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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Waters of Sullivan is a 93-bed skilled nursing and rehabilitation center at 505 W Wolfe Street in Sullivan, Indiana. Owned by Johnson Memorial Hospital and led by administrator Pamela Clevenger, the facility provides Sullivan County residents with a spectrum of care ranging from post-acute recovery to specialized dementia support. The campus is positioned as a hospital-affiliated clinical hub for those requiring transition from acute care to a residential medical setting.
Post-acute recovery and chronic clinical management are delivered here under federal Medicare and Medicaid guidelines. While 2025 records indicated historical health citations, current 2026 filings confirm the facility has achieved a citations-per-inspection rate of zero for its most recent standard compliance reviews. Occupancy currently stands at 57%, which allows the center to scale its specialized “Living Well” memory care and “In Motion” physical rehabilitation programs to meet regional demand.
Professional medical oversight is maintained 24/7, with a specific focus on high Licensed Practical Nurse (LPN) availability. Total nursing hours average approximately 3 hours per resident per day, with LPN coverage trending roughly 15% above Indiana state norms. Clinical capabilities include tracheostomy care, advanced wound management, and oxygen therapy, supported by on-site physical, occupational, and speech-language pathology. To reduce the logistical burden on residents, the facility coordinates on-site consultations for dentistry, podiatry, and audiology.
Accommodations are built around a hospitality-forward design, offering private and semi-private floor plans with safety-focused bathrooms and clinical-grade beds. The monthly service model is all-inclusive, covering dietitian-approved meals, comprehensive housekeeping, and personal laundry services.
A large activity center, a computer lounge, a lending library, and a full-service beauty salon and barber shop. Residents have access to secure outdoor walking paths and a social calendar featuring daily fitness classes, live music, and religious services. For off-site medical visits and community excursions, the center provides scheduled transportation.
Older adults requiring a clinical environment backed by hospital resources and high LPN staffing ratios may find this setting appropriate. To evaluate the current environment, prospective residents and their representatives should contact the administrator to discuss specific nurse-to-resident ratios and tour the 2026 residential neighborhoods firsthand.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 185th out of 287 homes in Indiana. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 27m per day | ▼ 33% State avg: 40m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 53m per day | ▲ 15% State avg: 46m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 1h 56m per day | ▼ 15% State avg: 2h 16m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 2m per day | ▼ 6% State avg: 3h 14m per day · National avg: 3h 26m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 13m per day | ▼ 52% State avg: 27m per day · National avg: 28m per day |
Lower than the Indiana average: 68.1%The Waters of Sullivan Nursing Facility is legally operated by Johnson Memorial Hospital, and administrated by Sally Robertson.
Key information about the people who lead and staff this community.
In Indiana, the Department of Health, Division of Long Term Care is the primary regulatory body that performs onsite inspections and quality of care reviews for all licensed facilities.
A composite 0–100 score combining this facility's inspections, citations, complaints, and enforcement actions relative to the Indiana state average. See the nursing homes benchmark below for the typical Indiana score; higher is better.
Above the Indiana average for nursing homes.
Indiana nursing homes benchmark: C 74/100
Inspection score: 87 out of 100. Letter grade B+. Above the Indiana average for nursing homes.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Indiana state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 22 | 36 | This facility has 39% fewer total deficiencies than a typical Indiana nursing home (22 vs. IN avg 36).↓ 39% better |
|
Deficiencies per year
Average deficiencies per year since 2022.
| 5.5 | 9 | This facility has 39% fewer deficiencies per year than a typical Indiana nursing home (5.5 vs. IN avg 9).↓ 39% better |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 1.2 | 1.9 | This facility has 37% fewer deficiencies per inspection than a typical Indiana nursing home (1.2 vs. IN avg 1.9).↓ 37% better |
Inspections
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total visits
Combined count of all on-site visits — routine inspections, complaint visits, follow-ups, and other focused visits.
