Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Sunshine Children's Home And Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was involved in an abuse incident during showering when a CNA reflexively smacked the resident's leg after being kicked. The RN present reported the incident immediately. The resident was unharmed, but the action violated the facility's abuse prevention policy. Staffing shortages and lack of specific instructions for the CNA were contributing factors.
Two residents in a LTC facility suffered femur fractures due to CNAs providing care alone, contrary to care plans requiring two-person assistance for all activities of daily living. The CNAs did not check the Kardex, leading to significant injuries. Both residents were completely dependent and unable to communicate their needs.
A facility failed to report a suspected abuse incident to local law enforcement within the required timeframe. A CNA reflexively smacked a resident's leg during a shower after being kicked. The incident was reported to the State Agency but not to local law enforcement, as required by policy. The resident, severely impaired in decision-making, showed no injuries. The CNA was removed and terminated, but the facility did not contact local authorities, believing the incident was not a crime.
Resident Abuse Incident During Showering
Penalty
Summary
The facility failed to ensure that a resident was free from abuse during a showering incident. A Certified Nurse Assistant (CNA) and a Registered Nurse (RN) were assisting the resident in the shower room when the resident kicked towards the CNA. In response, the CNA reflexively smacked the resident's upper right leg with an open hand to push the leg away. The RN was startled by this action and immediately reported the incident to the supervisor. The facility's policy on abuse prohibition emphasizes protecting residents from abuse, neglect, and mistreatment, but this incident indicates a lapse in adherence to that policy. The resident involved in the incident was admitted with severe cognitive impairment, affecting their ability to make decisions regarding daily living tasks. Prior to the incident, the resident was assessed as being comfortable with stable vitals and no signs of distress or injury. Following the incident, a thorough examination revealed no physical injuries or changes in the resident's condition, indicating that the action did not result in physical harm. However, the incident itself constituted a breach of the facility's abuse prevention policy. Interviews conducted during the investigation revealed that the CNA involved was not typically assigned to the resident and was covering due to staffing shortages. The CNA described the action as a reflexive response to being kicked, with no intention to harm. The Director of Nursing acknowledged the reflexive nature of the CNA's response but emphasized the importance of adhering to training and protocols to prevent such incidents. The facility's internal investigation documented the incident and led to the suspension and eventual termination of the CNA involved.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 1) CNA #1 was immediately removed from the unit, interviewed, and investigative statements obtained, followed by immediate suspension pending completion of the investigation. Resident was promptly assessed by the Nurse supervisor and noted to have no redness or marks to his body including upper right leg. No sign of discomfort, upset, or change from baseline status was seen. A comprehensive investigation was initiated that included review of policy and procedure, interview of staff, review of surveillance footage, and medical record. It was confirmed that CNA #1 had participated in multiple trainings on Abuse since date of hire 8/5/24. CNA #1 was initially trained in the abuse prohibition policy on date of hire 8/5/2024 as well as Care of Cognitively Impaired Residents on 8/12/2024 and Response to Abuse of Residents on 8/24/2024. In addition, CNA #1 completed follow-up training on Abuse, Neglect, and Mistreatment on 9/20/2024. Since that time, she received and reviewed monthly newsletters that contained ongoing education on various aspects of the Abuse Prohibition Policy. On investigation, CNA #1 was tearful and remorseful. She indicated over and over, “I would never hurt him, I thought I was going to be kicked and I just reflexively reached out to prevent it.” Resident is noted to have unpredictable non-purposeful movements especially during bathing. His plan of care was updated to include strategies during shower and ADL care as well as behavioral strategies to address these movements and to support the resident during ADL care. CNA #1 was terminated upon completion of the investigation. Residents’ parents were notified; investigative findings as well as corrective actions were reviewed. The parents were satisfied and appreciative of the update. 2) To protect residents at risk, the facility will continue to monitor, through daily morning report review, behavior health rounds, care plan meetings, and occurrence report reviews, for any changes in condition, changes in behavior, or injuries of unknown origin. All identified changes will be subject to the investigative process. In addition, quarterly Psychosocial assessments have been updated to include an enhanced list of risk factors and interventions that will guide comprehensive care planning, referrals to the Behavioral Health team, and indicated staff training. An initial review of all 122 residents was conducted by the interdisciplinary team which identified a total of 8 residents with similar behaviors during care. ADL care plans were updated with new interventions and behavioral care plans updated and in 4 cases, initiated. 3) To reduce the risk of further occurrences, all staff including but not limited to direct care staff and ancillary staff will be re-inserviced. Education will focus on all aspects of the Abuse Prohibition Policy as well as managing residents with aggressive/active and non-purposeful movements. Education will include didactic presentations, online learning exercises, competency-based training, staff meetings, and/or monthly newsletters. 4) The Director of Nursing will monitor ongoing compliance rates of all departments to the successful completion of quarterly educational efforts related to abuse prevention. Compliance rates will be monitored using an audit tool that will calculate compliance rates for quarterly training. The Director of Nursing will conduct the audits and report in writing, at least quarterly, to the Administrator and Quality Committee, the findings and any corrective actions for a period of not less than 18 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 1/21/2025 by the Director of Nursing.
