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Nursing HomeMedicaid Investigative

Waters of Sullivan Nursing Facility, the

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

505 W Wolfe St, Sullivan, IN 4788293 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.0/5

based on 23 Google reviews

5
4
3
2
1
Waters of Sullivan Nursing Facility, the Nursing Home in Sullivan, IN — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (18 vs median 6)

Bottom 25% in IN · Below recommended RN staffing · Worst in INFINITY HEALTHCARE CONSULTING chain · No penalties on record

Source: Medicare data

What this means for your family

While many families report positive experiences with the activity staff and general care, the reports of medical neglect and poor dietary management are concerning. We strongly recommend that you conduct an unannounced visit and specifically ask how the facility handles medical emergencies and dietary restrictions for diabetic residents.

Google Reviews

Google Reviews

23 reviews on Google
The Waters of Sullivan receives highly polarized feedback, with some families praising the compassionate staff and engaging activities, while others report severe neglect and administrative failures. Critical reviews highlight dangerous lapses in medical care, poor communication regarding dietary needs, and unprofessional conduct among staff. Prospective families should be aware of these significant inconsistencies in quality of care.

Quality Themes

Tap a score for details
Food5.0Staff6.0Clean6.0Activities9.0Meds2.0MemoryN/AComms6.0Value8.0

Strengths

  • Compassionate and attentive nursing staff
  • Engaging activity program
  • Clean and well-maintained environment
  • Responsive administrative communication

Concerns

  • Neglect of medical needs and failure to address health emergencies (mentioned by 2 reviewers)
  • Inconsistent or incorrect dietary/meal services (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02023(3)4.52024(4)3.82025(13)3.82026(4)

Distribution · 24 analyzed

5
17
4
1
3
1
2
0
1
5

How They Respond to Reviews

61%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1I noticed your administration is quite responsive to feedback; how do you typically involve families in the care planning process?
  • 2With the active program mentioned by many, what kind of daily activities or social events can my loved one look forward to?
  • 3Could you walk me through your specific protocols for managing medications and ensuring accuracy with prescriptions?
  • 4How does the nursing team handle medical emergencies or sudden changes in a resident's health status during the night?
  • 5How do you ensure that dietary needs and specific meal preferences are consistently met for every resident?
  • 6What steps has the facility taken recently to address the recent state inspection findings and improve staffing levels?

Personalized based on this facility's data


Key Review Excerpts

They treated my mother with such care and dignity. They never failed to address any concerns or answer any questions we had.

Long-term resident's family · 2025★★★★★

He orders his meals 1 day ahead. They have been consistently incorrect. He is diabetic, but they don't have a diabetic menu for him to choose from.

Family member · 2024★★★☆☆

Wish I could give zero. They dumped my sick mother in a room and pretty much ignored her. When she complained about not being able to breathe they ignored her and told her she was fine.

Family member · 2025☆☆☆☆
Source: 23 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.53hrs
71%
Registered nurses for medical care
Total Nursing
3.31hrs
81%
All nurses + aides combined
Staff Turnover
33%
Lower is better (< 30% = good)
RN Turnover
43%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

8

measures

Worse Than Avg

4

measures

Mixed Results

5

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility3.2%
Better than Avg
Here
3.2%
US
15.5%
IN
13.6%
Sullivan
19.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility26.4%
Worse than Avg
Here
26.4%
US
12.1%
IN
24.8%
Sullivan
14.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility11.8%
Better than Avg
Here
11.8%
US
19.5%
IN
23.5%
Sullivan
26.0%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility9.4%
Better than Avg
Here
9.4%
US
14.4%
IN
11.4%
Sullivan
16.9%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility13.6%
Mixed vs Avgs
Here
13.6%
US
15.3%
IN
13.0%
Sullivan
18.9%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility98.2%
Better than Avg
Here
98.2%
US
93.4%
IN
93.6%
Sullivan
93.8%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility62.7%
Worse than Avg
Here
62.7%
US
79.8%
IN
79.0%
Sullivan
69.0%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility80.1%
Mixed vs Avgs
Here
80.1%
US
81.8%
IN
81.5%
Sullivan
69.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
IN
1.3%
Sullivan
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

21deficiencies
Well above state avg (7.6)
8 complaint-triggered

Families have filed complaints triggering inspections, with recent concerns about nursing staffing levels and facility administration in December 2025. The facility shows recurring issues across quality of care, medication management, and nutrition services, with problems like respiratory care, care planning, and food safety appearing across multiple surveys from 2023 to 2025. While all deficiencies show correction dates, the pattern of repeated violations in core care areas suggests systemic challenges.

Apr 24, 2026Complaint
2
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Feb 13, 2026Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Dec 5, 2025Complaint
3
0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0835Potential for harm · WidespreadCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Aug 1, 2025Routine
19
0804Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0565Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0582Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0740Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Feb 28, 2025Complaint
2
0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0804Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Jun 21, 2024Routine
9
0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0773Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Waters of Sullivan Nursing Facility, the

Organization Type

for profit

Chain Affiliation

Chain Name

Infinity Healthcare Consulting

Chain Size

70 facilities nationwide

Chain avg rating: 2.2/5 · Rank 62 of 69 (Worst)

Ownership & Management

Owners

Johnson Memorial Hospital

Owner · Organization

100%

Key personnel

Abbott, AlexaContracted Managing EmployeeDecola, RobertW-2 Managing EmployeeBerkhouse, StevenOfficer / DirectorDunkle, DavidOfficer / DirectorBerkhouse, StevenOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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