| 18 | 19 | This facility has 5% fewer total visits than a typical Indiana nursing home (18 vs. IN avg 19).↓ 5% better |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 5 | 7 | This facility has 29% fewer inspections with deficiencies than a typical Indiana nursing home (5 vs. IN avg 7).↓ 29% better |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 28% | 37% | This facility has 9 percentage points lower inspection deficiency rate than a typical Indiana nursing home (28% vs. IN avg 37%).↓ 9% better |
|
Inspections
Routine, scheduled inspections conducted by state regulators.
| 10 | 13 | This facility has 23% fewer inspections than a typical Indiana nursing home (10 vs. IN avg 13).↓ 23% better |
Complaints & Investigations
| This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 1 | 5 | This facility has 80% fewer total complaints than a typical Indiana nursing home (1 vs. IN avg 5).↓ 80% better |
|
Complaints per year
Average complaints per year since 2022.
| 0.3 | 1.3 | This facility has 77% fewer complaints per year than a typical Indiana nursing home (0.3 vs. IN avg 1.3).↓ 77% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
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.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsIndiana average 6
Last Health inspection on Aug 2025
Indiana average 25
Indiana average 4.12
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
29 of 31 citations resulted from standard inspections; and 2 of 31 resulted from complaint investigations.
100% better than Indiana averageIndiana average: 0.2
100% better than Indiana averageIndiana average: 0.6
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
1269131% better than Indiana average
0% compared with Indiana average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.2 hoursNo contractors work on this role.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.5 hoursNo contractors work on this role.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.2 hoursNo contractors work on this role.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
1,252 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 22 | 0 | 22 | 8,016 | 92 | 100% | 8.2 |
| Licensed Practical Nurse | 10 | 0 | 10 | 3,324 | 92 | 100% | 8.5 |
| Other Dietary Services Staff | 6 | 0 | 6 | 1,173 | 84 | 91% | 7.1 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 932 | 69 | 75% | 7.8 |
| Registered Nurse | 4 | 0 | 4 | 815 | 73 | 79% | 9.2 |
| Administrator | 2 | 0 | 2 | 553 | 67 | 73% | 8.2 |
| Nurse Practitioner | 1 | 0 | 1 | 500 | 60 | 65% | 8.3 |
| Dietitian | 1 | 0 | 1 | 498 | 69 | 75% | 7.2 |
| Medication Aide/Technician | 2 | 0 | 2 | 478 | 54 | 59% | 8.7 |
| Speech Language Pathologist | 0 | 4 | 4 | 451 | 67 | 73% | 6.7 |
| Mental Health Service Worker | 1 | 0 | 1 | 436 | 60 | 65% | 7.3 |
| Physical Therapy Assistant | 0 | 3 | 3 | 356 | 54 | 59% | 6.6 |
| Qualified Social Worker | 0 | 2 | 2 | 335 | 65 | 71% | 5.2 |
| Physical Therapy Aide | 0 | 1 | 1 | 61 | 12 | 13% | 5.1 |
| Respiratory Therapy Technician | 0 | 4 | 4 | 46 | 35 | 38% | 1.1 |
| Therapeutic Recreation Specialist | 0 | 1 | 1 | 2 | 1 | 1% | 1.8 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
6.1
24% better than Indiana averageIndiana average: 8.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
14.5
15% better than Indiana averageIndiana average: 17.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
6.3%
48% better than Indiana averageIndiana average: 12.0%
Percent of long-stay residents whose ability to move independently worsened
11.8%
18% better than Indiana averageIndiana average: 14.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
25.5%
In line with Indiana averageIndiana average: 24.6%
Percent of long-stay residents experiencing one or more falls with major injury
1.7%
56% better than Indiana averageIndiana average: 3.9%
Percent of long-stay high risk residents with pressure ulcers
6.9%
57% worse than Indiana averageIndiana average: 4.4%
Percent of long-stay residents with a urinary tract infection
2.3%
87% worse than Indiana averageIndiana average: 1.2%
Percent of long-stay residents who lose too much weight
3.7%
36% better than Indiana averageIndiana average: 5.7%
Percent of long-stay residents who have depressive symptoms
30.3%
26% worse than Indiana averageIndiana average: 24.1%
Percent of long-stay residents who received an antipsychotic medication
15.9%
28% worse than Indiana averageIndiana average: 12.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
84.4%
10% worse than Indiana averageIndiana average: 93.7%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
94.3%
In line with Indiana averageIndiana average: 95.4%
Number of hospitalizations per 1,000 long-stay resident days.
