Sunset Nursing And Rehabilitation Center, Inc

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

_________________________________________________________________Immediate Jeopardy was identified, and the facility Administrator and Corporate Administrator were notified on 11/04/2025 at 5:26 PM. Immediate Jeopardy was removed on 11/05/2025 at 10:21 PM prior to survey exit based on the following corrective actions:- Facility hall monitors were instated for all three (3) shifts to ensure residents stayed out of other resident rooms- All residents in the facility were assessed for aggression risk.- Resident #1 was placed on continuous 1:1.- As of 11/06/2025, 100% of all staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.- Staff education was completed online, and multiple department facility staff working were interviewed on 11/06/2025 and were able to demonstrate understanding of the education. There were no discrepancies identified in the education provided and the responses from the interviewed staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Nursing and Rehabilitation Center, Inc

232 Academy Street Boonville, NY 13309

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

and Resident #1 had an alarming floor mat and stop sign at the door. They eventually moved Resident #1 off the dementia unit to another unit. They thought the family was notified by the supervisor or the Director of Nursing the next day. They determined there was no sexual contact because the family who witnessed

the incident did not see any sexual behaviors.During an additional interview on 11/07/2025 at 11:48 AM,

the Administrator stated:-on 10/05/2025 they were notified by the Director of Nursing regarding the 10/05/2025 incident between Residents #1 and #4. -They were not notified of the 10/09/2025 incident with Residents #1 and #3 until they moved Resident #1 off the unit on 10/24/2025. -They were notified by the Director of Nursing of the 10/23/2025 incident on 10/24/2024 at the same time they were notified of the 10/09/2024 incident when Resident #1 was moved to a different unit. -The Director of Nursing typically notified them verbally or in person of any incidents. They stated a thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation determines. The Director of Nursing was responsible for investigations.During an interview on 11/03/2025 at 12:46 PM, the Director of Nursing stated they were notified on 10/05/2025 Resident #1 and Resident #4 were found in Resident #1's roommate's bed without pants on. They were informed by Registered Nurse Supervisor #10. They were not made aware of the 10/09/2025 incident until they read it on the 24-hour report on 10/10/2025. Resident #3 was found in Resident #1's bed with their breasts exposed and Resident #1 was seated in their chair observing. They were informed on the morning of 10/24/2025 of the 10/23/2025 incident between Residents #1 and #4 when Resident #4 was found in Resident #1's bed with their breasts exposed. They based their investigation outcome on both staff interviews and the family member witness that there was no sexual contact for any of the instances. If there was abuse, they would report the incidents. They stated they could not speculate abuse occurred.10NYCRR 415.4 (b)(2)(3)___________________________________________________________________________________________ Jeopardy was identified, and the facility Administrator and Corporate Administrator were notified on 11/04/2025 at 5:26 PM. Immediate Jeopardy was removed on 11/05/2025 at 10:21 PM prior to survey exit based on the following corrective actions:- Facility hall monitors were instated for all three (3) shifts to ensure residents stayed out of other resident rooms- All residents in the facility were assessed for aggression risk.- Resident #1 was placed on a 1:1 at all times. - As of 11/06/2025, 100% of all staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.- Staff education was completed online, and multiple department facility staff working were interviewed on 11/06/2025 and were able to demonstrate understanding of the education. There were no discrepancies identified in the education provided and the responses from the interviewed staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Nursing and Rehabilitation Center, Inc

232 Academy Street Boonville, NY 13309

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

10/05/2025 incident between Residents #1 and #4. -They were not notified of the 10/09/2025 incident with Residents #1 and #3 until they moved Resident #1 off the unit on 10/24/2025. -They were notified by the Director of Nursing of the 10/23/2025 incident on 10/24/2024 at the same time they were notified of the 10/09/2024 incident when Resident #1 was moved to a different unit. -The Director of Nursing typically notified them verbally or in person of any incidents. They stated a thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation determines. The Director of Nursing was responsible for investigations.During an interview on 11/03/2025 at 12:46 PM, the Director of Nursing stated they were notified on 10/05/2025 Resident #1 and Resident #4 were found in Resident #1's roommate's bed without pants on. They were informed by Registered Nurse Supervisor #10. They were not made aware of the 10/09/2025 incident until they read it on the 24-hour report on 10/10/2025. Resident #3 was found in Resident #1's bed with their breasts exposed and Resident #1 was seated in their chair observing. They were informed on the morning of 10/24/2025 of the 10/23/2025 incident between Resident #1 and Resident #4 when Resident #4 was found in Resident #1's bed with the resident with their breasts exposed. They based their investigation outcome on both staff interviews and the family member witness.

