Bring a large pot of generously salted water to a boil. Add the paccheri and cook until al dente according to package directions (usually 11–13 minutes). Reserve 1/4 cup pasta water, then drain.

While the pasta cooks, heat olive oil in a large skillet over medium-high. Add crumbled sausage and cook, breaking it up with a spoon, until deeply browned and the internal temperature reaches 160°F (71°C), about 5–6 minutes.

Reduce heat to medium. Add minced garlic, sun-dried tomatoes, and red pepper flakes. Sauté until garlic is fragrant, about 1 minute.

Pour in the heavy cream and stir to combine. Bring to a gentle simmer and let it thicken slightly, 2–3 minutes. Remove from heat, then stir in the Pecorino Romano until melted and smooth.

Add the drained paccheri directly to the skillet. Toss vigorously, adding splashes of reserved pasta water as needed to achieve a silky, clingy sauce. Taste and adjust salt and pepper.

Divide among warmed bowls. Scatter torn basil, an extra grind of black pepper, and more Pecorino on top. Serve immediately.