Below 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 Sunset Nursing And Rehabilitation Center, Inc during CMS and state inspections, most recent first.
Several residents with cognitive impairment and wandering behaviors were repeatedly found in compromising situations with another resident, including being undressed or exposed, without timely assessment by an RN or notification of families. Care plans were not updated to address abuse risk, and social work or medical follow-up was lacking. Staff interviews revealed prior similar incidents that were not always reported or investigated, and interventions such as alarm mats were ineffective in preventing recurrence.
The facility did not report multiple incidents of alleged sexual abuse involving a resident and two other residents lacking capacity to consent. Despite staff intervention and internal documentation, the DON and Administrator failed to notify the state health department or law enforcement as required, citing lack of injury or confirmed sexual contact. This failure to report constituted Immediate Jeopardy and substandard quality of care.
A resident with severe cognitive impairment was repeatedly involved in sexually inappropriate behavior with two other cognitively impaired residents. Facility staff failed to thoroughly investigate these incidents, did not obtain complete witness statements, and did not document how abuse was ruled out or what protective measures were implemented. The DON and Administrator were not always notified promptly, and there was uncertainty about family notification. This resulted in Immediate Jeopardy and substandard quality of care.
Administration failed to ensure residents were free from abuse and neglect, did not consistently report or investigate incidents of resident-to-resident abuse, and lacked proper communication and implementation of policies. The DON was responsible for investigations, but the Administrator was not always promptly informed, and the facility's QAPI plan did not address abuse. These failures resulted in Immediate Jeopardy for multiple residents.
Three residents with dementia did not receive individualized, dementia-informed care or timely updates to their care plans despite exhibiting significant behavioral symptoms, including aggression, inappropriate sexual behavior, and agitation. Staff and nursing documentation showed repeated incidents without adequate follow-up from social services or behavioral health, and interventions were often generic or ineffective.
The facility's governing body did not ensure consistent communication or implementation of policies between leadership and the Administrator, resulting in multiple unreported and insufficiently investigated incidents of potential abuse. The DON ruled out abuse based on staff and family interviews without reporting to the state, and the Administrator was not consistently informed or involved in investigations, nor were resident mental health assessments completed.
The facility did not provide requested accident, incident, and abuse reports to the surveyor in a timely manner, despite multiple requests and clarifications. The Administrator and DON delayed the submission of complete documentation, resulting in noncompliance with regulations requiring prompt and full disclosure of such records.
Failure to Protect Residents from Abuse and Inadequate Incident Response
Penalty
Summary
Multiple incidents occurred in which residents with severe cognitive impairment and a history of wandering were found in compromising situations with another resident, including being found in bed together without pants or with clothing removed and exposed. In several cases, staff or family members discovered the incidents, and the involved residents were separated and placed on increased monitoring. Despite these events, there was no documented evidence that a registered nurse assessed the residents immediately following the incidents, even when complaints of pain or signs of distress were present. Additionally, there was no documentation that the residents' families were notified of the incidents as required. Care plans for the residents involved were not updated to reflect the risk or occurrence of abuse or potential victimization, and interventions were limited to increased monitoring without addressing the underlying risks. Social work and psychosocial assessments were not documented following the incidents, and medical providers were not consistently notified or involved in post-incident evaluations. Staff interviews revealed that similar incidents had occurred previously and were sometimes not reported or investigated, and that interventions such as alarm mats were ineffective in preventing recurrence. Facility leadership, including the DON and Administrator, were not consistently notified of all incidents, and investigations were incomplete or delayed. The facility did not report the incidents to the state health department, citing a lack of evidence of injury or mental anguish, despite multiple staff and witness accounts indicating resident distress and inability to consent. The lack of timely assessment, reporting, care plan updates, and comprehensive investigation contributed to the deficiency in protecting residents from abuse and neglect.
