Waters of Sullivan Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Sullivan Nursing Facility, The, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 30, 2022

  Based on record review and interview, the facility failed to ensure safety procedures were followed during a bed bath resulting in actual harm when a resident rolled out of bed and sustained a fracture to the shoulder (Resident B) and to ensure a resident was transferred safely resulting in actual harm when a resident sustained a laceration which required staples to repair (Resident C) for 2 of 3 residents reviewed for accidents. Findings include: 1. Resident B's record was reviewed on 6/29/22 at 10:15 a.m. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure facial hair was covered with beard restraints in the kitchen area for 6 of 6 observations of the kitchen; the facility failed to ensure food met the minimal holding temperature for 1 of 1 test trays reviewed; and the facility failed to ensure the hall tray food delivery carts were maintained clean and free of dried debris for 2 or 2 food carts reviewed. These concerns had the potential to affect 47 of 48 residents who eat food served from the kitchen. Findings include:1. During the initial kitchen observation with the Dietary Manager, on 4/24/26 at 8:58 a.m., Dietary Aide 4 was observed with facial hair and no beard restraint in place. […]

• No harm, potential for more than minimal, widespreadF725Dec 5, 2025

  Based on interview and record review, the facility had failed to ensure enough nursing staff to provide resident care while covering laundry services since the end of October. This deficient practice had the potential to affect 48 of 48 residents who resided in the facility. Findings include:During an interview on 12/4/25 at 2:30 p.m., CNA 4 indicated she sometimes worked in laundry during her shift on the floor. She tried her best to not let it affect resident care and felt the nursing staff had stepped up to answer call lights when able. During an interview on 12/4/25 at 10:35 p.m., CNA 6 indicated she did laundry during her shift and had had to work much harder. The nursing staff had had to answer more call lights which was probably affecting charting and medication administration. […]

• No harm, potential for more than minimal, widespreadF835Dec 5, 2025

  Based on record review and interview, the Administrator failed to manage the facility in a manner that provided quality of life related to bug infestation, lack of available direct care staff, and a safe living condition of the facility environment. This deficient practice had the potential to affect 48 of 48 residents who resided in the facility. Findings include:Confidential interviews were conducted during the course of the survey, and indicated the Administrator never came on the floor to speak with staff or the residents. They felt she did not know the residents or staff at all and had shown a total lack of caring for the challenges being faced in the facility. The moral in the facility had suffered under the current Administrator. […]

• No harm, potential for more than minimal, widespreadF804Aug 1, 2025

  Based on observation, interview, and record review, the facility failed to provide meals that were palatable during 2 of 2 mealtime observations. This deficient practice had the potential to affect 52 of 52 residents receiving food served from the kitchen. Findings include:During breakfast meal service in the main dining room on 7/28/25 at 8:03 a.m., a breakfast menu was noted to be dated 7/11/25 and indicated breakfast trays were served at 7:45 a.m. The first breakfast tray was served at 8:23 a.m. On 7/28/25 at 8:23 a.m., Certified Nurse's Aide (CNA) 11 served a male resident his breakfast tray and indicated she was unable to cut the waffle very easily because it was hard and crunchy. The waffle was noted to be dark brown and hard on half of it. […]