Cycle 1
Health 2025-08-01 · Fire 2025-08-01
18 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Sullivan, IN
Waters Of Sullivan Nursing Facility, The
1-star overall rating with 1-star inspections with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
505 W Wolfe St, Sullivan, IN
(812) 268-6361
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1985-06-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
70 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,271
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.77
Performance 19.68% · Measure score 3.77 · Achievement 3.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.50
Performance 6.49% · Measure score 4.50 · Achievement 4.50 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.09
Baseline 61.67% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 4.61
Adjusted total nurse staffing
0
Baseline 3.35 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 10.53% · Lower 95% interval 7% |
| Discharge to community | 64.17% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 46 · Observed rate 69.57% · Lower 95% interval 52.97% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 4.65% |
0.77%
3.9 pts worse
|
Numerator 2 · Denominator 43 |
| Discharge self-care score | 31.25% |
53.69%
22.4 pts worse
|
Numerator 10 · Denominator 32 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 8 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 1 · Denominator 43 · Adjusted rate 2.78% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 2.7% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 93 |
| Discharge function score | 31.25% |
56.45%
25.2 pts worse
|
Numerator 10 · Denominator 32 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 2 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
93.6%
0.1 pts worse
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 83.0% · Q2 93.5% · Q3 100.0% · Q4 100.0% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.3% |
95.4%
1.1 pts worse
|
95.5%
1.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.8%
0.9 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 2.4% · Q4 5.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 28.7% |
24.6%
4.1 pts worse
|
11.4%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 22.2% · Q3 17.1% · Q4 22.9% · 4Q avg 28.7% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.6%
1.7 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 9.4% · Q4 3.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
23.5%
8.6 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 12.1% · Q3 6.2% · Q4 19.4% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
14.8%
7.7 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 3.8% · Q3 3.7% · Q4 7.4% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.0% |
13.3%
0.7 pts worse
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 12.0% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
11.7%
3.5 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 9.1% · Q3 3.1% · Q4 16.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.2%
0.6 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 2.4% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
24.2%
0.3 pts better
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 28.4% · Q3 26.7% · Q4 17.8% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.1%
1.6 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.9% · Q3 4.8% · Q4 2.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.5% |
81.6%
18.1 pts worse
|
81.7%
18.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 62.7% · Q3 84.1% · Q4 89.3% · 4Q avg 63.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.5% |
10.5%
11 pts worse
|
12.0%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 20.6% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.7% |
79.0%
16.3 pts worse
|
79.7%
17 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.5% |
22.4%
8.9 pts better
|
23.9%
10.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 11.8% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-21 · Fire 2024-06-21
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-05-12 · Fire 2023-05-12
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-01
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-08-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-09-19
E · Potential for more than minimal harm
2024-06-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-15
F · Potential for more than minimal harm
2023-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-17
D · Potential for more than minimal harm
2023-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-12-05
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-01-06
E · Potential for more than minimal harm
2025-12-05
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-08-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-08-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-03
C · Minimal harm
2025-08-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-02-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-21
E · Potential for more than minimal harm
2024-06-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-26
D · Potential for more than minimal harm
2023-05-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-05-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-05-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-05-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-05-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-05-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-04
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Abbott, Alexa
Contracted Managing Employee · Individual
Berkhouse, Steven
Operational/Managerial Control · Individual
Berkhouse, Steven
Corporate Director · Individual
Berkhouse, Steven
Corporate Officer · Individual
Decola, Robert
W-2 Managing Employee · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Director · Individual
Dunkle, David
Corporate Officer · Individual
Miller's Health Systems Inc
Operational/Managerial Control · Organization
The Waters Of Sullivan Nursing Facility LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Envive Of Sullivan
Sullivan, IN
1-star overall rating with 2-star inspections with $6,350 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Serenity Spring Senior Living At Jasonville
Jasonville, IN
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Health Center At Glenburn Home
Linton, IN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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