Removal Plan
- Facility hall monitors were instated for all three 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
- 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 and were able to demonstrate understanding of the education
Failure to Timely Report Alleged Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported immediately, but not later than two hours after the allegation was made, to the Administrator and the New York State Department of Health, as required by state law. Three separate incidents involving a resident engaging in sexually inappropriate behavior with two other residents, both of whom lacked capacity to consent, were not reported to the appropriate authorities. In each case, staff intervened and separated the residents, but the incidents were not reported to the state agency or law enforcement, and in one instance, the Administrator was not notified until more than two weeks after the event. The facility's own policy required immediate reporting of any suspected abuse to the Supervisor/Administrator and mandated that the DON notify the Department of Health and law enforcement within two hours. Despite this, documentation showed that staff and supervisors were aware of the incidents, completed incident reports, and conducted internal assessments, but did not notify external authorities. The rationale provided by facility leadership was that there was no pain, injury, or mental anguish noted, and they could not confirm any sexual contact, leading them to determine the incidents were not reportable. Interviews with staff and administration confirmed that the incidents were not reported as required. The Administrator and DON both acknowledged delays in notification and a lack of reporting to the state and law enforcement. All residents involved were determined to lack capacity to consent to sexual behaviors, and the facility's failure to report these incidents constituted Immediate Jeopardy and Substandard Quality of Care, placing all residents at risk.
Removal Plan
- Facility hall monitors were instated for all three 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
- 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 and were able to demonstrate understanding of the education
Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three of eight residents reviewed. Specifically, on three separate occasions, a resident with severe cognitive impairment was witnessed by visitors and/or staff engaging in sexually inappropriate behavior with two other residents who also lacked capacity to consent. There was no documented evidence that these incidents were thoroughly investigated to determine if abuse occurred or that measures were put in place to protect residents from further abuse during the investigation process. The facility's policy required immediate reporting and thorough investigation of any suspected abuse, including obtaining witness statements, assessing the residents involved, and notifying appropriate supervisory staff. However, for the incidents in question, documentation was incomplete or missing. For example, one incident report was not completed, and the investigations that were provided included only summaries and unsigned witness statements. There was no evidence that family members who witnessed the events were interviewed, and staff who were present were not always asked to provide statements. Additionally, there was no documentation of how abuse was ruled out or what interim protective measures were implemented for other residents during the investigation. Interviews with staff and administration revealed inconsistencies in the reporting and investigation process. Some staff were told not to document the incidents, and the Director of Nursing acknowledged that investigations were incomplete, with missing witness statements and assessments. The Administrator and Director of Nursing were not always notified of incidents in a timely manner, and there was uncertainty about whether families were informed. The lack of thorough investigation and documentation resulted in Immediate Jeopardy and Substandard Quality of Care for the residents involved.
Removal Plan
- Facility hall monitors were instated for all three 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
- 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 and were able to demonstrate understanding of the education
Failure to Prevent, Report, and Investigate Resident Abuse and Neglect
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to maintain the highest practicable well-being of residents. Specifically, administration did not ensure residents were free from abuse, neglect, and exploitation, and failed to properly identify, communicate, and consistently implement policies and procedures. The survey found that for two of four residents reviewed, the facility did not protect them from abuse, and for three of eight residents, incidents of resident-to-resident abuse were not reported to the State Agency, law enforcement, or the Administrator as required. Additionally, alleged violations involving abuse, neglect, or mistreatment were not thoroughly investigated for three of eight residents reviewed. Interviews revealed that the Administrator was not always promptly informed of incidents and relied on the DON for updates and investigations. The Administrator stated that reporting of incidents depended on the investigation and witness statements, and they did not feel certain incidents were reportable due to lack of confirmed intimate contact. The facility's QAPI plan did not previously include abuse as a focus area, and the loss of the social worker left unit managers and CNAs to manage residents with inappropriate behaviors. The Administrator acknowledged delays in being informed of incidents and described the investigation process as involving staff interviews, resident assessments, and implementation of interventions based on findings.
