Inspection Reports for The Waters of Sullivan Nursing Facility
505 W WOLFE ST, SULLIVAN, IN, 47882
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 29, 2025, found the facility in compliance following a paper review related to complaint investigations. Prior inspections showed a mix of results, with some complaint investigations citing deficiencies in medication administration and dietary services, while others found no issues. Earlier reports noted deficiencies mainly in medication management, food safety, infection control, care planning, and Life Safety Code compliance, including a door without a self-closing device and generator maintenance lapses. Complaint investigations were mostly unsubstantiated or found no deficiencies, except for two complaints in early 2025 that resulted in citations for medication and dietary services. The inspection history shows some recurring issues but also periods of compliance, with no enforcement actions or fines listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
53 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 29, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00449803 and IN00452651 completed on February 28, 2025.
Findings
Waters of Sullivan was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations.
Complaint Details
The visit was related to investigations of complaints IN00449803 and IN00452651; compliance was found.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Feb 26, 2025
Visit Reason
This visit was for the investigation of complaints IN00449803, IN00452651, IN00454291, and IN00447096.
Findings
The facility was found deficient in pharmaceutical services related to timely medication administration for one resident and in dietary services related to serving food at safe and appetizing temperatures for three residents. Two complaints had deficiencies cited, while two complaints had no deficiencies related to the allegations.
Complaint Details
Complaint IN00449803 had federal/state deficiencies cited at F755 related to medication administration. Complaint IN00452651 had federal/state deficiencies cited at F804 related to dietary services. Complaints IN00454291 and IN00447096 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure medications were obtained and administered in a timely manner for one resident. | SS=D |
| Failed to ensure food was served at a safe and appetizing temperature for three residents. | SS=D |
Report Facts
Census: 53
SNF beds: 9
SNF/NF beds: 44
Medicare residents: 10
Medicaid residents: 30
Other payor residents: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sally Robertson | Administrator | Signed the report and is named as the facility administrator. |
| Director of Nursing | Interviewed regarding medication administration and pharmacy policies; name not provided. | |
| Dietary Manager | Interviewed and observed regarding food temperature and dietary services; name not provided. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Nov 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446662 and IN00446735.
Findings
No deficiencies related to the allegations in complaints IN00446662 and IN00446735 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00446662 and Complaint IN00446735 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF: 2
Census Bed Type - SNF/NF: 46
Total Census: 48
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 19
Total Census Payor: 48
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Sep 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441722 at The Waters Of Sullivan Nursing Facility.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00441722 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 55
Census Payor Type Total: 55
Medicare Census: 3
Medicaid Census: 30
Other Payor Census: 22
SNF/NF Beds: 50
SNF Beds: 5
Inspection Report
Re-Inspection
Census: 55
Capacity: 93
Deficiencies: 0
Aug 15, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/02/24 was performed to verify compliance with applicable regulations.
Findings
The Waters of Sullivan Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm systems and smoke detectors.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Jul 25, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00439476.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00439476 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 54
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 29
Census Payor Type - Other: 22
Inspection Report
Life Safety
Census: 52
Capacity: 93
Deficiencies: 1
Jul 2, 2024
Visit Reason
The Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code to assess compliance with fire safety requirements.
Findings
The facility was found not in compliance due to failure to ensure that the corridor door to a hazardous area (storage room of combustible supplies) was provided with a self-closing device that would cause the door to automatically close and latch. This deficiency could affect 10 residents and staff in the vicinity of room 35.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The corridor door to resident room 35, used for storage of combustible supplies, was not provided with a self-closing device and failed to automatically close and latch into the door frame. | SS=E |
Report Facts
Certified beds: 93
Census: 52
Residents and staff potentially affected: 10
Cardboard boxes of supplies: 24
Room dimensions: Approximately 16 feet by 14 feet
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karl Eck | RDO | Laboratory Director or Provider/Supplier Representative who signed the report |
| Maintenance Director | Interviewed regarding the deficient corridor door | |
| Administrator | Reviewed findings at exit conference and involved in corrective action | |
| Maintenance Supervisor/designee | Installed self-closing device and responsible for ongoing maintenance |
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 9
Jun 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 17 to June 21, 2024.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care plan meetings for some residents, failure to notify physicians of changes in condition, inadequate supervision during medication administration, improper storage and documentation of respiratory equipment, lack of physician documentation for declination of pharmacy recommendations, incomplete lab testing per physician orders, food safety violations, and inadequate infection control practices.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure care plan meetings were conducted quarterly for 2 of 24 residents reviewed. | SS=D |
| Failed to ensure physician was notified of a resident's change in condition related to edema. | SS=D |
| Failed to ensure a resident was supervised while administering medications. | SS=D |
| Failed to ensure respiratory equipment was stored in a plastic bag and obtain physician order for CPAP settings. | SS=D |
| Failed to ensure physician documentation to justify declination of pharmacy recommendation for unnecessary medication. | SS=D |
| Failed to ensure physician ordered lab tests had been completed. | SS=D |
| Failed to discard expired food items, maintain temperature logs, monitor sanitizer concentration, label and date food items without manufacturer expiration dates, and store food at least six inches from the floor. | SS=E |
| Failed to maintain infection prevention measures during meal service, medication administration, and hand hygiene. | SS=D |
| Failed to complete second step TB skin test for 5 of 10 employees reviewed. | SS=D |
Report Facts
Survey dates: 5
Census: 50
Total capacity: 50
Residents reviewed for care plan meetings: 24
Residents with missing quarterly care plan meetings: 2
Residents reviewed for medication supervision: 1
Residents reviewed for respiratory care: 1
Residents reviewed for unnecessary medications: 5
Residents reviewed for lab testing: 5
Employees reviewed for TB testing: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sally Robertson | Administrator | Signed the report |
| Kay Eastham | Activity Assistant | Named in infection control hand hygiene in meal service |
| LPN 4 | Noted leaving medications unattended in Resident 104's room | |
| LPN 7 | Failed to wash hands between residents during blood sugar checks | |
| CNA 7 | Failed to sanitize hands after touching hair and ear during meal service | |
| LPN 21 | Noted unbagged CPAP equipment and lack of physician order for CPAP settings | |
| Cook 11 | Observed during kitchen inspection | |
| Dietary Director | Interviewed regarding food safety policies and practices | |
| Regional Nurse Consultant | Provided multiple policy documents and interviews |
Inspection Report
Renewal
Deficiencies: 0
Jun 21, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
Waters of Sullivan Nursing Facility was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Apr 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429172 at The Waters of Sullivan Nursing Facility.
