The Waters of Sullivan Nursing Facility

Nursing Home, Assisted Living, Respite Care & Skilled Nursing · Sullivan, IN

CMS overall rating

505 W Wolfe St, Sullivan, IN 47882 View map

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The Waters of Sullivan Nursing Facility accepts Medicaid, Medicare, and private pay.

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The Waters of Sullivan Nursing Facility accepts Medicaid, Medicare, and private pay.

Overview of The Waters of Sullivan Nursing Facility

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.

Facility Direct Line (812) 268-6361 admissions@watersofsullivan.com

Quality ratings

Measured by Centers for Medicare & Medicaid Services (CMS)

Staffing hours breakdown

Hours per resident per day — compared to state averages

Total nursing care / resident

3h 7m per day

vs avg

5 of 6 metrics below state avg

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.	32m per day	▼ 21% 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.	47m per day	■ Avg 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.	2h 0m per day	▼ 12% 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 1m per day	▼ 7% State avg: 3h 14m per day · National avg: 3h 26m per day
Physical Therapist Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.	1m per day	▼ 84% State avg: 4m per day · National avg: 4m 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.	15m per day	▼ 45% State avg: 27m per day · National avg: 28m per day

Capacity and availability

113 days

93-bed community

A larger shared setting that may offer more common spaces and organized community services.

1 year in operation

A newer community that may feature more recent facilities and programs.

Walk Score: 60 / 100

Moderately walkable. Some errands can be accomplished on foot, with a mix of nearby amenities.

About this community

Occupancy

Occupancy rate

57%

Lower than the Indiana average: 68.1%

Occupied beds

53 / 93

Average occupied beds in Indiana homes 70 beds

Facility TypeNursing Home / Skilled Nursing Facility / Nursing Facility Distinct Part

StatusActive

IssuanceMarch 1, 2025

ExpirationFebruary 28, 2027

License Number25-000163-1

The Waters of Sullivan Nursing Facility is legally operated by Johnson Memorial Hospital, and administered by Sally Robertson.

Profit StatusFor-profit

Medicare (SNF)

16 units

SNF/NF (Combined)

77 units

Total beds

93 units

Staffing

Key information about the people who lead and staff this community.

Director of NursingMackenzie Drake

Accept Medicaid

Accept Medicare

Rehabilitation Services

Respite Care

24-Hour Staffing

Fax(812) 268-4454

On-Site Nursing

Therapies (Physical

Occupational

Speech)

Restorative Therapy

Early To Late-Stage Dementia Care

On-Site Psychiatric And Psychological Services

Ongoing Dementia And Behavioral Education

Beauty/Barber Shop

Onsite Podiatry

Dental

Audiology Services

Operating Hours24 hours - 7 days a week

Since 2022 · 4 years of data 56 deficiencies 1 complaint 18 inspections

Inspection Score

At the Indiana average for assisted living residences (83/100)

Inspection Scorecard This scorecard compares key inspection, deficiency, 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.

Since 2022 vs. Indiana state average

Overall vs. IN average

Latest Inspection December 5, 2025 Complaint Investigation

Deficiencies Deficiencies are formal regulatory issues recorded during state inspections.	This Facility	IN Average	vs. IN Avg
Total deficiencies Formal regulatory issues recorded by inspectors across all inspection types.	56	36	This facility has 56% more total deficiencies than a typical Indiana assisted living residence (56 vs. IN avg 36).↑ 56% worse Rank #234 / 317 Total deficiencies — State benchmarked This home is ranked 234th out of 317 homes in Indiana for Deficiencies. Shows this facility's deficiencies compared to the Indiana average among 317 comparable communities in the ranking pool. Facilities with the same value for a metric share the same rank. Rankings are based only on facilities in Indiana that report data for that category. Facilities without available data are excluded from the ranking.
Deficiencies per year Average deficiencies per year since 2022.	14	9	This facility has 56% more deficiencies per year than a typical Indiana assisted living residence (14 vs. IN avg 9).↑ 56% worse
Deficiencies per inspection Average deficiencies per inspection.	3.1	1.9	This facility has 63% more deficiencies per inspection than a typical Indiana assisted living residence (3.1 vs. IN avg 1.9).↑ 63% worse Rank #248 / 317 Deficiencies per inspection — State benchmarked This home is ranked 248th out of 317 homes in Indiana for Deficiencies per inspection. Shows this facility's deficiencies per inspection compared to the Indiana average among 317 comparable communities in the ranking pool. Facilities with the same value for a metric share the same rank. Rankings are based only on facilities in Indiana that report data for that category. Facilities without available data are excluded from the ranking.

