Waters Of Sullivan Nursing Facility, The
WATERS OF SULLIVAN NURSING FACILITY, THE in SULLIVAN, IN — inspection on April 24, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the resident's care plan indicated no specific food preferences were indicated by the resident. A 5 day Minimum Data Set (MDS) assessment, dated 2/26/26, indicated the resident was cognitively intact.
Review of a nutrition assessment, dated 2/22/26, indicated food preferences were on the tray card (a daily menu provided to the resident to record food selections).
No additional information was recorded on the assessment record. On 4/24/26 at 2:13 p.m., during an interview the Director of Nursing (DON) indicated food preferences were recorded on the resident's nutritional assessments. On 2/24/26 at 2:17 p.m., during an interview the DON and Dietary Manager (DM) both indicated the resident had not told either of them of any food preferences.
The DM indicated the residents were provided a daily menu and were asked to indicate what they wanted each day.
The DM indicated she was not the person assigned to complete the nutritional assessments for the residents, but she would include likes and dislikes if the resident informed her of them. On 2/24/26 at 2:30 p.m., the DM provided a copy of the daily menu for 4/24/26 that was provided to the resident.
She indicated likes and dislikes would be recorded at the bottom of the menu selection.
The document lacked indications of likes or dislikes. On 4/24/26 at 2:50 p.m., the DON provided a document, titled, Clinical Nutrition documentation, dated4/2017, and indicated it was the policy currently being used by the facility.
The policy indicated, .Policy.The resident has the right to make their own food choices as it relates to their individual differences, cultural and ethnic preferences.
This citation relates to Intake 2807671. 410 Indiana Administrative Code (IAC) 1.3-21(a)(4) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155262 04/24/2026
Waters of Sullivan Nursing Facility, The 505 W Wolfe St Sullivan, IN 47882
a. On 1/22/26, Resident G indicated the food quality was poor.
b. On 2/18/26, Resident H indicated the food was cold and was often late. c. On 2/20/26, Resident G indicated the food was cold and often out of items. d. On 2/24/26, Resident J indicated the food was cold.
On 4/24/26 at 2:45 p.m., the Director of Nursing (DON) provided an undated document, titled, Cooking and Cooling, and indicated it was the policy currently being used by the facility.
The policy indicated, .Policy: Foods will be cooked thoroughly reaching the appropriate internal temperatures specific to each item.
Cooked foods will be cooled properly to ensure food safety.
On 4/24/26 at 2:45 p.m. the DON provided an undated document, titled, .Minimum Cooking Food Temperatures and Holding Times, and indicated it was the policy currently being used by the facility.
The policy indicated, .Poultry 165 degrees Fahrenheit.Food Cooked.165 degrees Fahrenheit.
- On 4/24/26 at 12:22 p.m., observed the dietary food service carts for the East and [NAME] halls
during the noon lunch meal service.
The carts contained individual trays with meal service, cups containing liquids and eating utensils.
The carts were soiled with heavy coating of brown debris along the rails at the bottom of the carts.
The wheels were observed to have a heavy coating of brown debris.
On 4/24/26 at 12:25 p.m., during an interview the Dietary Manager (DM) indicated the carts were cleaned after every meal service.
She indicated the outside was wiped down as needed.
On 4/24/26 at 2:47 p.m., the Director of Nursing provided an undated document, titled, Storing utensils, tableware, and equipment, and indicated it was the policy currently being used by the facility.
The policy indicated, .Procedure.3.
Clean and sanitize trays and carts used to carry clean tableware and utensils. Do this daily or as often as necessary.
This citation relates to Intake 2807671. 410 Indiana Administrative Code (IAC) 3.1-21(i)(1) 410 Indiana Administrative Code (IAC) 3.1-21(i)(3)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.