There was no sexual contact for any of the instances. They stated they could not speculate. A thorough investigation had proper witness statements, the Director of Nursing being notified timely, and multiple interviews. The care plans and interventions should also be reviewed to ensure they were appropriate and working. For the 10/05/2025 incident, they reviewed the records for the residents, looked at the Accident and Incident reports, the interventions currently in place and made sure the supervisor put in some new interventions. The 10/09/2025 incident they were not made aware of, so the investigation was quick since Resident #1 was not in bed with Resident #3. The 10/23/2025 incident they reviewed the interventions in place, they did not think Resident #1 should be on that unit, so they moved the resident. The staff made it sound like Resident #1 was after people, but the resident was confused and did not know what they were doing. The Director of Nursing looked through the three (3) folders containing the investigations and stated there was not much in the folders and they were unaware of where the staff statements were. The Director of Nursing stated they did not know if family was called for the 10/05/2025 incident. The 10/09/2025 investigation was incomplete as there were missing witness statements and they were unsure if family was notified of this incident for Resident #1. The 10/23/2025 incident investigation was not complete as they needed to tidy up the witness statements from the staff. They could not locate any assessments for any of

the incidents except for one (1) assessment done on 10/24/2025 the day after the 10/23/2025 incident.

They based their investigation outcome on both staff interviews and the family member witness that there was no sexual contact for any of the instances. 10NYCRR 415.4(b)(1)(i) Immediate Jeopardy was identified, and the facility Administrator and Corporate Administrator were notified on 11/04/2025 at 5:26 PM. Immediate Jeopardy was removed on 11/05/2025 at 10:21 PM prior to survey exit based on the following corrective actions:- Facility hall monitors were instated for all three (3) shifts to ensure residents stayed out of other resident rooms- All residents in the facility were assessed for aggression risk. - Resident #1 was placed on a 1:1 - As of 11/06/2025, 100% of all staff currently working in the facility were educated

on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.Staff education was completed online, and multiple department facility staff working were interviewed on 11/06/2025 and were able to demonstrate understanding of the education. There were no discrepancies identified in the education provided and the responses from the interviewed staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Nursing and Rehabilitation Center, Inc

232 Academy Street Boonville, NY 13309

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744

liked to travel. They also met with Resident #9 a few times. Resident #9 did not have behaviors, but the resident could not have a roommate.10 NYCRR 415.12

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Nursing and Rehabilitation Center, Inc

232 Academy Street Boonville, NY 13309

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

the unit managers should be assisting with interventions with the support of the certified nurse aides with managing residents with inappropriate behaviors.During a follow up interview on 11/07/2025 at 11:48 AM,

the Administrator stated they were made aware of the 10/5/2025 the next day on 10/6/2025 but were not aware of the 10/09/2025 incident until 10/24/2025 after they were informed of the 10/23/2025 incident when

the resident was moved off the unit. They were informed of all the incidents by the Director of Nursing. A thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation. The Director of Nursing was responsible for investigations and verbally updated them on their investigative findings. 10 NYCRR 483.70(i)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Nursing and Rehabilitation Center, Inc

232 Academy Street Boonville, NY 13309

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Based on record review and interviews during the abbreviated survey (#2639795), the facility did not comply with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standard and principles that apply to professionals providing services in such a facility.

Specifically, the facility did not provide requested accident and incident reports including abuse incident documentation when requested by the New York State Department of Health surveyor in a timely manner.Findings include:Refer to F-F609 - Reporting of Alleged ViolationsRefer to F-F610 Investigate/Prevent/Correct Alleged ViolationsOn 10/29/2025 at 8:45 AM, the surveyor provided the Administrator a request for documents including their accident and incident reports for September 2025 and October 2025.On 10/29/205 at 9:45 AM, the Administrator provided copies of accident and incident reports for September 2025 and October 2025.On 10/29/205 at 10:45 AM, after review of the files provided,