Inspections State inspections evaluate whether the facility meets health and safety standards.	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 had 5% fewer total visits than the Indiana average (18 vs. IN avg 19). More inspections can mean more regulatory scrutiny rather than worse care.↓ 5% fewer
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 assisted living residence (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 assisted living residence (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 assisted living residence (10 vs. IN avg 13).↓ 23% better

Complaints & Investigations Complaints are formal concerns filed by residents, families, or staff. Investigations are on-site follow-ups.	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 assisted living residence (1 vs. IN avg 5).↓ 80% better Rank #1 / 293 Total complaints — State benchmarked This home is ranked 1st out of 293 homes in Indiana for Total complaints. Shows this facility's total complaints compared to the Indiana average among 293 comparable communities in the ranking pool. Facilities with the same value for a metric share the same rank. Rankings are based only on facilities in Indiana that report data for that category. Facilities without available data are excluded from the ranking.
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 assisted living residence (0.3 vs. IN avg 1.3).↓ 77% better

Inspection Reports Summary 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 with all investigated complaints and no deficiencies cited.
The June 21, 2024 annual inspection cited nine deficiencies including medication supervision, infection control, food safety, and care planning failures.
The July 2, 2024 Life Safety Code survey found one deficiency for a corridor door lacking a self-closing device affecting resident safety.

Show Inspection Reports

Inspections since 2023

Total health inspections 4

State average N/A

Last Health inspection on Aug 2025

Total health citations

State average N/A

Citations per inspection

7.75

State average N/A

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.

Breakdown of citation severity (last 3 years)

Critical health citations

In line with State average

State average: N/A

Serious health citations

In line with State average

State average: N/A

0 critical citations State average: N/A

0 serious citations State average: N/A

30 moderate citations State average: N/A

1 minor citation State average: N/A

Citations history (last 3 years)

Abuse/Neglect moderate citation Aug 01, 2025

Corrected

Nursing Services minor citation Aug 01, 2025

Corrected

Nutrition moderate citation Aug 01, 2025

Corrected

Nutrition moderate citation Aug 01, 2025

Corrected

Total staff 66

Employees 51

Contractors 15

Staff to resident ratio 1.27 : 1

0% compared with State average

State average ratio: 0 : 0

Avg staff/day 25

Average shift 7.8 hours

0% compared with State average

State average: 0 hours

Total staff hours (quarter) 17,975

Nursing staff breakdown

9.2 hours

8.5 hours

8.2 hours

Contractor staffing

1,252 contractor hours this quarter

Respiratory Therapy Technician: 4 Speech Language Pathologist: 4 Physical Therapy Assistant: 3 Qualified Social Worker: 2 Physical Therapy Aide: 1 Therapeutic Recreation Specialist: 1

Staff by category


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

22 Certified Nursing Assistant

% of Days 100%

10 Licensed Practical Nurse

% of Days 100%

6 Other Dietary Services Staff

% of Days 91%

2 Clinical Nurse Specialist

% of Days 75%

4 Registered Nurse

% of Days 79%

2 Administrator

% of Days 73%

1 Nurse Practitioner

% of Days 65%

1 Dietitian

% of Days 75%

2 Medication Aide/Technician

% of Days 59%

4 Speech Language Pathologist

% of Days 73%

1 Mental Health Service Worker

% of Days 65%

3 Physical Therapy Assistant

% of Days 59%

2 Qualified Social Worker

% of Days 71%

1 Physical Therapy Aide

% of Days 13%

4 Respiratory Therapy Technician

% of Days 38%

1 Therapeutic Recreation Specialist

% of Days 1%

View All Staffing Data

No penalties in the past 3 years

No civil money penalties or payment denials were reported in the last 3 years.

