WATERS OF CLIFTY FALLS, THE
950 CROSS AVE, MADISON, IN 47250 · CCN 155209
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 138
- Avg residents/day
- 101.4
- Phone
- 8122734640
Inspection history vs Indiana & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Indiana avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-06-04 | 22 | 7.6 | 9.5 | +14.4 worse |
| 2 | 2024-06-24 | 15 | 7.9 | 9.8 | +7.1 worse |
| 3 | 2023-04-04 | 16 | 8.8 | 9.3 | +7.2 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 7 |
| Resident assessment and care planning | 3 |
| Nursing and physician services | 1 |
| Resident rights | 3 |
| Nutrition and dietary | 1 |
| Pharmacy service | 3 |
| Environmental | 2 |
| Administration | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.76 | 31.0% |
| RN staffing (reported) | 0.32 | 14.3% |
| Total nurse staffing (adjusted) | 2.09 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Chain
- Chain
- INFINITY HEALTHCARE CONSULTING
- Facilities in chain
- 70
- Chain avg overall
- 2.20 / 5
Inspection citations (53)1 actual harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2026-01-22 · Health
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2026-01-22 · Health
Potential for more than minimal harm
- GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-11-18 · Health · corrected 2025-11-25
Actual harm
- DF0908Keep all essential equipment working safely.2025-11-18 · Health · corrected 2025-11-25
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-10-20 · Health · corrected 2025-10-24
Potential for more than minimal harm
- DF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2025-07-14 · Health · corrected 2025-07-25
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2025-07-14 · Health · corrected 2025-07-25
Potential for more than minimal harm
- DF0554Allow residents to self-administer drugs if determined clinically appropriate.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- EF0583Keep residents' personal and medical records private and confidential.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- CF0732Post nurse staffing information every day.2025-06-04 · Health · corrected 2025-07-03
Potential for minimal harm
- DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0761Ensure 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.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0770Provide timely, quality laboratory services/tests to meet the needs of residents.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2025-06-04 · Health · corrected 2025-07-03
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-02-25 · Health · corrected 2025-01-23
Potential for more than minimal harm
- EF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2025-02-25 · Health · corrected 2025-03-20
Potential for more than minimal harm
- DF0602Protect each resident from the wrongful use of the resident's belongings or money.2024-08-30 · Health · corrected 2024-09-19
Potential for more than minimal harm
- DF0761Ensure 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.2024-08-30 · Health · corrected 2024-09-19
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-07-17 · Health · corrected 2024-08-14
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2024-07-17 · Health · corrected 2024-08-14
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- DF0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- DF0758Implement 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.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- EF0761Ensure 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.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-06-24 · Health · corrected 2024-07-17
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-04-04 · Health · corrected 2024-04-29
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-04-04 · Health · corrected 2024-04-29
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-02-27 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-27 · Health · corrected 2024-03-08
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-09-28 · Health · corrected 2023-10-27
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-09-28 · Health · corrected 2023-10-27
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-09-28 · Health · corrected 2023-10-27
Potential for more than minimal harm
- DF0744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.2023-09-28 · Health · corrected 2023-10-27
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-07-26 · Health · corrected 2023-08-11
Potential for more than minimal harm
- EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-07-26 · Health · corrected 2023-08-11
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- DF0758Implement 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.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- DF0761Ensure 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.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-04-04 · Health · corrected 2023-04-22
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| MAJOR HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2014-05-19 |
| THE WATERS OF CLIFTY FALLS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2014-05-19 |
| HANDY, SHAYNE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2014-05-19 |
| HORNER, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2014-05-19 |
| JONES, KATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2014-05-19 |
| HORNER, JOHN | Individual | CORPORATE OFFICER | — | 2014-05-19 |
| HANDY, SHAYNE | Individual | CONTRACTED MANAGING EMPLOYEE | — | 2014-05-19 |
| JONES, KATHY | Individual | CONTRACTED MANAGING EMPLOYEE | — | 2014-05-19 |
Other facilities in MADISON
| Name | Overall | Beds |
|---|---|---|
| HICKORY CREEK AT MADISON | ★★★★☆ | 36 |
| RIVER TERRACE HEALTH CAMPUS | ★★☆☆☆ | 57 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.