaint surveys investigating MS CI #17555 and MS CI #17669 at the facility from 5/24/2021 to 5/25/2021.
Complaint Details
Complaint investigations MS CI #17555 and MS CI #17669 were conducted and the facility was determined to be in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 2
Inspection Report — Dec 15, 2020
Routine
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/15/20. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — Dec 15, 2020
Routine
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 12/15/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 29, 2020
Routine
Date: Jun 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/29/20.
Findings
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.
Inspection Report — Dec 5, 2019
Annual Inspection
Date: Dec 5, 2019
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at facility from 12/03/19 to 12/05/19. During the survey, the SA determined that the facility was in compliance with Medicare and Medicaid regulations of participation.
Findings
The facility was found in compliance with Medicare and Medicaid regulations of participation during the annual recertification survey. No deficiencies were cited in the health or emergency preparedness surveys; however, a life safety deficiency was cited regarding corridor doors.
Deficiencies (1)
K0363 - Corridor doors protecting openings were damaged and unable to close to a positive latching position, failing to limit the passage of smoke in one of four smoke compartments affecting 14 of 58 residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 5, 2019
Annual Inspection
Date: Dec 5, 2019
Visit Reason
The State Agency (SA) determined during an annual recertification survey, conducted from 12/03/19 to 12/05/19.
Findings
The SA determined the facility was in compliance with the Mississippi Regulations for the Minimum Standards for the Institutions for Aged or Infirm.
Inspection Report — Oct 28, 2019
Complaint Investigation
Date: Oct 28, 2019
Visit Reason
The State Agency conducted a complaint survey investigating MS CI 00016135 on 10/28/19. Concerns identified in the complaint were related to the physical environment related to the facility being without air conditioning.
Complaint Details
Complaint MS CI 00016135 alleged issues with the physical environment related to lack of air conditioning. The complaint was not substantiated and no deficiencies were cited.
Findings
The concerns about the facility being without air conditioning were not substantiated, and no deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid requirements.
Report Facts
Complaint investigations: 1
3 CMS Surveys
CMS Survey — Nov 3, 2022
Nov 3, 2022
CMS Survey — Mar 6, 2024
Mar 6, 2024
CMS Survey — Jul 24, 2025
Jul 24, 2025
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