High-risk clinical events score 6.1

24% better than State average

State average: 8.0

Functional decline score 14.5

15% better than State average

State average: 17.1

Long-stay resident measures

Significantly above average

Need for Help with Daily Activities Increased 6.3%

48% better than State average

State average: 12.0%

Walking Ability Worsened 11.8%

18% better than State average

State average: 14.4%

Low Risk Residents with Bowel/Bladder Incontinence 25.5%

In line with State average

State average: 24.6%

Falls with Major Injury 1.7%

56% better than State average

State average: 3.9%

High Risk Residents with Pressure Ulcers 6.9%

57% worse than State average

State average: 4.4%

Urinary Tract Infection 2.3%

87% worse than State average

State average: 1.2%

Lost Too Much Weight 3.7%

36% better than State average

State average: 5.7%

Depressive Symptoms 30.3%

26% worse than State average

State average: 24.1%

Antipsychotic Use 15.9%

28% worse than State average

State average: 12.4%

Pneumococcal Vaccine 84.4%

10% worse than State average

State average: 93.7%

Influenza Vaccine 94.3%

In line with State average

State average: 95.4%

Hospitalizations per 1,000 days 1.63

In line with State average

State average: 1.60

ED visits per 1,000 days 2.11

43% worse than State average

State average: 1.48

Short-stay resident measures

Above average

Pneumococcal Vaccine 45.1%

45% worse than State average

State average: 81.7%

Antipsychotic medication increase 1.8%

34% worse than State average

State average: 1.4%

Influenza Vaccine 62.7%

21% worse than State average

State average: 79.0%

Re-hospitalized after SNF stay 13.5%

40% better than State average

State average: 22.4%

Emergency department visits 21.5%

105% worse than State average

State average: 10.5%

Falls with major injury 4.7%

504% worse than State average

State average: 0.8%

Ability to care for self at discharge 31.3%

42% worse than State average

State average: 53.7%

Successful return to home or community 64.2%

27% better than State average

State average: 50.6%

Breakdown by payment type

Medicare

31% of new residents, usually for short-term rehab.

Typical stay 1 - 2 months

Private pay

52% of new residents, often for short stays.

Typical stay 2 - 3 months

Medicaid

17% of new residents, often for long-term daily care.

Typical stay 11 - 12 months

Total residents 52

Medicare

17.3% of residents

Medicaid

57.7% of residents

Private pay or other

25% of residents

Programs & Services

Residents Group

Residents meet regularly to discuss policies, care quality, and activities

Active Resident Council

Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.

Financial Trends

Historical financial and operational data for The Waters of Sullivan Nursing Facility from 2012–2023, based on CMS SNF Cost Reports.

Key figures below are for fiscal year ending in 12/2023.

Occupancy Rate 50.6% ↓ 1.8pp vs 2022

Net Patient Income -$267.9K ↑ ~$839.1K vs 2022

Payroll Costs $3.0M ↑ ~$319.1K vs 2022

Operating Margin -4.8% ↑ 16.5pp vs 2022

Metric	2012	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Occupancy %	86.8%	83.6%	74.8%	68.2%	68.5%	72.8%	73.2%	66.8%	52.4%	52.5%	50.6%
Beds	93	93	93	93	93	93	93	93	93	93	93
Net Income	$532,288	$1,119,650	$544,880	$79,872	$205,373	$283,528	$305,544	$1,302,684	-$792,732	-$1,076,952	-$267,032
Gross Revenue	$6,594,268	$8,163,680	$7,714,222	$7,040,400	$7,084,829	$7,626,694	$7,625,703	$7,769,805	$5,886,139	$5,327,621	$5,942,559
Operating Expenses	$6,173,184	$6,969,035	$7,035,394	$6,754,970	$6,756,730	$7,164,383	$7,059,047	$7,377,840	$6,871,429	$6,305,256	$5,808,954
Net Patient Income	$499,832	$1,090,762	$502,261	$66,247	$141,081	$243,538	$263,687	$460,488	-$937,968	-$1,106,984	-$267,931
Net Patient Revenue	$6,673,016	$8,059,797	$7,537,655	$6,821,217	$6,897,811	$7,407,921	$7,322,734	$7,838,328	$5,933,461	$5,198,272	$5,541,023
Payroll Costs	$3,162,480	$3,180,060	$3,145,052	$2,990,693	$3,066,571	$3,249,799	$3,201,117	$3,375,380	$2,927,718	$2,692,021	$3,011,099
Operating Margin %	7.5%	13.5%	6.7%	1.0%	2.1%	3.3%	3.6%	5.9%	-15.8%	-21.3%	-4.8%
Medicare %	18.8%	18.6%	19.1%	21.1%	20.5%	17.6%	12.2%	18.0%	18.8%	7.1%	10.2%
Medicaid %	62.7%	63.0%	60.5%	58.8%	58.4%	56.1%	57.7%	53.6%	51.7%	54.8%	52.2%
Private %	18.4%	18.4%	20.4%	20.1%	21.2%	26.2%	30.1%	28.5%	29.6%	38.1%	37.6%
Net Patient Revenue/Day	$226	$284	$297	$294	$296	$300	$295	$345	$334	$292	$322
Cost/Day	$209	$246	$277	$291	$290	$290	$284	$325	$387	$354	$338
Avg Length of Stay	149.2 days	147.8 days	132.9 days	118.5 days	153.1 days	144.4 days	192.7 days	153.6 days	195.3 days	144.8 days	113.1 days

Finances and operations

Based on CMS SNF Cost Report for fiscal year ending in 12/2023.