Failure to Provide Individualized Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to ensure that three residents diagnosed with dementia received appropriate, individualized treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. For these residents, care plans were not sufficiently personalized or updated to reflect their specific behavioral symptoms and needs. The facility's policies referenced behavior monitoring and social work responsibilities, but there was no policy provided regarding dementia care or the dementia care unit when requested. Staff education materials on dementia were general and did not translate into individualized interventions for the residents reviewed. One resident with a history of stroke, dementia, and depression exhibited repeated sexually inappropriate and aggressive behaviors toward other residents, including entering other residents' rooms, undressing, and making inappropriate physical contact. Despite multiple incidents documented in nursing notes and staff interviews, there was no evidence of follow-up from behavioral health or social services, nor were care plan interventions updated to address these behaviors. Staff reported that interventions such as alarm mats were ineffective, and the resident was able to bypass or disable them. The care plan contained generic interventions and lacked specific, personalized strategies to address the resident's behavioral symptoms and memory impairment. Another resident with early-onset Alzheimer's disease and a history of agitation and psychotic disorder displayed frequent verbal and physical aggression, wandering, and inappropriate behaviors, including threats toward others. Nursing notes documented multiple behavioral incidents, but care plan updates and social work follow-up were lacking or delayed. Staff interviews indicated that interventions were not consistently effective or individualized, and documentation of non-pharmacological interventions was insufficient. A third resident with dementia and depression exhibited yelling out and agitation, but care plans and interventions were not personalized, and there was no documented social work reassessment following behavioral episodes. Across all three cases, the lack of timely, individualized care planning and follow-up contributed to the deficiency.
Failure of Governing Body to Ensure Effective Abuse Investigation and Reporting
Penalty
Summary
The facility's governing body failed to establish and implement effective policies for the management and operation of the facility, resulting in inconsistent communication between the governing body and the Administrator regarding regulatory compliance. During the abbreviated survey, three Immediate Jeopardy deficiencies were identified in the areas of Free from Abuse and Neglect, Reporting of Alleged Violations, and Investigate/Prevent/Correct Alleged Violations. The facility's QAPI plan outlined a systematic approach to quality assurance and performance improvement, but this was not effectively executed, as evidenced by the handling of multiple incidents involving potential abuse. Specifically, incidents involving several residents were investigated by the DON, who relied on staff and family interviews to rule out abuse, and did not report these incidents to the state health department because they did not believe abuse had occurred. The Administrator was not consistently notified of incidents in a timely manner and did not sign off on investigations, relying instead on verbal updates from the DON. Additionally, the Administrator did not assess the mental health of involved residents, citing role overlap and lack of responsibility. These actions and inactions led to a failure to ensure proper investigation, reporting, and prevention of abuse as required by regulation.
Delayed Provision of Required Incident and Abuse Reports
Penalty
Summary
The facility failed to comply with Federal, State, and local laws and regulations by not providing requested accident and incident reports, including those related to abuse and injuries of unknown origin, in a timely manner to the New York State Department of Health surveyor. The surveyor initially requested these documents from the Administrator, who provided some reports but omitted those specifically related to abuse and injuries of unknown origin, stating they were kept separately. Despite multiple requests and clarifications from the surveyor, the facility delayed providing the complete set of required documentation. The Administrator and Director of Nursing eventually provided some of the requested files, but not all were complete or provided promptly. Additional requests for accident and incident reports covering a broader time frame were also not fulfilled in a timely manner, with the final set of documents only being provided after repeated follow-ups. This delay in providing critical documentation constituted a failure to operate in compliance with applicable laws and professional standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Gardens Skilled Living Center | 17.9 mi | ★★★★★ | 0 | 0 |
| Rome Memorial Hospital, Inc - R H C F | 18.2 mi | ★★★★★ | 0 | 0 |
| Betsy Ross Rehabilitation Center, Inc | 18.4 mi | ★★★★★ | 2 | 0 |
| Colonial Park Rehabilitation And Nursing Center | 18.8 mi | ★★★★★ | 25 | 0 |
| The Grand Rehabilitation And Nursing At Rome | 18.9 mi | ★★★★★ | 29 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sunset Nursing And Rehabilitation Center, Inc.
100% money-back within 48 hours.
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.