Waters of Sullivan: Ignored Food Preferences - IN
The resident, identified in inspection records only as Resident B, is diabetic, has heart failure, and has high blood pressure. He is cognitively intact, meaning he understood exactly what was happening and could articulate his objections clearly. He told inspectors on the morning of April 24 that he had asked staff multiple times to stop sending him oatmeal. Nobody had written it down.
Inspectors reviewed his medical record that same afternoon. His care plan contained no food preferences at all. A nutrition assessment completed in late February noted that food preferences were recorded on the resident's tray card, a daily menu given to residents to mark their selections. No additional detail appeared anywhere in the assessment. When inspectors pulled the actual tray card from April 24, the section designated for likes and dislikes was blank.
The Director of Nursing told inspectors that food preferences were supposed to be recorded on nutritional assessments. The Dietary Manager said residents received a daily menu and were asked each day what they wanted. Neither of them said the resident had ever told them he disliked oatmeal.
That account sits uncomfortably next to what Resident B told inspectors himself: that he had raised the issue with staff several times.
Someone was not listening, or someone was not writing it down, or both. The inspection record does not resolve which.
The Dietary Manager acknowledged she was not the person responsible for completing nutritional assessments, but said she would record a resident's preferences if the resident told her directly. She then produced the day's menu for Resident B. The likes and dislikes section was empty.
The facility's written policy on resident food choice states that residents have the right to make their own food choices based on their individual differences, cultural and ethnic background, and personal preferences. The Director of Nursing presented that policy to inspectors as the document currently governing the facility's practices. It was dated April 2017.
For a resident managing diabetes, food is not incidental. A consistent carbohydrate diet, which Resident B was on by physician order, requires attention to what is actually eaten, not just what is theoretically offered. Oatmeal is not inherently off-limits on such a diet, but the point is simpler than that: he did not want it, he said so more than once, and the facility had no record that he had ever expressed a preference about anything.
The violation was rated minimal harm or potential for actual harm, the lowest category on the federal scale. Inspectors reviewed one resident for meal food preferences and found the failure in that single case.
What the record shows is a gap between the facility's stated system and how that system functioned for at least one person. The daily menu was supposed to capture preferences. The nutritional assessment was supposed to capture preferences. The care plan was supposed to reflect the resident's individual needs. None of them did.
Resident B is cognitively intact. He knew what he wanted, and he said it out loud, more than once. As of the morning inspectors arrived, he was still getting oatmeal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Sullivan Nursing Facility, The from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
WATERS OF SULLIVAN NURSING FACILITY, THE in SULLIVAN, IN was cited for violations during a health inspection on April 24, 2026.
The resident, identified in inspection records only as Resident B, is diabetic, has heart failure, and has high blood pressure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.