Findings
No deficiencies related to the allegations in Complaint IN00429172 were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaint IN00429172 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 46
Census Bed Type - SNF: 6
Census Bed Type - SNF/NF: 40
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Dec 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420456.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00420456 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 43
Total Capacity: 43
Census Bed Type: 38
Census Bed Type: 5
Census Payor Type: 1
Census Payor Type: 18
Census Payor Type: 24
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413453 at The Waters of Sullivan Nursing Facility.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Investigation of Complaint IN00413453 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 6
Census Bed Type - SNF/NF: 42
Total Census: 48
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 21
Inspection Report
Re-Inspection
Census: 45
Capacity: 93
Deficiencies: 0
Jun 29, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/31/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Waters of Sullivan Nursing Facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 45
Capacity: 93
Deficiencies: 3
May 31, 2023
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to perform an annual fuel quality test for the diesel generator and failure to maintain written records of weekly generator inspections for 2 of 52 weeks. Additionally, a power strip was improperly used to power a high current draw refrigerator, which was corrected during the survey.
Severity Breakdown
SS=F: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure an annual fuel quality test was performed for the diesel-powered generator. | SS=F |
| Failure to maintain written records of weekly inspections for the generator for 2 of 52 weeks. | SS=F |
| Use of a power strip as a substitute for fixed wiring to power a high current draw refrigerator. | SS=D |
Report Facts
Certified beds: 93
Census: 45
Weeks missing generator inspection records: 2
Generator weekly inspections required: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding generator maintenance and power strip usage | |
| Executive Director | Present at exit conference reviewing findings | |
| Maintenance Supervisor | Conducted weekly generator inspections and corrective actions | |
| Administrator | Inserviced staff and monitored compliance with corrective actions |
Inspection Report
Renewal
Census: 41
Capacity: 41
Deficiencies: 7
May 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 8 to May 12, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of hospital transfers, failure to revise care plans timely, improper catheter bag placement, improper oxygen therapy management, lack of monitoring and care planning for antipsychotic medication use, failure to address pharmacy recommendations timely, and incomplete employee personnel records.
Severity Breakdown
SS=D: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify the Office of the State Long-Term Care Ombudsman of hospital transfer for 1 of 3 residents reviewed. | SS=D |
| Failed to revise care plan for 1 of 12 residents reviewed for care plans. | SS=D |
| Failed to ensure urinary catheter drainage bag was prevented from contact with the floor for 1 of 2 residents reviewed. | SS=D |
| Failed to ensure a resident's supplemental oxygen concentrator machine was turned on and oxygen tubing was dated and properly placed for 1 of 1 resident reviewed. | SS=D |
| Failed to monitor side effects/behaviors and develop a care plan for the use of antipsychotic medication for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure pharmacy recommendations were addressed by a physician and implemented for 2 of 5 residents reviewed for unnecessary psychotropic medications. | SS=D |
| Failed to ensure employee records included all required documentation for 5 of 10 employee records reviewed. | — |
Report Facts
Census: 41
Total Capacity: 41
Deficiencies cited: 7
Inspection Report
Renewal
Deficiencies: 0
May 12, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on May 12, 2023.
Findings
Waters of Sullivan was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Nov 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394233.
Findings
The complaint IN00394233 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00394233 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census: 42
Census Bed Type - SNF: 4
Census Bed Type - SNF/NF: 38
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 50
Capacity: 50
Deficiencies: 0
Aug 8, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00380202 completed on June 30, 2022.
Findings
Miller's Merry Manor was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00380202. The complaint was corrected.
Complaint Details
Complaint IN00380202 - Corrected.
Report Facts
Census Bed Type: 50
Census Payor Type: 50
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