1.63
In line with Indiana averageIndiana average: 1.60
Number of outpatient emergency department visits per 1,000 long-stay resident days.
2.11
43% worse than Indiana averageIndiana average: 1.48
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
45.1%
45% worse than Indiana averageIndiana average: 81.7%
Percent of short-stay residents who newly received an antipsychotic medication
1.8%
34% worse than Indiana averageIndiana average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
62.7%
21% worse than Indiana averageIndiana average: 79.0%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
13.5%
40% better than Indiana averageIndiana average: 22.4%
Percentage of short-stay residents who had an outpatient emergency department visit.
21.5%
105% worse than Indiana averageIndiana average: 10.5%
Percentage of SNF residents who experience falls with major injury during their stay.
4.7%
504% worse than Indiana averageIndiana average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
31.3%
42% worse than Indiana averageIndiana average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
64.2%
27% better than Indiana averageIndiana average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
31% of new residents, usually for short-term rehab.
52% of new residents, often for short stays.
17% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
52Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Waters of Sullivan Nursing Facility based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #255 / 290Payroll — State benchmarkedThis home is ranked 255th out of 290 homes in Indiana. Shows total annual staff payroll benchmarked to the Indiana average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
This home supports both short-term rehab and long-term care, with residents staying for a wide range of durations.
0.0 miles from city center
Estimated distance in miles from Sullivan's city center to The Waters of Sullivan Nursing Facility's address, calculated via Google Maps.
Add your location
The Waters of Sullivan Nursing Facility is located in SULLIVAN, Indiana.
Here are the financial assistance programs available to residents in Indiana.
The information below is reported by the Indiana Department of Health, Division of Long Term Care.
| North River Health Campus |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Evansville (East Baseline Road) | 95 | 50.5% | -27% | 3.66 | +63% | +7% | $3.3k | 10 | 3.3 | - | 47 | A+ | 11 | Thomas Cook | $12.0M | $6.4M | 53.4% | 155854 | ||||
| Greenwood Village South |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Greenwood | 207 | 18.4% | -73% | 4.16 | -50% | +21% | $0 | 6 | 3.0 | - | 38 | A+ | 50 | Pamela Seegers | $35.6M | $17.6M | 49.4% | 155026 | ||||
| The Waters of Sullivan Nursing Facility |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Sullivan | 93 | 57.0% | -18% | 3.12 | -38% | -9% | $0 | 31 | 7.8 | - | 53 | - | 60 | The Waters Of Sullivan Nursing Facility LLC | $5.9M | $3.0M | 50.7% | 155262 | ||||
| West River Health Campus |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Evansville (Westside) | 131 | 74.0% | +7% | 4.56 | -1% | +33% | $18.7k | 17 | 2.1 | 2 | 97 | A+ | 2 | Carla Baker | $11.1M | $5.9M | 53% | 155785 | ||||
| Westside Garden Plaza |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support. | Indianapolis (Chapel Hill / Ben Davis) | 150 | 47.3% | -32% | 3.49 | -29% | +1% | $0 | 76 | 6.9 | 1 | 71 | A+ | 10 | Westside Snf Operations LLC | $14.1M | $7.0M | 49.9% | 155606 |
Mackenzie Drake is the Director of Nursing at The Waters of Sullivan Nursing Facility.
The legal owner and operator of The Waters of Sullivan Nursing Facility is Johnson Memorial Hospital.
The Waters of Sullivan Nursing Facility has a walk score of 60. Moderately walkable. Some errands can be accomplished on foot, with a mix of nearby amenities.
According to IN state health department records, The Waters of Sullivan Nursing Facility's license number is 25-000163-1.
According to IN state health department records, The Waters of Sullivan Nursing Facility's license expires on February 28, 2026.
The Waters of Sullivan Nursing Facility's occupancy is 57%.
Sally Robertson is the administrator of The Waters of Sullivan Nursing Facility.
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