Failure to Follow Care Plans Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that two residents received care in accordance with their comprehensive person-centered care plans, which required two staff members to assist with all activities of daily living. In the first instance, a Certified Nurse Assistant (CNA) provided care to a resident singlehandedly, despite the care plan indicating a need for two-person assistance. This resident, who was completely dependent on others for all activities of daily living and unable to communicate needs, suffered a left mid diaphysis femur fracture after being changed by the CNA without assistance. The CNA did not check the Kardex prior to providing care and was unaware that the resident required two-person assistance for all activities, not just transfers and showers. In the second instance, another CNA changed a different resident's diaper alone, even though the care plan and Kardex specified a two-person assist. This resident was also severely cognitively impaired and completely dependent on others for all activities of daily living. The CNA stated that they often changed the resident alone due to the nurse being busy and did not check the Kardex. The resident later exhibited a swollen leg and a noticeable change in leg alignment, leading to a diagnosis of a right comminuted mid shaft femur fracture. Both incidents highlight a failure to adhere to the facility's Safe Resident Handling policy, which mandates that the number of staff needed for care is indicated in the care plan and Kardex. The CNAs involved did not verify the care requirements before providing care, resulting in significant injuries to the residents. The facility's internal investigations confirmed these lapses in following the care plans, which contributed to the residents' injuries.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate actions for investigation regarding resident #2 included resident assessment by Nurse Practitioner, statement collection from indicated staff, review of medical record, review of Central Monitor pulse oximetry-heart rate data and review of video surveillance. Corrective actions included review of all policies and procedures pertaining to safe positioning and handling, ADL care as well as Osteopenia. Re-evaluation of resident’s care plans by Rehabilitation Services including transfer and ADL care. Comprehensive Plan of Care reviewed and updated on return form ACF and reviewed with caregivers. Review found that resident was identified, and care planned for- at risk for fracture related to immobility and complexity of [DIAGNOSES REDACTED]. #6 was suspended from duty pending investigation with subsequent disciplinary action and remediation for non-compliance with 2-person assist. The resident’s mother was notified and further updated by DNS and Administrator regarding the occurrence, investigative conclusions and updates to plan of care. Immediate corrective actions for investigation regarding resident #3 addressed both non-compliance with 2 person assist, as well as safe positioning for urinary catheterization for contracted residents. Immediate remediation with disciplinary action for CNA #7. Rounds on all units to confirm placement of picture signage with the emoji (not words) of a hand holding up 2 fingers indicating 2-person assist. This emoji is referred to as “I Take 2.” Mandatory acknowledgement for Nursing staff in employee portal of ‘Safe Handling Advisory.’ Corrective action include- Review of all policies and procedures pertaining to safe positioning and handling as well as Osteopenia. Review and updates to Policy and Procedure for Urinary Catheters with additional requirement of alternate positioning needs for procedure to be specified in the plan of care and require a medical order. Re-evaluation of resident by Rehabilitation Services on return from ACF for review of Plan of Care, including positioning for catheterization, transfer and ADL care. Inservices were conducted with nursing staff on these updates to resident #3 plan of care. Parents were notified and updated by DNS and Administrator, they verbalized understanding of resident [MEDICAL CONDITION] diagnosis, active treatment with infusion therapy already in place and continued risk for fracture. They expressed appreciation for the detailed report including updates to ADL care and catheterization. 