Net patient revenue

$5.5M

Net patient income

-$267.9K

For-profit LLC

Net patient revenue

$5.5M

Net patient income

-$267.9K

Other income

$899

Payroll costs

$3.0M 54.3% of net patient revenue

Other operating costs

$2.8M

Total costs

$5.8M

TYPE OF STAY

Mix of rehab and long-term care

This home supports both short-term rehab and long-term care, with residents staying for a wide range of durations.

Most new residents arrive under private pay (52% of admissions), and a typical private pay stay runs around 2 - 3 months.

Coverage residents most often arrive under.

Medicare 31%

Private pay 52%

Medicaid 17%

Coverage residents most often leave under.

Medicare 25%

Private pay 53%

Medicaid 22%

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.

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The information below is reported by the Indiana Department of Health, Division of Long Term Care.


Westminster Village Muncie	NH AL IL SNF	Muncie	-	303	A+	6	Studio / 1 Bed / 2 Bed
Christian Care Retirement Community	NH AL IL MC SNF	Bluffton (Toll Gate Heights)	-	145	-	4	1 Bed / 2 Bed / 3 Bed
Copper Trace Family-first Senior Living	NH AL MC SNF	Westfield	-	223	-	4	1 Bed / 2 Bed
Wellbrooke of Westfield	NH AL	Westfield	-	129	A-	5	Studio / 1 Bed
The Waters of Sullivan Nursing Facility	NH AL RC SNF	Sullivan	-	93	-	60	-

Nursing Home Explorer

Who is the Director of Nursing at The Waters of Sullivan Nursing Facility?

Mackenzie Drake is the Director of Nursing at The Waters of Sullivan Nursing Facility.

Who is the owner of The Waters of Sullivan Nursing Facility?

The Waters of Sullivan Nursing Facility is legally operated by Johnson Memorial Hospital, and administered by Sally Robertson.

Is The Waters of Sullivan Nursing Facility in a walkable area?

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.

What is the license number of The Waters of Sullivan Nursing Facility?

According to IN state health department records, The Waters of Sullivan Nursing Facility's license number is 25-000163-1.

When does The Waters of Sullivan Nursing Facility's license expire?

According to IN state health department records, The Waters of Sullivan Nursing Facility's license expires on February 28, 2027.

What is the occupancy rate at The Waters of Sullivan Nursing Facility?

The Waters of Sullivan Nursing Facility's occupancy is 57%.

Does The Waters of Sullivan Nursing Facility operate as a for-profit or non-profit?

The Waters of Sullivan Nursing Facility is registered as a for-profit in IN.

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The Waters of Sullivan Nursing Facility

Overview of The Waters of Sullivan Nursing Facility

Quality ratings

Staffing hours breakdown

Capacity and availability

About this community

Occupancy

License Details

Ownership & Operating Entity

Type Of Units

Staffing

Leadership

Payment & Insurance

Therapy & Rehabilitation

Staffing & Medical

Contact Information

Amenities & Lifestyle

Contact The Waters of Sullivan Nursing Facility

Inspection History

Inspection Scorecard This scorecard compares key inspection, deficiency, 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 Deficiencies are formal regulatory issues recorded during state inspections.

Inspections State inspections evaluate whether the facility meets health and safety standards.

Complaints & Investigations Complaints are formal concerns filed by residents, families, or staff. Investigations are on-site follow-ups.

Inspection Reports Summary An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.

Health Inspection History

Inspections since 2023

Breakdown of citation severity (last 3 years)

Citations history (last 3 years)

Staffing Data

Nursing staff breakdown

Registered Nurse

Licensed Practical Nurse

Certified Nursing Assistant

Contractor staffing

Staff by category

22 Certified Nursing Assistant

10 Licensed Practical Nurse

6 Other Dietary Services Staff

2 Clinical Nurse Specialist

4 Registered Nurse

2 Administrator

1 Nurse Practitioner

1 Dietitian

2 Medication Aide/Technician

4 Speech Language Pathologist

1 Mental Health Service Worker

3 Physical Therapy Assistant

2 Qualified Social Worker

1 Physical Therapy Aide

4 Respiratory Therapy Technician

1 Therapeutic Recreation Specialist

Penalties and fines

Quality of care over time

Long-stay resident measures

Short-stay resident measures

Breakdown by payment type

Medicare

Private pay

Medicaid

Facility Characteristics

Programs & Services

Residents Group

Active Resident Council

Financial Trends

Financial Performance

Payroll & Labor Costs

Payer Mix (percentage)

Finances and operations

Who this home usually serves

Mix of rehab and long-term care

Admissions

Discharges

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