the surveyor clarified with Administrator the accident and incidents should include all abuse or injuries of unknown origin. The Administrator stated those were separate files and they would provide them for September 2025 and October 2025. On 10/29/2025 at 11:55 AM, the surveyor requested from the Administrator a second time the abuse incidents and files for September 2025 and October 2025.On 10/29/205 at 12:49 PM, the surveyor requested from the Administrator a third time the abuse incidents and files from September 2025 and October 2025. The Administrator stated the Director of Nursing had the files and they would bring them to the conference room.On 10/29/2025 at 12:55 PM, the Administrator brought

in one file dated 10/5/2025 and stated the Director of Nursing had one more report they were finishing. The surveyor requested to review the unfinished file as it was.On 10/29/2025 at 2:12 PM, the Director of Nursing provided an incident report for an incident dated 10/23/2025 and stated the report was not completed. On 10/29/2025 at 4:18 PM, the surveyor requested additional accident and incident reports from April 2025 to date. On 10/31/2025 at 8:53 AM, the Administrator had not provided the requested accident and incident reports from April 2025 to date. On 10/31/2025 at 9:50 AM, the surveyor notified the Director of Nursing the 10/30/2025 at 4:18 PM requested accident and incident reports were not received.On 10/31/2025 at 9:53 AM, the Administrator provided hard copies of accidents and incidents since April 2025.10NYCRR 400.2

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Nursing and Rehabilitation Center, Inc

232 Academy Street Boonville, NY 13309

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Based on record review and interviews during the abbreviated survey (#2639795) the facility's governing body did not establish and implement policies regarding the management and operation of the facility.

Specifically, there was not consistent communication between the governing body and the facility Administrator to ensure regulatory compliance. Deficiencies identified during the abbreviated survey included three Immediate Jeopardies in Free from Abuse and Neglect (F-F600), Reporting of Alleged Violations (F-F609), and Investigate/Prevent/Correct Alleged Violations (F-F610). Findings include:The 10/2025 facility policy Quality Assurance Performance Improvement (QAPI) Plan, documented:-The facility maintains a planned, systematic, organization-wide approach to design process that will measure, assess and improve the organization's performance and focus on indicators of quality.-The purpose of quality assurance performance improvement in the organization is to take a proactive approach to continually improve the way they care for and engage with residents, care givers, staff and other partners, to realize their vision to improve the lives of the nursing home residents. -The facility will provide a means whereby negative outcomes related to resident care and safety can be identified and resolved through an interdisciplinary approach and positive outcome can be reinforced and expanded to improve care. Refer to F 600 Free from Abuse and NeglectRefer to F 609 Reporting of Alleged ViolationsRefer to F 610 Investigate/Prevent/Correct Alleged ViolationsDuring an interview on 11/3/2025 at 12:46 PM, the Director of Nursing stated the 10/5/2025, 10/9/2025, and 10/23/2025 incidents were investigated by interviewing staff and reviewing the care plans for proper interventions. They ruled out abuse for the 10/5/2025 incident based on the interview of Resident #5's family member who stated there was no physical contact between Resident #1 and Resident #4. The 10/9/2025 incident they thought it was just Resident #3 wandering into Resident #1's bed and lying down in the bed. The 10/23/2025 incident, abuse was ruled out because Licensed Practical Nurse #8 stated there was no physical contact made, and no one witnessed any physical contact. For all three incidents, they ruled out abuse based on witness statements. They did not report the potential abuse to the New York Stated Department of Health because they did not think abuse happened. During an interview on 11/6/2025 at 3:24 PM, the Administrator stated they did a performance improvement plan for abuse prevention and detection. They stated they recently had been filling in as the social worker while being the Administrator. They did not assess the involved resident's mental health on 10/5/2025, because that would have been the prior social workers responsibility. They did not assess the resident's mental health on 10/9/2025 and 10/23/2025 because they were the Administrator.During an additional interview on 11/7/2025 at 11:48 AM, the Administrator stated they were made aware of the 10/5/2025 incident between Resident #1 and Resident #4 the day after the incident, when the Director of Nursing called them. They were not notified about the 10/9/2025 incident until 10/24/2025 when they moved Resident #1 to another unit after the 10/23/2025 incident. They stated they previously did not sign off on incident investigations, but the Director of Nursing notified them verbally about incidents. 10NYCRR 415.26(b)(3)(1)

Event ID:

Facility ID:

If continuation sheet