2) As a corrective action following investigation for resident #2, the policy and procedure for ADL care was revised. As an added safety intervention, ALL residents greater than 35lbs and fully dependent in ADL performance will be two-person assist for all ADL care that requires moving. Review of all 122 residents indicates that 81 residents require 2-person assist. Revision of CNA assignments on all shifts to identify teams for ADL care to facilitate consistent compliance with 2-person assist. Mandatory training with competency assessment for all Nurses and CNAs to include updates to policy and implementation of team assignments. All residents admitted to Sunshine are care planned on admission for risk for Osteopenia and fracture due to the complex medical diagnoses, decreased mobility and non-ambulatory status. Mandatory review inservice was conducted including competency with all Nursing Staff on Osteopenia and Risk for Fracture and Safe Positioning and Handling. Training included use/navigation of resident Kardex to identify resident needs, working together CNA with CNA or NURSE-CNA to ensure safety. In addition, in order to identify others at risk, related to this occurrence for resident #3, a re-evaluation of all Sunshine residents requiring intermittent catheterization was conducted with the Rehab team for need for alternate positioning needs for this procedure. 3) Two-person assist compliance audits were initiated and completed by Nurse Managers and off shift Supervisors. Audits will be continued monthly on all shifts, for a period of 12 months. 4) Monthly audit results and chart reviews will be reported in writing, at least quarterly, to the Administrator and Quality Committee, their findings and corrective actions for a period of not less than 12 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 10/20/2024 by the Director of Nursing.
Failure to Report Suspected Abuse to Local Law Enforcement
Penalty
Summary
The facility failed to report an incident of suspected staff-to-resident abuse to local law enforcement within the required timeframe. During a shower, a Certified Nurse Assistant (CNA) reflexively smacked a resident's upper right leg with an open hand after the resident kicked towards the CNA. Although the incident was reported to the State Agency within the required two-hour window, it was not reported to local law enforcement. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, to both the State Agency and local law enforcement if the events involve abuse or result in serious bodily injury. The resident involved was severely impaired in decision-making regarding daily living tasks. Following the incident, the resident was assessed and found to have no injuries or changes in condition. The CNA involved was removed from the unit and later terminated. The Director of Nursing and the Administrator did not report the incident to local law enforcement, believing it was not a crime due to the lack of injury and the reflexive nature of the CNA's action. The Attorney General's office later communicated with the facility, but the local police were not contacted as required by the facility's policy.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 1) The Director of Nursing spoke with the NYS Attorney General’s Office and reviewed investigative findings and submitted requested information. Policy and Procedure on reporting to local authorities updated. 2) The Administrator spoke with the Lieutenant of the New Castle Police Department to review and confirm requirements of notification for any suspected abuse incidents. All resident occurrences were reviewed and confirmed that appropriate action was taken in all cases involving abuse. 3) To reduce risk of reoccurrence, the administrator or designee will immediately report any suspected cases of abuse to the appropriate State agency and law enforcement. Inservice training on abuse reporting requirements will be conducted for all staff at a minimum of no less than quarterly. 4) The Director of Nursing will monitor ongoing compliance by reviewing and signing off on all resident occurrences to ensure compliance with reporting requirements. Compliance rates for reporting of abuse and notification to local law enforcement will be monitored and will be reported in writing, by the Director of Nursing at least quarterly, to the Administrator and Quality Committee, their findings and corrective actions for a period of not less than 18 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 1/21/2025 by the Director of Nursing.
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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 Ossining
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Nursing Home Company Inc | 1.5 mi | ★★★★★ | 0 | 0 |
| Cedar Manor Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Sky View Rehabilitation & Health Care Center L L C | 3.3 mi | ★★★★★ | 6 | 0 |
| Springvale Nursing & Rehabilitation Center | 4.7 mi | ★★★★★ | 29 | 0 |
| Briarcliff Manor Center For Rehab And Nursing Care | 4.8 mi | ★★★★★ | 0 | 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.